Doncaster & Bassetlaw Teaching Hospitals NHS Foundation Trust (18 008 051a)

Category : Health > Hospital acute services

Decision : Upheld

Decision date : 20 Aug 2019

The Ombudsman's final decision:

Summary: The Ombudsmen find no fault in the way an NHS Trust and Council handled two discharges from hospital for a man who had undergone an operation. However, the Ombudsmen find the operation was delayed unnecessarily, but poor record keeping by the Trust means we cannot resolve why this happened. The Ombudsmen also find fault in the way the Council and NHS Trust handled the complaint. The Council and Trust have agreed to actions to address the injustice these failings caused.

The complaint

  1. Mr G complains about the care Nottinghamshire County Council (the Council) and Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust (the Trust) provided to his late father, Mr R, in early 2018. He complains that:
      1. James Hince Court (an Intermediate Care Placement, funded by the Council) failed to stop Mr R’s blood thinning medication despite instructions to do so, which delayed planned surgery
      2. The Trust sent patient transport to the wrong address, which delayed Mr R’s rescheduled surgery
      3. The Trust inappropriately discharged Mr R from hospital on 15 March 2018
      4. The Trust inappropriately found Mr R to be medically fit for discharge on 20 March 2018
      5. Mr R did not have capacity to consent to paying for a Short Term Care placement at St Michael’s View from 20 March 2018, as he had delirium and confusion due to a urinary tract infection.
  2. Mr G said these failings caused Mr R significant avoidable distress at a time when he was already very ill with bladder cancer. Mr G said this, in turn, caused him unnecessary distress. In addition, Mr G said Mr R was wrongly charged for Short Term Care at St Michael’s View.
  3. Mr G said the Council and the Trust have not taken adequate remedial action to acknowledge their failings or to address the impact. In bringing his complaint to the Ombudsmen he would like the Council and the Trust to acknowledge the failings that occurred in his father’s care. He would like them to take appropriate action to prevent recurrences. Further, Mr G would like the charges for Mr R’s placement at St Michael’s View to be waived.

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The Ombudsmen’s role and powers

  1. The Ombudsmen have the power to jointly consider complaints about health and social care. Since April 2015, these complaints have been considered by a single team acting on behalf of both Ombudsmen (Local Government Act 1974, section 33ZA, as amended, and Health Service Commissioners Act 1993, section 18ZA).
  2. The Ombudsmen investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, the Ombudsmen consider whether it has caused injustice or hardship (Health Service Commissioners Act 1993, section 3(1) and Local Government Act 1974, sections 26(1) and 26A(1), as amended).
  3. If the Ombudsmen are satisfied with the actions or proposed actions of the bodies that are the subject of the complaint, they can complete their investigation and issue a decision statement (Health Service Commissioners Act 1993, section 18ZA and Local Government Act 1974, section 30(1B) and 34H(i), as amended).

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How I considered this complaint

  1. I read the correspondence Mr G sent to the Ombudsmen and spoke to him on the telephone. I wrote to the Council and Trust to explain what I intended to investigate and to ask for comments and copies of relevant records. I considered all the comments and records they provided. I considered relevant legislation and guidance and took advice from a doctor with relevant knowledge and experience.
  2. I shared a confidential copy of my draft decision with Mr G, the Council and the Trust to explain my provisional findings. I invited their comments and considered those I received in response.

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What I found

Background

  1. In January 2018 Mr R lived alone without any formal support. At the end of the month doctors found he had a lesion in his bladder, which it suspected was bladder cancer. Surgeons booked Mr R in for surgery on 21 February.
  2. A couple of days after this outpatient appointment Mr R had a fall at home and spent a long time on the floor afterwards. Mr G found him and called an ambulance which took him to hospital. Doctors felt Mr R’s fall probably related to an infection. The hospital admitted Mr R and treated him for urosepsis (a condition where a urinary tract infection spreads from the urinary tract to the bloodstream), via antibiotics.
  3. Early in the admission a doctor talked to Mr R about plans for when he left hospital. Mr R shared concerns about his ability to get about and the doctor planned to refer him to a discharge team. A social worker took part in planning what would happen when Mr R’s admission ended.
  4. In early February Mr R left hospital and went into an Intermediate Care facility, for which there was no charge.
  5. Mr R’s surgery did not happen on the scheduled date, or the re‑scheduled date around a week later. Mr R remained in the Intermediate Care facility. In early March the facility started planning for Mr R to return home with support four times a day after his surgery.
  6. Mr R went into hospital for surgery in the middle of March. The operation went ahead. Mr R left hospital and went home the next day, with plans for support visits four times a day.
  7. A few days later a carer found Mr R on the floor. An ambulance took him back to hospital. Mr R stayed in hospital overnight and then, the next day, went into a Short Term Care Placement, for which he was charged the full cost.
  8. In the middle of April 2018 Mr R returned to hospital. He was found to have urosepsis. Medics found he was medically fit for discharge at the end of the month. A social worker made plans for him to return to the Intermediate Care placement.

Analysis

Complaint Handling

  1. Mr G made his complaint to the Council toward the end of April 2018. In early May 2018 the Council emailed the Trust and sent it details of the complaint. It said it felt it would be simpler to send two separate responses rather than trying to send a coordinated one. The Trust accepted this and the organisations proceeded on this basis.
  2. The Council sent its response in the second half of June and noted some issues would need to be answered by health services. The Trust sent its response six days later.
  3. The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 (the Complaint Regulations) came into force in April 2009. They set out the responsibilities of social services and health organisations in dealing with complaints about their service.
  4. The Complaint Regulations include, at section 9, a duty to work together on complaints about more than one organisation. They state that, in these circumstances, the responsible organisations must cooperate in handling the complaint. This includes duties to: establish who will lead the process; share relevant information; and, provide the complainant with a coordinated response.
  5. There is no evidence either organisation asked Mr G about his preferences. There is no evidence either organisation made enquiries of the other about what the other’s investigation would entail or how long it would be likely to take. On the evidence I have seen the Council designated each issue either for it or for health, but neither organisation considered whether they might involve both. Therefore, I do not consider there is evidence that the prospect of a joint investigation was properly explored before it was dismissed. This is fault. The Council was not automatically the lead agency because it received the complaint. Therefore, responsibility for this complaint lies equally with both organisations.
  6. The separate, uncoordinated approach may have been simpler for the organisations but it was not for Mr G. It meant he received two responses and had to liaise with two organisations. It also had consequences for the investigation of the complaint about why Mr R’s initial operation did not go ahead (I will say more about this below).
  7. On balance, I consider that if the Council and Trust had given this issue proper consideration it would have led to a joint investigation. If there had been a joint investigation it is likely important information (about the cancellation of the surgery) would have come to light sooner and would have led to findings and learning points sooner. Therefore, were it not for the fault, Mr G would have experienced less frustration and would have been put to less time and trouble. As such, the fault here led to an avoidable injustice. I have made recommendations to address this.

Complaint that James Hince Court failed to stop Mr R’s blood thinning medication despite instructions to do so, which delayed his surgery

  1. In late January 2018 the Urology clinic found Mr R had a tumour in his bladder. Surgeons planned to operate on 21 February 2018.
  2. Mr G said this operation did not take place because no one stopped Mr R’s prescription of clopidogrel (a blood-thinning medication). Mr G complained about the failure to stop the prescription.
  3. The Council’s complaint response of June 2018 said he would need to raise this with the relevant health organisation.
  4. The Trust’s response, several days later, said the hospital issued a discharge letter which gave instructions for the medication to be stopped seven days before 21 February. It said this letter was sent to James Hince Court and the GP.
  5. Mr G said neither the Council nor the Trust have not taken adequate remedial action to address this issue. He said he has no reassurance that this would not happen again to other patients. I agree the organisations did not get to the bottom of this. As noted in the previous section, I consider this was a result of the uncoordinated approach to answering the complaint.
  6. Records from the Trust show that, during Mr R’s hospital admission in early February 2018, doctors and other professionals were aware of the planned operation on 21 February 2018. There are references to this on 31 January 2018, and 2, 5, 8 and 9 February 2018. On 7 February 2018 a member of staff made a note in the ‘Communication with relatives’ section of a form. It stated they had a telephone conversation (it does not say who they spoke to) about the planned surgery on 21 February 2018. The note said Mr R would need to stop taking clopidogrel seven days before the operation, so would need to stop on 15 February 2018.
  7. There is evidence, from a medication administration chart, that James Hince Court understood it needed to stop Mr R’s prescription of clopidogrel, and did so. This chart recorded the medications Mr R had prescriptions for, and when staff gave them to him. The chart:
  • Includes a prescription for clopidogrel tablets and noted ‘To be stopped 7 days prior to surgical procedure. See discharge letter’
  • Show staff gave Mr R one clopidogrel tablet each day for five days in a row, from 9 to 13 February 2018. The record states that there were initially 28 tablets and, after the dose on 13 February 2018, 23 tablets remained
  • Records that staff did not administer a dose of clopidogrel for the next 15 days, from (and including) 14 to 28 February 2018
  • Records that staff started to give a dose of clopidogrel to Mr R again on 1 March 2018. After this dose 22 tablets remained.
  1. Therefore, I have not found evidence on the part of the Council. There is evidence that James Hince Court stopped giving Mr R clopidogrel in line with the Trust’s instructions.
  2. Staff at the Trust completed a range of records in relation to Mr R’s surgery, which took place on 14 March 2018. An admission form included a list of Mr R’s regular medication and included clopidogrel. It also noted this medication was ‘stopped 14-2-18’.
  3. The Trust advised me that the planned surgery was cancelled on 15 February 2018. It said the only information recorded about the cancellation is that it related to clopidogrel, but it is not more specific than that. The Trust said relevant staff cannot recall anything about this now, which is unsurprising given the passage of time.
  4. The Trust concluded that, working on the information to hand, the most likely explanation for the cancellation is that its Booking Team received information that Mr R had not stopped taking clopidogrel in time.
  5. I have not seen any evidence of the conversation (or other communication) that took place that led the Trust to believe Mr R had not stopped taking the medication in time. It is apparent there was a breakdown in communication – as the prescription had been stopped in time – but I cannot be any more specific. Therefore, even working on balance, I cannot say who was at fault here.
  6. Nevertheless, this issue does raise several concerns about the way the Trust recoded information. Firstly, as I understand it, Mr R needed to have seven full days without a dose of clopidogrel before the start of the date of surgery; i.e. to have a last dose on 13 February. However, the notes made on 7 February 2018 included ‘stop 15/02/18’. It seems this did not have any further consequences in this case, as the last dose was on 13 February, but it had the potential to cause confusion and to lead to a mistake.
  7. Secondly, there is a lack of information about why the surgery was cancelled. There is nothing recorded about who spoke to who, when, and what was discussed. This means the audit trail for the cancellation of this important surgery is significantly more limited than it should be. This is fault. This lack of information is a key reason why this investigation cannot make a finding about the breakdown in communication in this case. This, in turn, has left uncertainty and frustration which is an injustice in its own right. I have made recommendations to address this.

Complaint the Hospital sent patient transport to the wrong address, which further delayed Mr R’s surgery

  1. The hospital rescheduled Mr R’s surgery for 28 February 2018. An ambulance did not arrive at James Hince Court to collect Mr R and the surgery did not go ahead. The surgery was rescheduled and took place on 14 March 2018.
  2. Mr G complained about this. He said the transport went to Mr R’s home address, rather than James Hince Court. Mr G said neither the Trust have not taken adequate remedial action to address this issue. He said he has no reassurance that this would not happen again to other patients.
  3. The Trust acknowledged this mistake. It said its staff did not adequately communicate the need for transport to go to James Hince Court, rather than Mr R’s home address. It apologised for this error.
  4. The Trust reiterated this acknowledgment in correspondence with the Ombudsmen. It provided further explanation that when Mr R was discharged his temporary place of residence (James Hince Court) had not been put on the electronic patient administration system. It said, instead, it was written by hand on the discharge letter. The Trust said the ward clerk should have input the address onto the electronic system at this point.
  5. The Trust said in order to prevent this happening again it had rolled out an electronic bed management module linked to its electronic notes system. It said this would prompt the ward clark to check the discharge address.
  6. As a result of this mistake Mr R missed his scheduled surgery and needed to wait a further two weeks for it. On the balance of probabilities, the combined delay, caused by the miscommunication about clopidogrel and transport, is unlikely to have been clinically significant. However, this delay caused avoidable stress, above any Mr R may have ordinarily experienced in anticipation of an operation. This unnecessary stress in an injustice.
  7. The Trust has been open in acknowledging its error. It has apologised, identified why it happened and taken steps to prevent recurrences. I am satisfied it has provided a proportionate response to this complaint and have not recommended any further action.

Complaint that the Hospital inappropriately discharged Mr R on 15 March 2018

  1. Mr R came into hospital on 13 March 2018 and had surgery the next day. He left hospital and went back to James Hince Court on 15 March 2018. He then returned home with support from a home‑care service on 16 March 2018.
  2. Mr G complained his father was still very confused and should not have been discharged.
  3. In its initial response the Trust said its medical and nursing staff did not find any clinical reason for Mr R to remain in hospital. In a subsequent response the Trust noted Mr R had a raised temperature at one point after his operation. It said staff checked Mr R’s temperature only one more time after this raised result and before he left hospital. The Trust said nurses should have checked his temperature more than once. It said that if this had shown an abnormal temperature it would have been escalated and discussed. Aside from this, the Trust did not identify any shortcomings in its handling of Mr R’s care during this time.
  4. The Trust’s records show it checked and recorded Mr R’s physiological observations before surgery. The surgery went as planned and the surgeon noted a plan for Mr R to be discharged the next day.
  5. In the afternoon after the surgery staff noted that all of Mr R’s observations were within normal ranges, and his condition was stable. Staff recorded physiological observations at 15.05, 16.15, 17.00, 18.15, and 19.30. On each occasion they recorded that all of Mr R’s observations were within normal ranges. At 23.50 staff took his observations again and found he had a raised temperature. The next time they took his observations they were all within normal ranges. A discharge summary from 15 March 2018 noted that Mr R had made a good post-operative recovery and was fit for discharge.
  6. Experiencing a high temperature following an operation is fairly common. It would not, on its own, give clinicians significant cause for concern. There is evidence to show the clinicians acted appropriately in the context of the information available to them at the time. From a clinical perspective, there was nothing to indicate to the hospital that Mr R needed to remain in hospital. Therefore, I have not found fault here.

Events between 15 and 19 March 2018

  1. Records from the Council show that a carer visited Mr R on 17 March 2018 and noted he refused to get up and said he was tired. They also noted he seemed quite confused. The worker noted Mr R seemed a lot better by the time they left.
  2. On 19 March 2018 a carer found Mr R on the floor. He said he had been there for a while. The carer called an ambulance which took Mr R to hospital. The hospital found Mr R had symptoms of a urine infection and was confused.

Complaint that the Trust inappropriately found Mr R to be medically fit for discharge on 20 March

  1. Mr G said his father was still very confused and should not have been discharged. He said Mr R’s needs were such that he should have been kept in hospital rather than being discharged to St Michael’s View.
  2. Mr G said his father had to be rushed back to hospital after four days with sepsis and was in a critical condition. I have not seen evidence to support this. The records available to me show that Mr R left hospital on 20 March 2018 and moved into St Michael’s View. There are entries every day in the daily records from that date until 15 April 2018 when Mr R returned to hospital (26 days after he left hospital).
  3. In its response to the complaint the Trust said it found Mr R to be medically stable enough to leave hospital. It did not identify any flaws in this decision. The Trust said there were no clinical concerns about signs of an acute infection (that would require a hospital admission for intravenous antibiotics) or signs of sepsis.
  4. The Trust’s records show Mr R went into hospital, via the Emergency Department, on 19 March 2018. Staff noted he had had a fall the previous evening and could describe what had happened. A doctor physically examined Mr R and took physiological observations. They also took blood tests and completed an X-ray of Mr R’s shoulder and a CT scan of his head. The doctors found it was likely Mr R was suffering from a urinary tract infection, but did not find anything else that gave them concerns about his physical health. The hospital gave Mr R an intravenous infusion of fluids and also gave him things to eat and drink. It then discharged him on 20 March 2018 with a seven‑day course of oral antibiotics for a urine infection.
  5. The assessments the Trust completed were appropriate and suitably thorough. The results of their assessments and observations did not show anything to show that Mr R needed an inpatient admission in an acute hospital. Therefore, I have not found fault in the way the Trust made its decision that Mr R was medically stable enough to be discharged.

Complaint that Mr R did not have capacity to consent to paying for a Short Term Care placement at St Michael’s View, as he had delirium and confusion due to a urinary tract infection at the time

  1. Mr G does not accept that Mr R had the mental capacity to consent to paying for short term care. Further, Mr G believes Mr R’s needs were such that he should have received free NHS care rather than being transferred to a Short Term Care placement with associated costs.
  2. During the complaints process the Council concluded it acted appropriately and, as such, there was no cause to waive St Michael’s View’s fees. It said Mr R made an informed decision to go to St Michael’s View, in the knowledge that he would be asked to make a financial contribution toward the cost of his care.
  3. The Council’s records show a social worker saw Mr R on the ward on 20 March. They talked to him about the circumstances of his fall which Mr R recalled. In addition, the social worker noted they ‘Discussed future support plans. Feels that he is now medically stable to return home and wished for a period of short term care – aware of his financial status has over the threshold for financial support’.
  4. The social worker also recorded that they spoke to Mr R’s son and wrote in the notes ‘he agreed that a period of short term care would benefit his father – confirmed threshold of savings and would look towards requesting placement in [a particular] area’.
  5. The Mental Capacity Act 2005 (the Act) is the framework for acting and deciding for people who lack the mental capacity to make particular decisions for themselves. The Act (and the Code of Practice 2007) describes the steps a person should take when dealing with someone who may lack capacity to make decisions for themselves. It describes when to assess a person’s capacity to make a decision, how to do this, and how to make a decision on behalf of somebody who cannot do so themselves.
  6. There is an expectation that professionals should start by presuming the person has the mental capacity to make their own choices (Section 1(2) of the Act and Paragraphs 2.3 to 2.5 of the Code of Practice).
  7. In line with the Act, it was appropriate for the Council to talk to Mr R about his wishes, regardless of whether he was showing signs of confusion. Further, the Council’s records suggest the social worker had a coherent conversation with Mr R. Based on this there is no clear suggestion a capacity assessment was required.
  8. The records support the Council’s conclusion that Mr R made a choice to leave hospital and go into short term care placement. Further, there is evidence to show the financial implications of this were discussed. Therefore, I find no fault.

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Agreed actions

  1. Within one month of the date of the final decision both the Council and the Trust should write to Mr G and acknowledge they did not handle his complaint in line with the Complaint Regulations. They should acknowledge they each held a responsibility to explore the possibility of a joint investigation but dismissed this without full and proper consideration. The Council and Trust should also acknowledge this caused Mr G avoidable frustration and time and trouble, and they should apologise for their part in creating this injustice.
  2. Within one month of the date of the final decision the Trust should write to Mr G and acknowledge it did not properly record the information about why Mr R’s surgery was cancelled. It should also acknowledge that this fault has meant that there is a lack of clarity about why the surgery was cancelled and about where relevant information came from. The Trust should also apologise for the avoidable uncertainty and frustration this fault caused Mr G.
  3. Within two months of the date of the final decision both the Council and Trust should take steps to ensure its internal complaint procedures are in keeping with the Complaint Regulations, in particular regard to the duty to cooperate with other relevant organisations. In the same timescale they should also take proportionate steps to ensure its staff are aware of the relevant procedures and using them appropriately.
  4. Within two months of the date of the final decision the Trust should review its procedures for cases of elective surgery with pre‑surgery conditions. It should ensure that the procedures are adequate and that relevant staff are aware of them, and are using them. In particular, attention should be paid to ensuring:
  • the conditions, and any relevant dates, are properly and fully understood and recorded when they are set;
  • there is a clear understanding of who, how and when the Trust will check adherence to the conditions;
  • a proportionate amount of information is recorded to allow others to understand how and why any decisions to cancel or rearrange surgery have been made.

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Decision

  1. I have completed my investigation on the basis that there failings which led to an injustice. The Council and Trust have agreed to take action to address the injustice suffered.

Investigator’s decision on behalf of the Ombudsmen

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Investigator's decision on behalf of the Ombudsman

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