Summary: The Ombudsmen found fault by the Council and Trust with regards to the handling of an elderly woman’s discharge from hospital in October 2016. The Ombudsmen also found fault with these organisations’ handling of a complaint from the woman’s family. The Council and Trust have agreed to apologise for the distress caused and pay a financial remedy in recognition of this.

The complaint

1. The complainant, who I will call Mr F, is complaining about the care and treatment provided to his aunt, Mrs G, by London Borough of Croydon (the Council) and Croydon Health Services NHS Trust (the Trust) in October 2016. Specifically, Mr F complains that the Trust and Council discharged Mrs G without properly assessing her needs and failed to ensure she had appropriate care in place.

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The Ombudsmen’s role and powers

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)).
3. If the Ombudsmen find evidence of fault causing injustice, they may suggest a remedy. Recommendations might include asking the organisation to apologise or to pay a financial remedy, for example, for inconvenience or worry caused. We might also recommend the organisation takes action to stop the same mistakes happening again (Health Service Commissioners Act 1993, section 3(1) and Local Government Act 1974, sections 26(1) and 26A(1)).
4. 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

5. In making this final decision, I discussed the complaint with Mr F and considered the written materials he sent me. I made enquiries of the Council and Trust and considered their comments and supporting evidence, including the clinical records. In addition, I took account of relevant law, statutory guidance, and local policy.
6. I also considered comments on my draft decision from the Council, Trust and Mr F.

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What I found

7. Department of Health (DoH) guidance: Ready to go? Planning the discharge and the transfer of patients from hospital and intermediate care (March 2010) (the ‘Ready to go guidance’) is the core guidance around hospital discharge. It contains ten key steps for staff to follow during discharge planning, including:

• start planning for discharge or transfer before or on admission;
• identify whether the patient has simple or complex discharge and transfer planning needs and involve the patient and carer in your decision;
• involve patients and carers so that they can make informed decisions and choices that deliver a personalised care pathway and maximise their independence.

8. The DoH also publishes guidance entitled: Definitions – Medical Stability and ‘Safe to Transfer’ (2003). This provides guidance on when a patient can be safely considered to be ‘medically fit for discharge’. This lists three key criteria for making this decision and stresses professionals should address them at the same time, if possible. According to the protocol, a person is considered to be safe for discharge when:

• a clinical decision has been made that the patient is ready for transfer;
• a multidisciplinary team decision has been made that the patient is ready for transfer; and,
• the patient is safe to discharge/transfer.

9. A patient can be defined as clinically or medically stable if tests (such as blood tests and observations) are considered to be within the normal range for the patient. A patient is ‘fit for discharge’ when all relevant physiological, social, functional, and psychological factors have been taken into account. This can require a multidisciplinary assessment.

Mental Capacity Act

10. The Mental Capacity Act 2005 (the MCA) applies to people who may lack mental capacity to make certain decisions. Section 42 of the MCA provides for a Code of Practice (the Code) which sets out steps organisations should take when considering whether someone lacks mental capacity.
11. Both the MCA and the Code start by presuming individuals have capacity unless there is proof to the contrary. The Code says all practicable steps should be taken to support individuals to make their own decisions before concluding someone lacks capacity.

Key facts

12. Mrs G was admitted to hospital on 26 October 2016, having had a fall at home. A scan revealed that she had suffered a fracture to her right shoulder. The treating doctors felt Mrs G may also be suffering from a urinary tract infection (UTI).
13. The doctors carried out further investigations, including a scan of Mrs G’s head, blood tests and a full examination. These confirmed Mrs G had not injured her head during her fall. The blood tests revealed no significant infection, but doctors commenced Mrs G on a course of oral antibiotics.
14. Mrs G was subsequently assessed by the Emergency Department Liaison Team (EDLT - the team responsible for coordinating hospital discharges).
15. Mrs G was discharged home on 27 October with a care package including three daily care visits to assist her with personal care and meal preparation.
16. The following day, Mrs G suffered a further fall and was readmitted to hospital.
17. A social worker assessed Mrs G and found she would be suitable for reablement care. The assessment found Mrs G had a stairlift in her home. However, the assessor established this was not working and it was agreed a bed would be set up for her downstairs while the stairlift was being repaired.
18. Mrs G was discharged home again on 3 November with a package of care involving three daily care visits.

Analysis

Discharge

19. Mr F complained that the Trust and Council failed to properly assess Mrs G before discharging her home on 27 October. Mr F said that, although Mrs G had a stairlift, this was not working. Mr F said the family had raised concerns that Mrs G may be confused as a result of her fall and infection and would struggle to cope at home. Mr F said he gave a social worker his cousin’s contact number and asked her to call the family before discharging Mrs G. However, he said this did not happen.
20. Mr F said the Council and Trust should have completed a home circumstances check before discharging Mrs G. Mr F said that, had the Council and Trust completed a robust assessment as they did prior to Mrs G’s second discharge on 28 October, her second fall might have been prevented.
21. Furthermore, Mr F said the arranged carers failed to visit Mrs G on both the evening of 27 October and the morning of 28 October.
22. The Trust said clinicians assessed Mrs G in the Emergency Department (ED) when she was admitted on 26 October and determined she had fractured her shoulder but was clinically fit for discharge.
23. The Trust said an EDLT nurse assessed Mrs G on 27 October. The Trust said the nurse found Mrs G could be discharged home with a package of care and would also benefit from a key safe, care alarm and commode. The Trust said the nurse then referred Mrs G to a social worker for assessment.
24. The Trust said a social worker arranged for Mrs G to be discharged home with three daily care visits. It said a carer visited Mrs G at home at 4.15pm on 27 October but was unable to gain entry and failed to return later. The Trust also acknowledged a carer attempted to visit Mrs G on the morning of 28 October but went to the wrong address. The Trust apologised for this.
25. The Trust referred Mr F’s complaint that the social worker failed to contact the family prior to Mrs G’s discharge to the Council for a response.
26. The Council told Mr F that it first received a referral for Mrs G on 28 October (the day of her second admission to hospital) and that it was not involved in the discharge of 27 October.
27. As part of his complaint to the Ombudsmen, Mr F provided the first name of the social worker he spoke to on 27 October following Mrs G’s first admission. In its response to my enquiries, the Council reiterated that it was not involved in the first discharge and said there was no social worker with that name in the team at the time of Mrs G’s admission.
28. However, I note the Council’s records contain correspondence relating to a later admission in November 2016 from a social worker in its reablement team with that name. In my view, it is likely this is the social worker the family spoke to.
29. It is clear from the case records and correspondence, therefore, that there are significant discrepancies between the Trust’s records and those of the Council with regards to Mrs G’s admission on 26 and 27 October 2016.
30. The ‘Ready to go’ guidance emphasises the importance of effective multiagency discharge planning. This should include a holistic consideration of patient’s health and social care needs.
31. The clinical records suggest Mrs G was medically fit for discharge on 27 October. A Computed Tomography (CT) scan of her head revealed no abnormalities. Although Mrs G did have a urinary tract infection, clinicians determined this could be treated in the community with a course of oral antibiotics. On this basis, I accept there was no clinical reason for Mrs G to remain in hospital.
32. However, Mrs G also required an assessment of her social care needs to determine whether she could be safely discharged home.
33. The Trust’s records show an EDLT nurse assessed Mrs G following her admission on 27 October 2016. She recorded that Mrs G ”lives on her own in a house, no social care, has some help from family. [Mrs G] has a stair lift for access to bedroom, toilet and bathroom. [Mrs G] is usually mobile with a stick and says that she is very independent and wishes to remain so. [Mrs G] has agreed to a x3 daily [package of care] on discharge to assist with hygiene and food needs.” The nurse’s note contains an addendum confirming Mrs G had been seen by a social worker and was to be discharged with the proposed care package.
34. In my view, the evidence contained in the Trust’s records, as well as Mr F’s account of events, suggests a social worker did see Mrs G on 27 October. I consider it likely therefore, on balance of probabilities, that the social worker simply failed to record her assessment. This means it is impossible to determine what further consideration, if any, was given, to Mrs G’s social care needs. This is fault by the Council.
35. Furthermore, I found no evidence to suggest the Council or Trust assessed Mrs G’s capacity to consent to her discharge home.
36. Section 4.11 of the Code sets out that, in order for somebody to lack capacity to make a particular decision, they must have an “impairment of the mind or brain” that affects their ability to make that decision.
37. Section 4.12 of the Code provides examples of conditions that may cause such an impairment. These include dementia, physical conditions causing confusion or drowsiness and delirium. Mrs G’s clinical records show she had history of dementia. She had also sustained a recent blow to the head and was suffering from a urinary tract infection (a common symptom of which is confusion). In addition, Mrs G’s family had raised concerns about her mental function. This should have led the Trust or Council to complete a mental capacity assessment in keeping with the Mental Capacity Act. That they did not do so is fault.
38. As a result, neither the Trust nor Council discussed Mrs G’s discharge with her family. Had they done so, they would likely have determined that, although Mrs G had a stairlift, it was not working and required repair. This meant Mrs G, who had her right arm in a sling due to her shoulder injury, could not safely mobilise upstairs to her bedroom and bathroom.
39. In the circumstances, Mrs G should have been seen by the Trust’s therapy team to assess her mobility needs and consider her ability to cope to cope at home (as happened following her second admission on 28 October). There is no evidence of such an assessment in the clinical records. This is fault by the Trust.
40. It is not possible to say whether Mrs G’s subsequent fall would have been prevented even if the discharge had been in keeping with DoH guidance. Nevertheless, this represented a missed opportunity to explore whether Mrs G required additional support to assist her safe discharge home.
41. This situation was compounded by problems with Mrs G’s care visits following her discharge. The evidence suggests the carer who was due to visit Mrs G on the day of her discharge did so before she had arrived home from hospital. She did not return later in the day. Similarly, the carer who was due to visit Mrs G on the morning of 28 October went to the wrong address. This is fault.
42. The evidence provided by Mr F suggests Mrs G fell at around 6.30am on 28 October. The carer who was due to attend the property would not have arrived until later in the morning. On this basis, I am satisfied the carer would have been unable to prevent the fall even if she had attended as planned. However, I accept the failed care visits caused Mrs G and her family unnecessary distress and anxiety.

Complaint handling

43. The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 (the Regulations) places a duty on health and social care organisations to investigate complaints properly and in a way that will resolve them efficiently. There is also a duty to cooperate when a complaint is made to one organisation and contains material relevant to the other.
44. Section 9 of the Regulations states that, in these circumstances, the responsible bodies must co-operate 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.
45. It is evident from the complaints correspondence that Mr F raised concerns about both health and social services in his complaints. This should have led the Trust and Council to provide a coordinated response to Mr F’s complaint. That they did not do so is fault.
46. This caused Mr F unnecessary time and trouble.

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Agreed actions

47. Within one month of my final decision, the Council and Trust will write to Mr F and Mrs G with a coordinated response. Within this response, the Trust and Council will:

• Apologise for the distress caused to Mrs G by their failure to handle Mrs G’s discharge on 27 October 2016 in accordance with Department of Health guidelines. The Council and Trust will each pay Mrs G £200 in recognition of this.
• Apologise for the time and trouble Mr F was put to as a result of their failure to handle his complaint in accordance with the Regulations. The Council and Trust should each pay Mr F £50 in recognition of this.

48. Within one month of my final decision, the Council and Trust will also write to the Ombudsmen to explain what action they will take to:

• Ensure discharge procedures are robust and emphasise the importance of holistic multidisciplinary assessment prior to discharge for patients with complex needs in accordance with Department of Health guidance. The Trust and Council should also explain how they will monitor and audit these procedures on an ongoing basis.
• Ensure they have appropriate procedures in place for undertaking mental capacity assessments that reflect the requirements of the Mental Capacity Act 2005 and the accompanying Code of Practice.
• Ensure their complaints procedures reflect the Regulations, with specific regard to the duty to cooperate when handling complaints about services that are relevant to both organisations.

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Final decision

49. I found fault by the Council and Trust with regards to the handling of Mrs G’s discharge on 27 October 2016.
50. In my view, the actions the Trust and Council have now agreed to take represent a reasonable and proportionate remedy to the injustice arising to Mrs G and Mr F from this fault.
51. I have now completed my investigation on this basis.

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Investigator's decision on behalf of the Ombudsman