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Royal Free London NHS Foundation Trust (18 010 287a)

Category : Health > Hospital acute services

Decision : Upheld

Decision date : 25 Mar 2019

The Ombudsman's final decision:

Summary: Ms B complained about poor communication between the Council and two NHS Trusts which led to a delay in her father, Mr D, receiving community rehabilitation when he was discharged from hospital after he had a stroke. The Ombudsmen found poor communication and conflicting information between the Council and the two NHS Trusts led to a delay of two months before Mr D received community rehabilitation. This is likely to have had an adverse impact on Mr D’s wellbeing. The Council and the two NHS Trusts have agreed to the Ombudsmen’s recommendations to act to improve their procedures, apologise to the complainant and her father and make a payment to acknowledge the injustice caused.

The complaint

  1. The complainant, who I shall refer to as, Ms B, complains there was poor communication between East Sussex County Council (the Council), Royal Free London NHS Foundation Trust (RFL Trust) and East Sussex Healthcare NHS Trust (ESH Trust) about the arrangements for her father’s, Mr D’s, care when he was discharged from hospital. Ms B says RFL told her Mr D would receive six weeks of free care but this did not happen. Ms B says poor communication between the organisations led to a delay of over two months to assess her father and provide therapy at home which impacted on his wellbeing. The complainant would like the organisations named in the complaint to acknowledge fault, learn from the mistakes made and improve. She would also like financial redress to acknowledge the adverse impact on her father and the distress she experienced.

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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, 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)).
  3. If it has, they may suggest a remedy. Our 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.
  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

  1. I have considered information provided by the complainants and by the organisations complained about. I have considered a previous complaint to the LGSCO complaint reference: 17014075 and I considered the law and guidance relevant to this complaint. All parties have had an opportunity to respond to a draft of this decision.

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What I found

  1. The provisions on the discharge of hospital patients with care and support needs are contained in Schedule 3 to the Care Act 2014 and the Care and Support (Discharge of Hospital Patients) Regulations 2014. The NHS may seek reimbursement from local authorities for a delayed transfer of care in the circumstances set out in Schedule 3 to the Care Act and its regulations.
  2. Sections 9 and 10 of the Care Act 2014 require local authorities to carry out an assessment for any adult with an appearance of need for care and support. They must provide an assessment to all people regardless of their finances or whether the local authority thinks an individual has eligible needs. The assessment must be of the adult’s needs and how they impact on their wellbeing and the results they want to achieve. It must also involve the individual and where suitable their carer or any other person they might want involved.
  3. The eligibility threshold for adults with care and support needs and carers is set out in the Care and Support (Eligibility Criteria) Regulations 2014. The threshold is based on identifying how a person’s needs affect their ability to achieve relevant outcomes, and how this impacts on their wellbeing. For a person to have needs which are eligible for support, the following must apply:
  1. The needs must arise from or be related to a physical or mental impairment or illness.
  2. As a result of the needs, the adult must be unable to achieve two or more of the following outcomes:
    • managing and maintaining nutrition;
    • maintaining personal hygiene;
    • managing toilet needs;
    • being appropriately clothed;
    • being able to make use of their home safely;
    • maintaining a habitable home environment;
    • developing and maintaining family or other personal relationships;
    • accessing and engaging in work, training, education or volunteering;
    • making use of necessary facilities or services in the local community including public transport and recreational facilities or services; and
    • carrying out any caring responsibilities the adult has for a child.
  1. As a consequence of inability to achieve these outcomes, there is likely to be a significant impact on the adult’s wellbeing.
  1. Where councils have determined that a person has any eligible needs, they must meet those needs. When the eligibility determination has been made, councils must provide the person to whom the determination relates (the adult or carer) with a copy of their decision.
  2. Reablement is a community based short-term service offered by councils which offers intensive support in the person’s home. Reablement helps individuals regain skills, confidence and independence around their daily living skills, community access and integration. Reablement has a stronger focus on helping the person to regain skills and capabilities to reduce their needs. Where local authorities provide reablement to those who require it, this must be provided free of charge for a period of up to six weeks under section 2 of the Care Act 2014. Local authorities have the power to charge where these services are provided beyond six weeks. However, local authorities should consider continuing providing these services free of charge in view of the preventative benefits.
  3. The Health and Social Care Connect (HSCC) was set up in the Council’s area to bring together three separate services (health referrals, social care assessments and a public adult social care line). It offers a single point of contact of access for adult health and social care enquiries, assessments, services and referrals.
  4. The Joint Community Rehabilitation Service (JCRS) is a county wide service commissioned by several health authorities and the Council. The service is led by the Council and ESH Trust and is intended to promote faster recovery from illness and/or injury, prevent unnecessary acute hospital admission and premature admission to long-term residential care, support timely discharge from hospital and maximise independence. The service provides rehabilitation and reablement services which are time-limited from one to six weeks. Access to the service is via HSSC.
  5. ESH Trust has a Community Stroke Rehabilitation Team (CSRT) that provides advice, assessment and support to individuals over the age of 16 years. Individuals must have a confirmed diagnosis of a stroke or acquired brain injury. Referrals are received by email via HSCC.
  6. The National Institute for Health and Care Excellence (NICE) Clinical guideline [CG162] provides guidance on stroke rehabilitation in adults. This says “Local health and social care providers should have standard operating procedures to ensure the safe transfer and long-term care of people after stroke, including those in care homes. This should include timely exchange of information between different providers using local protocols… Provide information so that people after stroke are able to recognise the development of complications of stroke, including frequent falls, spasticity, shoulder pain and incontinence…”.
  7. The Ombudsmen will consider, in a complaint involving the NHS and the council, whether there are formal or informal arrangements between bodies and the nature of those arrangements. Where the NHS and council work together under partnership arrangements and the distinction between roles and responsibilities is unclear, the Ombudsmen will not spend disproportionate time deciding individual responsibility. In these situations, if the Ombudsmen find fault they will attribute it to the partnership and expect each body to contribute to any proposed remedies.

What happened

  1. Mr D is disabled and has a history of dementia. He had a severe stroke in early 2017 and went into hospital to receive treatment. While in hospital Mr D received therapy from an occupational therapist and physiotherapist.
  2. An occupational therapist working within RFL Trust referred Mr D via HSCC for community therapy/rehabilitation before he was discharged. The referral form said Mr D needed two-to-one support with daily living, transfers and personal care. The box referring to CSRT is marked for action as is the social care and carers assessment.
  3. The Council said the referral form was sent to the JCRS in error but this was quickly resolved and the form then sent to the CSRT. A Council officer spoke to the CSRT which said they could not assess Mr D while he was still in hospital. The CSRT later declined the referral and said Mr D did not meet the criteria for the service due to his ‘cognitive issues’ and because he had no rehabilitation potential.
  4. The Council arranged a homecare package which required Mr D to pay the cost of his care. Mr D was discharged from hospital in mid-March 2017 and went to live with his daughter, Ms B. Ms B said her discussions with the RFL Trust and a lack of financial information from the Council led her to believe her father would receive six weeks of free care (reablement).
  5. The Council completed an adult social review in April and noted “refer to MDT for stroke rehab/physio”. Near the end of April, the RFL Trust contacted HSCC about a referral for physiotherapy support for Mr D. The RFL Trust was chasing the physiotherapy input because Mr D had been home for six weeks but had not yet any community physiotherapy support.
  6. A Council officer went to visit Mr D again at the beginning of May. Mr D’s carers told the officer he had moved his hands and his feet. Ms B also told the officer she was concerned that her father had not received any community therapy. Ms B felt her father would have recovered better if community physiotherapy had been provided. The officer agreed to discuss Mr D’s case further with a senior officer.
  7. A few days later the Council officer discussed Mr D’s case at a meeting which included a representative from the JCRS. The Council officer said she was concerned Mr D had not received any support from the CSRT or the JCRS although he had been at home for six weeks following his discharge from hospital. The officer explained the CSRT had declined the referral. The representative from the JCRS advised the officer to contact HSCC to see if Mr D’s case could be passed to the JCRS.
  8. Following this contact Mr D received JCRS input in May which consisted of an assessment and provision of a stand aid hoist to safely practice standing, provision of a wheelchair and advice to Ms B and other carers about maintaining the range of movement in Mr D’s right arm.


  1. The issue of what financial information the Council shared with the complainant and Mr D has already been dealt with by the previous LGSCO investigation referred to in this decision statement. Therefore, I have not considered this issue as it relates to the Council. However, I have considered what the complainant says the RFL Trust told her about six weeks of free care.
  2. Ms B says the RFL Trust led her to believe Mr D would receive six weeks of free care. In response to Ms B’s complaint the RFL Trust said its staff is not involved in the financial arrangements for an adult social care package. It said an occupational therapist recalled speaking to Ms B to explain what reablement was and told her that it was free of charge for up to six weeks. However, it said the therapist did not tell Ms B her father would be entitled to this care.
  3. I have reviewed the medical records and nursing notes provided by RFL Trust. The notes do not record a discussion between Ms B and the occupational therapist about reablement or the associated costs. This is fault as discussions between nursing staff and patients/representatives should be recorded in the notes. As a result, I cannot know what was said at the time or what Ms B understood from the discussion she had with the occupational therapist. Without further evidence, I cannot reach a view on whether the occupational therapist told Ms B her father would receive free care. Therefore, I cannot consider this point further.
  4. The medical records show the occupational therapist recommended community rehabilitation for Mr D and this was confirmed by a referral to HSCC. The referral included background information about Mr D such as a copy of the medical discharge letter and reports from hospital based therapists. The referral form highlighted referral to the CSRT and ‘Early Supported Discharge’.
  5. The Council confirmed the referral form was initially sent in error to the JCRS team. The evidence available shows this error was promptly dealt with and the form then sent to the CSRT. This error is unlikely to have contributed significantly to any delay in Mr D receiving support in the community.
  6. The reports from the hospital’s occupational/physio therapists clearly state Mr D needed rehabilitation in his own familiar surroundings (at home) hence the referral. However, the medical discharge summary written by a doctor says, “has not shown much improvement in his deficits since admission and hence is not an appropriate candidate for rehab”. It is unclear whether rehab refers to hospital based rehabilitation or community rehabilitation. The unclear information from the RFL Trust is likely to have caused some confusion once the referral form was received by the CSRT.
  7. The ESH Trust said when deciding on whether to accept the referral it considered the information in the medical discharge summary as quoted. It also referred to the therapies report which said Mr D had cognitive and communication impairments and had not demonstrated any “carry-over of information”. The CSRT Team Lead reviewed the referral and declined it on the basis “the referral was involving equipment issues and [Mr D] had a diagnosis of longstanding vascular dementia which was his main ongoing condition.”
  8. The occupational therapist who made the referral was aware of Mr D’s needs and limitations at the time the referral was sent. In a covering email attached to the referral form the occupational therapist noted a care package and equipment would be in place prior to Mr D’s discharge. The therapist said, “will benefit from therapy follow up in his home environment where he may participate in functional activities more automatically”. The therapist asked for the referral to be considered as urgent. The ESH Trust has not provided evidence to show how it considered this specific information.
  9. The ESH Trust has not provided a standardised assessment or outcome of the referral form which records how it arrived at its decision not to accept the referral. This is not in line with good practice outlined in the NICE CG162 guidelines. There is also no evidence to show how the ESH Trust considered the other information and supporting documents which stated Mr D would benefit from therapy in his home environment. Therefore, I find the ESH Trust at fault. This fault is likely to have contributed to a delay in Mr D receiving community therapy at home. The delay is likely to have had an adverse impact on his wellbeing.
  10. Once the CSRT decided not to accept the referral there is evidence to show an officer left a telephone message with the HSCC to confirm the decision on the referral. A decision outlined on a standardised form or a rejection letter could have been sent to the HSCC and this would have formally notified the Council of the rejection decision.
  11. There is evidence to show the referring therapist from the RFL Trust followed up on the referral and did not understand why it was declined by the CSRT. There is no evidence to show the referral process included steps whereby the referrer would receive formal notification of the decision. This area should be improved.
  12. When the Council spoke to Ms B in February about finances it agreed to tell her what the CSRT’s plan was. I have not seen evidence the Council told Ms B the decision made by the CSRT when it knew the referral was declined. This is fault and is likely to have caused Ms B avoidable uncertainty and frustration.
  13. A Council officer reviewed Mr D’s care needs following a home visit in April 2017. The officer noted he had been without stroke rehabilitation for several weeks. Once the officer discussed the case further Mr D’s case was escalated for further discussion at the beginning of May. Following this discussion Mr D then received community therapy from the JCRS.
  14. The therapy provided by the JCRS between May and July 2017 consisted of providing some equipment and advice to carers. There was a delay of about two months from the date Mr D was discharged to the date he was initially seen by the JCRS. This was an urgent referral and a delay of two months is fault. The Council and the ESH Trust are responsible for the delay. This is likely to have had an adverse impact on Mr D’s wellbeing as he would have benefitted from receiving therapy sooner. Ms B would have also experienced avoidable frustration and time and trouble pursuing a complaint.

Further considerations

  1. The ESH Trust said the CSRT does not offer an urgent response time with 4 to 8 hours. It says where the HSCC requests an urgent response it will discuss whether another service such as the crisis team need to respond.
  2. The CSRT has improved the referral process as if it declines a referral it sends an email to HSCC and HSCC should email the referrer.

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Agreed recommendations

  1. Within six weeks of the final decision the Ombudsmen recommend:
    • the RFL Trust reiterate to its staff the importance of recording discussions with patients and/or their representatives in nursing notes. It should also highlight the importance of providing consistent and clear information in discharge summaries and hospital based therapy reports which are attached to referrals for community therapy;
    • the Council and the ESH Trust review the improvements made to the referral process for the CSRT, JCR reablement team and HSCC to ensure the outcome decision of a referral is properly recorded and the referring officer/organisation is formally notified when necessary;
    • the Council and the ESH Trust write a joint letter of apology to
      Mr D and Ms B to apologise for the adverse impact the delay of two months had on Mr D’s wellbeing and the avoidable frustration caused to Ms B; and
    • the Council and ESH Trust jointly pay £250 to Ms B to acknowledge the impact the faults had on her and her father and for her time and trouble in pursuing the complaint.

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Final decision

  1. I uphold Ms B’s complaint and I have completed the investigation because the authorities have agreed to the Ombudsmen’s recommendations.

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Investigator's decision on behalf of the Ombudsman

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