The Ombudsman's final decision:
Summary: The Ombudsmen find fault by the Trust, in that it sent Mr M’s follow-up appointment letters to the wrong address and as a result he was discharged from follow-up care. This meant Mr M did not have the opportunity to discuss his care with a specialist. However the Ombudsmen find it was reasonable of the Trust and Council not to refer Mr M for continuing healthcare, and that he was provided with stroke rehabilitation in line with the relevant standards and guidance.
- Mr M complains about how he was treated in hospital following a major stroke in July 2016, his discharge from hospital and the follow-up support provided. In particular he says:
- He was not treated effectively for the stroke in hospital.
- He was wrongly discharged to a residential home without the Trust making the Council aware of the extent of his problems.
- His daughter was not involved in the decision to discharge him to the residential home, and was wrongly informed he had agreed to it, when he did not have the capacity to understand or make that decision.
- He was not assessed for continuing healthcare at the time of discharge.
- After his discharge, appointment letters for the stroke clinic were sent to the wrong address and he was discharged from follow-up care.
- Mr M says these failings have had a detrimental effect on his recovery and an ongoing impact on him.
The Ombudsmen’s role and powers
- 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)
- 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)).
- 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.
- 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)
- The Ombudsmen cannot investigate late complaints unless they decide there are good reasons. Late complaints are when someone takes more than 12 months to complain to the Ombudsmen about something an organisation has done. (Local Government Act 1974, sections 26B and 34D, as amended, and Health Service Commissioners Act 1993, section 9(4).)
- In Mr M’s case, I decided to consider his complaint now because the cognitive issues resulting from his stroke prevented him from complaining sooner.
How I considered this complaint
- During my investigation, I have considered information provided to us by Mr M. I wrote to the Council and Trust, to tell them what I intended to investigate, and request copies of relevant records. I considered the comments and documents they sent. I also took account of the law and guidance relevant to this complaint.
- I also took advice from two of the Ombudsmen’s clinical advisers: a stroke physician and a nurse.
- I also considered comments from Mr M, the Council and the Trust on a draft version of this decision.
What I found
Applicable legislation and guidance
- Paragraphs 71 to 72 of the General Medical Council’s ‘Good Medical Practice’ (2013) relate to the issue of mental capacity. It says doctors must take account of the MCA and the Code. Point 16 of the Nursing and Midwifery Council’s The Code: Standards of conduct, performance and ethics for nurses and midwives (2008) is also relevant. This says that nurses must be aware of the legislation about mental capacity.
- Department of Health 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.
- The term ‘rehabilitation’ is sometimes used to describe a particular type of service designed to help a person regain or re-learn some capabilities where these capabilities have been lost due to illness or disease. Rehabilitation services can include provisions that help people attain independence and remain or return to their home and participate in their community, for example independent living skills and mobility training for people with visual impairment.
Background and chronology
- In July 2016, Mr M had a stroke and was admitted to hospital for initial treatment (not part of this complaint). On 29 July, he was transferred to the Trust’s Stroke Unit for treatment and rehabilitation. During this time, he experienced cognitive issues and fluctuating capacity.
- A multi-disciplinary team (MDT) made up of health and social care practitioners decided he would benefit from a period in residential care. This aimed to see if his condition would improve so that he could return home. The Trust said Mr M had no nursing needs, but required support with daily living and safety, because of cognitive and mobility issues resulting from the stroke.
- Mr M was assessed and found not to meet the threshold for continuing healthcare referral. He was referred to adult social care for assessment for a residential care home placement, and was discharged there in August 2016. Mr M’s income was above the threshold and so the placement was self-funded. He stayed in the residential home until February 2017, after which he received some reablement care and was able to return home.
- Mr M said that while he was in the care home, he was “absolutely out of contact with the world” because of the cognitive issues caused by the stroke. He said that gradually, things started to come back to him, but he continues to feel the effects cognitively even now. He said he feels all the arrangements for discharge were made behind his back and he was simply left in the Care Home.
- Mr M said it was not until he left the Care Home that he became aware all of his income had been taken up by the Care Home fees. He said he had to use his savings to pay his day to day expenses. All of this has had a significant effect on his finances.
Treatment and care of stroke in hospital
- I found that the Trust’s care and treatment of Mr M’s stroke was in line with the relevant standards. In Mr M’s case, the relevant guidance is the National Institute for Health and Care Excellence (NICE) clinical guideline 162, Stroke Rehabilitation in Adults.
- As noted above, Mr M was assessed by the MDT, which included a physiotherapist, occupational therapist, and speech and language therapist. The frequency of these assessments was in line with the NICE guidance. This says therapy should be offered five days per week for 45 minutes, depending on what the patient is able to tolerate. Although the records do not state the length of the therapy sessions, they show that sessions were offered five days per week.
- Assessments should gather information on a person’s needs and circumstances, and make sense of that information in order to identify what the person will need. The MDT should agree what advice, support or treatment to provide, in line with the Department of Health guidance Ready To Go, referred to above. Assessments should also come to decisions on the process and timing of discharge from hospital.
- A swallow assessment was done by the speech and language therapist on 8 August. This showed that Mr M had no difficulty swallowing and so the plan on discharge was for a normal diet and fluids.
- Physiotherapy and occupational therapy assessments were undertaken both jointly and separately, with the occupational therapy team reviewing Mr M daily. They looked at neurological and cognitive perception, with muscle strength and sitting balance reviewed by the physio. The physiotherapist also assessed mobility. During his admission, this progressed to Mr M being able to walk using a walking stick and with supervision by one person.
Decision not to refer for continuing healthcare assessment
- Department of Health guidance: Definitions – Medical Stability and ‘Safe to Transfer’ (2003) (the ‘Safe to transfer guidance’) gives 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.
- 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. As in Mr M's case, this can require a multidisciplinary assessment.
- Mr M felt that he was discharged too early from hospital. However in its response to Mr M’s complaint, the Trust said he was medically fit for discharge at the time. This is a reasonable response which is based on the information in the clinical records. The notes do not indicate that he was medically unwell. There were no specific medical interventions on the ward. The clinical notes suggest his needs were identified as a degree of physical disability, including risk of falls, and significant issues with cognitive function. This would be expected from the stroke he experienced, and would be considered social rather than health needs.
- As part of planning Mr M’s discharge, the Trust carried out a Discharge Referral Guide screening. This was to identify what level of need Mr M had at that time, and looked at 11 different categories including medication, skin integrity, behaviour and medication. The Guide says that “eligibility for NHS continuing care [funding] should be considered before a patient is referred to social services” if a patient scores five or more in this assessment. Mr M scored two points on the assessment, for cognition and mobility, as assessed on the ward. As Mr M scored less than five, he was referred to the Council’s adult social care team to be assessed for a respite placement.
- The Trust’s response that no CHC assessment was done because no health needs were identified is reasonable and based on the information in the clinical records. The information recorded in the Discharge Referral Guide reflects the assessments done on the ward.
- Mr M also said that he felt the Trust gave incorrect information about his condition to the Care Home. He said his needs were more extensive than the Trust had indicated. While I recognise this is Mr M’s recollection, the clinical records show that although Mr M needed support, this was for social care and he did not have any health needs at the time.
Decision to discharge to Care Home
- Mr M’s view is that the decision to discharge him from hospital was made by the Trust, and therefore that the NHS should pay for the care he received. However, the records show the decision to discharge Mr M to a care home was made jointly by the Trust and the Council’s adult social care team, with the social worker liaising with the therapists on the hospital team.
- While Mr M was in hospital, the occupational therapist assessed his social situation. This included obtaining information from his daughter regarding his usual activities. It was established that prior to admission to hospital he lived at home where he was independent and self-caring. Functional assessments were also undertaken by the occupational therapist. As a result of both this and the physio assessments, treatment plans and goals were identified.
- It is evident from entries in the clinical records, that there were on-going concerns that while he was in hospital, Mr M had some cognitive impairment with evidence of night time wandering. The assessments also found Mr M to be confused, and that he had problems with memory, problem-solving, poor awareness of his surroundings and needed constant supervision on the ward. All of the assessments reached a consensus that Mr M did not have capacity to make decisions about arrangements following his discharge from hospital.
- As a result of this, a Best Interests meeting was held. A key principle of the Mental Capacity Act 2005 is that any act done for, or any decision made on behalf of a person who lacks capacity must be done, or made, in that person’s best interests. Section 4 of the Act provides a checklist of steps that decision-makers must follow to determine what is in a person’s best interests. My current view is that the Trust and Council complied with these steps. Mr M’s records include detailed notes of a thorough Best Interests meeting, which included a telephone conversation with Mr M’s daughter. As Mr M did not have capacity to deal with his finances at the time, his daughter was dealing with this on his behalf, so it was in line with the guidance for her to be consulted.
- The notes of the Best Interests meeting show that all available discharge options were considered for Mr M in detail: to go home with a care package, a period of respite care at the same home where his wife was resident, a different care home, or discharge with no services. Based on the evidence I have seen so far, both Trust and Council staff took reasonable steps to help Mr M understand the decision. The records show that the stroke doctor and therapists spoke to Mr M about discharge planning “several times… to give him the opportunity to understand”. A written diary/ communication book that had been established by a friend was also used to write down the options for Mr M to read. While I accept that Mr M feels the Trust and Council made a decision without him, it seems that they followed the correct process in planning his discharge from hospital given that he did not have capacity to make the decision himself.
- Mr M said the Trust told his daughter that he had agreed to go into the Care Home, but that this was not the case. I recognise this is Mr M’s understanding, but I have not seen any record that his daughter was told this. As noted above, the assessments that took place recorded that he did not have the capacity to agree to this decision at the time, and that his preference was to return to his own home. The records show that the Trust explained to Mr M’s daughter that he had expressed a preference to return to his own home. The risks of this were outlined to her as Mr M had said he wanted to drive to see his wife, which he would not be able to do, and there was the risk of him trying to resume living as he had been before the stroke, when he was not able to do things such as make meals and hot drinks.
- The note of the telephone call also shows that Mr M's daughter was told of the occupational therapist’s assessment that Mr M would benefit from respite care in a residential setting, and agreed that the Care Home where his wife lived would be preferable. It was also noted that Mr M thought well of the home and that his wife had received good care there.
- The Council told us that it did not carry out a financial assessment because Mr M’s daughter told them he had “over the financial threshold at that time” (the financial threshold is £23,250 in capital).
- It is recorded that a discussion with Mr M’s daughter took place, and it was explained to her that Mr M would stay in the Care Home for a short period, depending on how his recovery progressed. The social worker documented that her aim was to “help [Mr M] and his family arrange a period of self-funding respite”. However, even though the social worker was involved with this aspect, it seems to have been a private arrangement, with Mr M’s daughter paying the bills directly to the Care Home. Because of this there was no responsibility on the Council to set out to Mr M and his family what the longer-term costs might be.
Lack of follow-up care after leaving hospital
- Mr M said that being discharged to the Care Home meant he got no further treatment from the Trust. A plan for occupational therapy and physiotherapy was provided to the Care Home for Mr M to follow while he was there. It is also noted that the community stroke team were to be involved by reviewing Mr M every fortnight, but it is not clear if this happened.
- Mr M was also due to have an initial follow-up clinic appointment with the stroke consultant, six to eight weeks after he was discharged. However, the Trust sent the appointment letter to his home address so he did not receive it. The Trust then sent further appointment letters for 9 November 2016 and 11 January 2017, none of which reached Mr M. As he did not receive the letters, he was unable to respond or attend the appointments, and as a result he was discharged from follow-up care.
- The Academy of Medical Royal Colleges published guidance for doctors when writing to patients (September 2018). This states that among other things, clinical letters should communicate any management plans to the patient and their GP. In other words, it is expected that letters such as the one discharging Mr M from follow up care, should have been sent to him and his GP. Within this broad guideline, it is good practice to inform the GP when a patient has not attended an outpatient appointment. However the Trust has not indicated whether it informed Mr M’s GP or not.
- My current view is that there is fault here by the Trust. It has accepted the letters were sent to the wrong address. However, it is not possible to say whether there was a negative impact on Mr M’s rehabilitation as a result of the follow-up appointments not taking place. This is because at the time of discharge, the MDT had already concluded that Mr M’s would not have benefitted from much further therapy.
- Follow-up care after a stroke would typically include discussing the patient’s progress, medication review, discussing any possible investigations needed, looking at expectations for recovery and what the future might hold, review of the long and short term impact of the stroke and general prognosis.
- The key thing Mr M is likely to have missed as a result of not attending the outpatient appointments is the opportunity to discuss his care with a specialist. Our physician adviser commented that after a stroke, things can be a bit of a blur for patients. They may not be their “usual selves”, and even though family or friends may have discussed things with them, during recovery patients may want to hear from a doctor about what happened to them. In other words, as well as the long-term management of the cause of the stroke itself, there is also a psychological benefit from explanations from a specialist.
- I found that as a result of the Trust incorrectly addressing the appointment letters, Mr M missed the opportunity to engage in a follow-up process that may have benefited him. In the information provided, I have not seen any apology from the Trust for this, or any acknowledgement of the impact this may have had on Mr M.
- I understand that Mr M felt the decision to discharge him to the Care Home was made behind his back and that CHC should have been applied. However, based on the information I have seen, the Trust and Council followed the correct process by making efforts to communicate with him about this while he was in hospital. They involved his daughter who was dealing with his finances, and held a detailed Best Interests meeting which fully explored a range of options for Mr M on discharge.
- However, I have not seen any indication that the Trust has acknowledged the impact of wrongly addressing the follow up appointment letters, meaning Mr M was unable to attend clinic appointments. I have made recommendations to address this point, below.
- Within four weeks of this final decision, the Trust should contact Mr M to apologise for not sending his follow-up appointment letters to the correct address, and to acknowledge and apologise for the impact of this on him.
- Within eight weeks, the Trust should set out how it will prevent recurrence of this fault in future.
- The Trust will send the Ombudsmen evidence that they have completed these actions, and will provide Mr M with a copy of the steps it will take to prevent recurrence.
- I find the Trust was at fault in that it did not send Mr M’s follow-up appointment letters to the correct address, which meant he missed out on some follow-up care. I have recommended that the Trust take steps to remedy this.
- I consider that the actions the Trust has agreed to take will satisfactorily remedy the injustice I found. Therefore, I have completed my investigation
Investigator’s final decision on behalf of the Ombudsmen
Investigator's decision on behalf of the Ombudsman