The Ombudsman's final decision:
Summary: Mrs A has complained about a delay in discharge of her grandmother, Mrs B, from hospital in October 2018. The Ombudsmen found fault with Walsall Trust which caused an undue delay in discharge. We did not find fault with the Council.
- Mrs A has complained about a proposed discharge of her grandmother, Mrs B, from hospital in September and October 2018. Mrs A said following her grandmother’s admission to hospital in September 2018, despite being fit for discharge, delays by Staffordshire Council (the Council) and the Walsall Healthcare NHS Trust (Walsall Trust) meant that by the time a discharge to a nursing home placement was organised, her grandmother had contracted pneumonia and sadly died shortly afterwards in hospital.
- Mrs A feels her grandmother’s death could have been avoided if not for the delays by the Council and Walsall Trust. She also said this was an extremely stressful time trying to organise her grandmother’s discharge as Mrs A’s father was also seriously ill.
- As an outcome of this complaint Mrs A would like the Council and Walsall Trust to acknowledge their mistakes and put in place service improvements to prevent this happening to other people. She would also like to know if her grandmother’s death was avoidable.
The Ombudsmen’s role and powers
- 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. 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)
How I considered this complaint
- During the course of my investigation I have considered evidence from Mrs A, the Council and Walsall Trust as well as taking into account any relevant legal and national guidance. I invited Mrs A, the Walsall Trust and the Council to comment on my draft decision. Mrs A made one comment and I considered this before issuing my final decision.
What I found
- Mrs B was 94 and had been living in sheltered accommodation with a package of care from an agency (the Agency) which came in to provide care several times a day. She suffered from Chronic Obstructive Pulmonary Disease (COPD), hypertension and had mobility issues.
- On 14 September 2018 paramedics attended Mrs B’s home as there were concerns she had been passing stools containing blood. She was admitted to Walsall Manor Hospital to be assessed. Mrs B was assessed as medically fit for discharge, however it was now a Friday and the Agency said it could not put in place a new package of care until the Monday, 17 September.
- On 17 September the Agency said it could not take Mrs B back into its care, so the option of a discharge to a nursing home became the priority. Mrs A said she had been in touch with one in particular (the Home) to see if it had capacity.
- On 17 September a social worker from the Council came to Mrs B’s home to assess her. However, Mrs B was in hospital so the social worker spoke to Mrs A. The social worker told Mrs A that her grandmother would need a hospital social care assessment. She then rang the hospital to let them know not to discharge Mrs B until a care package was in place.
- Walsall Trust in its complaint response said after the Agency withdrew care, its Discharge Co-Ordinator decided on 18 September that Mrs B would need a Section 2 assessment notification to the Council and a Continuing Healthcare (CHC) checklist needed to be carried out.
- The Community Care (Delayed Discharges) Act 2003 places duties upon the NHS and councils to communicate about the discharge of inpatients. This is done through “Section 2” and “Section 5” notifications. The Section 2 notification is from the NHS to inform a council a patient needs to be assessed. The Section 5 notification is for the NHS to inform a council of a patient’s proposed discharge date so that the appropriate plans can be put in place.
- CHC funding is for patients who are assessed as having a primary health need. If they are found to be eligible then the NHS can fund the patient’s health and social care. An initial CHC checklist is carried out on patients to see if they require a full assessment.
- Walsall Trust said the Section 2 notification was commenced on 19 September and a request was put to the ward to carry out a CHC checklist. The information on the Section 2 notification form is intended to be minimal. According to the Care Act Statutory Guidance, Annex G, it consists of details of the patient and whether CHC eligibility has been considered. On 20 September the Section 2 was fully completed but Walsall Trust was still waiting for the CHC checklist.
- On 21 September the checklist was completed, and the paperwork was sent to the Intermediate Care Services (ICS). The Walsall Trust’s website describes the ICS as this:
“The Intermediate Care Service is a multi-disciplinary team operated jointly between Walsall Healthcare NHS Trust and Walsall Adult Social Care.
It provides intensive help to patients and their relatives, or carer if they have one, for a short period of time so that they can leave hospital as soon as their health has improved sufficiently.
The team offers support to help the patient regain independence. This could be at home, or in a short-stay care home bed, in the best way to meet their needs”
- Walsall Trust said 21 September was a Friday and the ICS was then closed over the weekend. This meant that the paperwork was not dealt with until Monday, 24 September, when the ICS emailed the Section 2 notification to the Midlands Partnership NHS Foundation Trust (the Midlands Trust). The Council commissions Midlands Trust to carry out hospital social care assessments. The social worker then sends the request to the Council’s Brokerage Service which makes decisions on funding for placements.
- A social worker was allocated the case on 26 September and visited Mrs B on the ward the next day when she carried out a social care assessment. The social worker spoke to Mrs A who said her grandmother would like to be discharged to the Home. The social worker explained this may involve a third party top up and she would need to send the request to the Brokerage Service. A third party top up is a fee to cover the difference in the nursing home fees between what is funded by the Council and what is paid for by the resident’s friend or relative.
- On 28 September the social worker was informed there was a place at the Home. She priced up the placement and continued working on her request to the Brokerage Service.
- The social worker sent the request to the Brokerage Service on 1 October. Unfortunately, on the same day, Mrs B began to deteriorate. She sadly died on 3 October with the cause of death being hospital acquired pneumonia.
- Walsall Trust in its complaint response acknowledged the distress the process caused, particularly in light of the available bed at the Home. However, it said it had duty of care to ensure that assessments are carried out appropriately and accurately to ensure that individuals care needs are best met upon discharge, making the steps outlined necessary.
- Walsall Trust told the Ombudsmen it followed Care Act Statutory Guidance (Annex G) with the only delays being the initial delay when it was given the impression by the Agency it would continue to care for Mrs B at home, and the delay of the weekend while ICS was closed. It also said that the only requirement according to Annex G regarding timescales is as soon as possible, but the documents required assessment and gathering of information to complete and ensure accuracy.
- The Council said the social worker carried out their assessment within 48 hours and it was never actually given a Section 5 by Walsall Trust letting it know when Mrs B’s proposed discharge would be. However, in any event, it had to wait for the Brokerage Service before allowing Mrs B to be discharged to the Home.
- Taking the first possible delay into account, from 14 to 17 September, this was caused by the Agency at first stating it could support Mrs B and then deciding on 17 September it could not. This delay was not a fault on the part of either Walsall Trust or the Council.
- The next possible delay was from 17 September when the Agency told Walsall Trust it would not be taking Mrs B back with a care package at home, to 24 September when the Section 2 notification was actually sent to Midlands Trust.
- Walsall Trust involved the Discharge Co-ordinator on 18 September. Then from 19 to 21 September the Section 2 notification was being done alongside the CHC checklist. The Section 2 notification form is very brief and would not take more than a day to complete. It was completed on 20 September.
- The Care Act Guidance Annex G states the NHS should give the local authority as much notice as possible to carry out an assessment.
- In addition the Section 2 notice should state whether or not a patient is likely to need CHC and the NHS must have carried out a CHC assessment and decided what services, if any, it must provide. It must inform the Council of these.
- Taking this into account Walsall Trust was right to await the CHC checklist result before sending the notification and checklist result to the Council. However, the checklist took from 19 to 21 September to complete and held up the process.
- The National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care states:
“Completion of the Checklist is intended to be relatively quick and straightforward. It is not necessary to provide detailed evidence along with the completed Checklist (Paragraph 86)”
“Where an individual is ready to be safely discharged from acute hospital it is very
important that this should happen without delay. Therefore the assessment
process for NHS Continuing Healthcare should not be allowed to delay hospital
discharge. (Paragraph 111)”
- This checklist was carried out on the ward and should have been done as soon as possible so as not to slow down the process. Walsall Trust has not explained why the checklist took two days to complete. The checklist is designed to be simple and there is no clear reason why it took two days. Generally we would expect it to be completed within a day and therefore this is a fault on the part of Walsall Trust.
- There was then the delay of 21 to 24 September when the ICS office was shut for the weekend. However, if the checklist had been completed even a day sooner then this would not have been an issue. I will deal with the impact of this delay later in this statement.
- The next possible delay is from 24 September when the Council received the notification of assessment to 1 October when the social worker sent the request to its Brokerage Service to be agreed.
- Annex G states that the minimum period for the local authority to carry out the assessment is two days after receiving the assessment notice.
- The Council carried out the assessment within 48 hours of receiving the request which was acceptable and within guidelines. The social worker then took from 27 September to 1 October to send the request to the Brokerage Service. An assessment should be carried out over an appropriate and reasonable timescale taking into account the urgency of needs (Care Act Statutory Guidance Appendix 2 (6.29)). I do not find this was an excessive amount of time for her to complete her written assessment of Mrs B, price up the placement and write her request to the Brokerage Service. Therefore, I have not found fault on the part of the Council.
- Regarding the impact of the delay, going from the timescale it took the social worker to assess Mrs B and send the request to the Brokerage Service, the earliest it could have been sent to the Brokerage Service was 28 September.
- The Council has said the target timescale for dealing with a brokerage request is 48 hours. Therefore, the earlier date for discharge would have been 30 September, just one day before Mrs B’s deterioration.
- It is impossible to say how long the symptoms take to develop after contracting pneumonia. In addition, research has shown that when a patient goes into hospital their oral bacteria can change to the more resistant or virulent bacteria present in the patients in the hospital. This makes a patient more susceptible to infections such as pneumonia as the bacteria in their mouths is more likely to cause infection, and more resistant to antibiotics. Therefore, even after her first week in hospital Mrs B was more at risk of developing pneumonia bacteria.
- The longer a patient stays in hospital the more their risk of infection increases. However, on the balance of probabilities we cannot say whether the earlier discharge would have prevented Mrs B from developing pneumonia. This is because there are many factors involved with the risk of developing pneumonia, and she was vulnerable to this illness as she was an elderly patient suffering from COPD. The risk was higher in hospital but was a constant risk even if she had been moved to the nursing home earlier. However, the delay does leave Mrs A with uncertainty about whether her grandmother could have avoided developing pneumonia.
- Due to the impact of the fault on Mrs A I recommend Walsall Trust:
- By 2 April 2020 write to Mrs A apologising for the uncertainty caused by the delay in her grandmother’s discharge
- And by 2 June 2020 carry out action to reduce the waiting times for CHC checklists to be carried out on the ward. Evidence of this action should be shared with Mrs A and the Ombudsmen.
- I have found fault by Walsall Trust that led to a delay in Mrs B’s discharge and uncertainty about her death. However, I do not find fault with the Council.
Investigator's decision on behalf of the Ombudsman