The Ombudsman's final decision:
Summary: Ms A complains that her mother, Mrs B, was unsafely discharged from hospital before she was ready, and without the right care in place at home. The Ombudsmen find no fault in the decision that Mrs B was ready for discharge from hospital. However, the Council has accepted there was fault in its arrangements for Mrs B’s care once she returned home and it has provided an appropriate remedy.
- Ms A complains that in February 2018 her mother, Mrs B, was unsafely discharged from hospital before she was ready, as she was not mobile and lived alone. She further complains that a package of care arranged by the Council was not in place as it should have been once her mother arrived home.
- Ms A said these failings had a detrimental effect on Mrs B’s recovery and an ongoing impact on her dignity and confidence. Ms B says she herself was distressed by the way her mother was discharged, and by having to provide personal care to her once she returned home.
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), as amended).
- 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
- In reaching this decision, I discussed the complaint with Ms A, and considered the written information she sent me. I made enquiries of the Trust and Council, and considered their comments and information including clinical and social care records. I also took nursing advice from one of our independent clinical advisers, and took account of relevant legislation and guidance.
- Miss A, the Trust and Council all had an opportunity to comment on a draft version of this decision.
What I found
Relevant legislation and guidance
- 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 for 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.
- Mrs B was admitted to a hospital managed by the Trust in January 2018 with symptoms of confusion. She was treated for low sodium levels and a chest infection. Mrs B was then transferred to a rehabilitation ward, where she remained for two weeks before being discharged home.
- Mrs B already had identified care needs before her admission to hospital. She had been living at home with a package of care, with care workers attending twice a day to help prepare meals and assist with personal care.
- A needs assessment was completed once Mrs B was ready to be discharged from hospital. The assessment states that Mrs B’s mobility had worsened and her care needs had increased. It was documented that she would benefit from an increased care package once she returned home.
- Mrs B was discharged on a Friday afternoon. In line with the new care package, a care worker was due to attend her home that evening, but this did not happen. Ms A followed this up and the new care package began over the weekend. In the meantime, Ms A provided the care Mrs B needed.
- Ms A complained to the Trust and the Council. She said Mrs B was discharged home before she was ready and the care she needed was not in place. Ms A was dissatisfied with the responses from the Trust and Council, and complained to the Ombudsmen.
- When a patient already has care needs prior to being admitted to hospital, discharge planning should involve a multi-disciplinary team (MDT). This is to ensure that discharge is safe and that the patient’s needs will be met once discharged. In Mrs B’s case, the multi-disciplinary team providing her care and carrying out discharge planning on the rehabilitation unit involved nursing, social work, occupational therapy and physiotherapy.
- Occupational therapists’ role is to ensure that any equipment that the patient needs within their home to support independence is delivered prior to discharge. Physiotherapists assess the patient’s physical mobility and work with the patient to help return them to their pre-admission mobility status.
- Social workers can either start a package of care to enable the patient to continue living at home; or re-instate a package of care that the patient may already have in place. Care may also be reduced or increased depending on the assessed needs of the patient. Nurses involved in the day to day care of the patient on the ward are crucial in assessing the patient on a regular basis and reporting back to the appropriate discipline, in Mrs B’s case, physiotherapy and occupational therapy.
- In order to plan the support Mrs B would need on discharge from hospital, a needs assessment was completed by the hospital social work team. This was based on information gathered from discussions with Mrs B and Ms A, and information from physiotherapy and occupational therapy.
- Rehabilitation aims had been set for Mrs B on her transfer to the rehabilitation ward. The Trust response refers to a meeting between Mrs B’s family and staff involved in her care, when the family was advised that although the Trust would try to rehabilitate Mrs B to as near her pre‑admission status as possible, “there was a possibility that she had reached a new baseline”. Notes of the meeting support this response, saying that “this may not be the same level as pre‑admission.” The needs assessment outlined Mrs B’s pre‑admission status, her home environment, the package of care that had already been in place, and the interventions and equipment that would be needed to discharge her back home.
- The clinical records and needs assessments state that prior to admission, Mrs B had a twice daily package of care, and Ms A attended in the evening to make her an evening meal and ensure that she was comfortable in bed. However, it was documented that Ms A was no longer able to carry out the evening visits on discharge due to her own work commitments. Mrs B lived in a two-storey house but the physiotherapy notes say she was set up for downstairs living. There was a step up into her property and there were grab rails in place for entry. The physiotherapist documented that before her admission to hospital, Mrs B was able to mobilise independently indoors using a frame or trolley caddy, although Ms A says she used two walking sticks.
- During her time on the rehabilitation ward, Mrs B received physiotherapy and occupational therapy input to ensure that on discharge her activities of daily living and basic care activities could be met, either independently or with carers. It is noted she “progressed well with rehab”. The goals set at the start of rehabilitation were for Mrs B to be independent using indoor aids (sitting to standing, walk to the bathroom, and walk further with her frame), to be able to complete one step into and out of the property with bilateral rails within three weeks, to mobilise outdoors with supervision and appropriate aid within three weeks, and to complete the stairs with supervision within six weeks.
- The needs assessment that was completed two days before Mrs B’s discharge from hospital, documents under the heading “Current Status” that Mrs B achieved the goals set for using indoor aids. Onward referrals were made for community therapy with the aim of completing the step up to her property, mobilising outdoors, and using the stairs within the time frames set out above.
- I recognise that Ms A considers Mrs B was not ready to be discharged. Ms A told us her recollection was that while Mrs B was in hospital, she could not get up from her wheelchair by herself and was unable to walk without assistance. However the records made at the time leading up to Mrs B’s discharge from hospital indicate that she was able to move independently from sitting to standing, and to walk with her frame. Ms A said Mrs B was unable to go up the step into her house when she first arrived home. Transport staff were there to help with this. Community physiotherapy was arranged to support her with using the step into her house, and mobilising at home outdoors once she had returned home.
- Mrs B was also referred to community occupational therapy to review shower transfers, and safety and independence with personal care. Equipment was also provided for Mrs B to support her independence at home: a perching stool for meal preparation, a toilet frame, and a high back armchair.
- A patient is ‘fit for discharge’ when physiological, social, functional and psychological factors have been taken into account following a multidisciplinary assessment if appropriate. The records state Mrs B was medically fit for discharge, had met the rehabilitation goals set and was referred for appropriate community therapy to support her with ongoing mobility and independence at home.
Care package on return home
- As noted above, the needs assessment completed for Mrs B two days prior to discharge, determined that her care package should be increased once she returned home. The records indicate that the Council carried out an appropriate needs assessment based on information from Mrs B, Ms A, nurses, occupational therapy and physiotherapists who had been involved in her care on the rehabilitation unit.
- However, although the care package was requested and was due to start the evening Mrs B was discharged, no care worker arrived that evening. The care package did not start until the next day when Ms A followed matters up with the Council. Ms A said this meant Mrs B was left without care when she first returned home from hospital, and in the meantime Ms A had to step in to provide support.
- In its response to Ms A’s complaint, the Council accepted that care had not been provided to Mrs B on the Friday evening as it should have been. The Council apologised to Mrs B and Ms A for this. The Council said lessons would be learnt and that staff had been reminded of the process for arranging care on discharge.
- In response to our enquiries, the Council said that in arranging Mrs B’s care package, it had followed the process for an unplanned discharge from hospital, rather than for a planned daytime discharge. However the Council said that in doing so, the protocol was still not followed correctly. The Council accepted that in line with the protocol, there should have been contact with the Council’s Brokerage Team to identify a suitable care provider and confirm a start date and time. The needs assessment, support plan and funding request would then have to be approved by the Brokerage Team before the care package could be put in place. Where a care package is being re-started, the request would still need to go through the Brokerage Team for approval and confirmation to the provider.
- In Mrs B’s case, it appears the Council directly contacted the agency that had provided Mrs B’s care at home before her hospital admission, rather than putting the request to the Brokerage Team as set out in the process above. Contacting the agency directly seems to have led to some confusion, as the provider did not receive formal confirmation that Mrs B had been discharged. The Council said that as the provider had not received confirmation of Mrs B’s discharge time, the provider understood that she remained in hospital.
- The Council accepted that in Mrs B’s case, it did not follow the protocol as it should have done. It said it had taken steps to prevent recurrence by reminding staff of the protocol for arranging a care package on discharge. It has also introduced an additional step in the process whereby any deviation from protocol must be signed off by a manager. The Council also said that as a result of learning from Ms A’s complaint, it had updated its induction process for new staff on the hospital social work team. New staff must now shadow a duty worker for two months before they are able to act as a duty worker themselves.
- The Council has taken reasonable steps to prevent recurrence of missed care on discharge from hospital. That this happened caused understandable anxiety for Mrs B and Ms A, as they were worried that Mrs B would not get the care she needed. There was also an injustice to Ms A, who had to provide care, including personal care, for Mrs B that evening, which she said was not appropriate. I recognise this led to worry and distress for Mrs B and Ms A. However, the Council has appropriately apologised for what happened.
- The Ombudsmen find no fault in the decision that Mrs B was fit for discharge from hospital. The Council has accepted fault in that care was not in place when Mrs B arrived home, and that this caused distress and anxiety to Mrs B and Ms A. The Council has provided an appropriate remedy.
Investigator's decision on behalf of the Ombudsman