Summary: Ms Y complained about delays in her father’s discharge from hospital, poor personal care, and said he was wrongly placed in isolation. We found delays by the Trust and Council in arranging Mr Z’s discharge from hospital, leading to Mr Z remaining in hospital unnecessarily and causing distress to Ms Y. We have recommended the Trust and Council apologise to Ms Y, provide a financial remedy, and take steps to improve services.

The complaint

1. Ms Y complains about delays by the Council and the Trust in discharging her father, Mr Z, from hospital. She says the Trust and Council failed to work together to discharge Mr Z in a timely way with a suitable support plan and care package. Ms Y complains the Trust and the Council did not communicate with the family about discharge planning, and did not tell them a mental capacity assessment was carried out. Ms Y says the Trust failed to escalate its concerns, when it became clear the Council was unable to provide her father with an appropriate package of care. 
2. Ms Y also complains that personal care during Mr Z’s admission was poor, and that he was not given the dialysis he needed because of staffing issues. She also says he was placed in isolation unnecessarily.
3. Ms Y also complains about the way the Trust and the Council handled her complaint.
4. Ms Y says the prolonged admission had a detrimental effect on her father’s health and meant his care needs increased significantly. She adds that her father missed out on important social interaction and his quality of life was poor. She also says the situation caused her great distress, and that the family incurred travelling expenses in visiting her father over his time in hospital.

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The Ombudsmen’s role and powers

5. 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)
6. 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)).
7. 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.
8. 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

9. During my investigation of this complaint, I have considered information provided to us by Ms Y and discussed the complaint with her. I wrote to the Council and Trust to tell them what I intended to investigate, and requested copies of relevant records. I considered the comments and documents they sent. I have also considered the law and guidance relevant to this complaint.
10. I took clinical advice from a nurse and a physician.
11. Ms Y, the Trust and Council had an opportunity to comment on my draft decision. I have taken their comments into account when making a final decision.

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What I found

Applicable legislation and guidance

Hospital Discharge

12. 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

Medically fit for discharge

13. 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.

14. 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.

Care and support

15. 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.
16. The Care Act Statutory Guidance and Support (CSSG) refers to the importance of joined up working between local organisations, including councils and health bodies. Section 15.3 of the guidance states “Local authorities must carry out their care and support responsibilities with the aim of joining-up the services provided or other actions taken with those provided by the NHS… This general requirement applies to all the local authority’s care and support functions for adults with needs for care and support”.

Background

17. Before his admission to hospital, Mr Z lived in sheltered accommodation, with a Council-funded social care package arranged around his regular dialysis appointments. This comprised two carer visits on days when Mr Z received dialysis, and three visits on the other days. Mr Z also had a personal assistant, funded by direct payments from the Council. Mr Z was unable to walk without assistance, as he was paralysed on one side following a previous stroke. Mr Z was partially blind and deaf.

What happened

18. In December 2018, Mr Z’s collarbone was fractured while he was being transported to a dialysis appointment. He was admitted to hospital where the fracture was treated using a collar and cuff. Around a week after he was admitted, Mr Z had a myocardial infarction (heart attack) and was treated by the cardiology team.
19. Mr Z’s dialysis continued during his admission, and he also had occupational therapy and physiotherapy. During his first occupational therapy session at the end of December, the therapy team recorded he had previously had a carer at home and could not mobilise in between visits. On 16 January 2019, Mr Z was declared medically fit for discharge. The hospital social care team carried out an initial assessment, and found that because of his fracture, Mr Z would need an increased package of care to help him mobilise. He was assessed as needing two carers attending four times a day, once he returned home. The social care team discussed this with Mr Z’s daughter, and documented she wished his current care agency to provide the increased package of care. However, the agency said it did not have the capacity for this at the time.
20. In February 2019, the social care team prepared a draft support plan for discussion with Ms Y and a discharge planning meeting was held. Double handed care for bed transfers only, rather than every care call, was raised as a possibility.
21. The records also show that Mr Z was experiencing episodes of delirium at this time, and needed assistance at night if he was confused and tried to get out of bed. A meeting with the occupational therapist discussed how Mr Z’s overnight needs would be managed in the community, including a possible temporary respite placement. However, Mr Z’s preferred option was to return home.
22. On 15 March 2019, Mr Z had an unresponsive episode and was transferred to the Trust’s coronary care unit for treatment over the weekend. On 17 March he was able to return to the ward, and it is noted that discharge planning was to continue. Mr Z was documented as medically fit for discharge again on 22 March. A discharge planning meeting was held with the family on 18 April. It was agreed that Mr Z would not require overnight care, but he would still need two carers to help him mobilise during the day. Because of his complex care requirements, and ongoing need for care to fit around his regular dialysis, Mr Z’s preference was for the same care provider he had used before being admitted to hospital. However, the provider was still unable to supply two carers four times a day. It was agreed that Mr Z would be reassessed after the Easter weekend.
23. A reassessment took place on 1 May and reiterated that Mr Z would not be safe with only one carer on discharge. The Trust made a new referral to the Council’s adult social care team on 9 May. The Council agreed the care package on 30 May, with a different provider, and Mr Z was discharged on 10 June.

Analysis

24. I have set this section out under separate headings of the complaint for ease of reading.

Discharge from hospital

25. Ms Y complains that other than the short period in March when Mr Z was unwell, her father was fit for discharge from January onwards. She says the Trust’s response that his long hospital admission was “mainly due to fluctuations in his condition and complex discharge planning” was not accurate. Ms Y says the Trust did not tell her about any changes in Mr Z’s condition, other than the March episode, that required him to remain in hospital after he was declared medically fit in January.
26. The Department of Health guidance Ready to Go? describes discharge from hospital not as an isolated event, but an ongoing process that starts from the patient’s admission. When a patient requires more specialist care on leaving hospital, this is known as a complex discharge. Mr Z’s requirements (two carers rather than one) met this definition. Discharge planning for Mr Z began in January, when he was first declared medically fit for discharge, and the Trust made a referral to the social care team on 7 February. The records indicate the appropriate professionals were involved in discharge planning, and that there was ongoing dialogue between them: physiotherapists, occupational therapists and the hospital social work team.
27. Each hospital should have its own discharge policy in line with the national guidance from the Department of Health. The Trust’s Policy for Patient Discharge is in line with the national guidance from the Department of Health.
28. After being found medically fit for discharge, the Trust referred Mr Z to the rehabilitation and reablement team for input following discharge. However, he then had some setbacks in his recovery, including periods of delirium in January, February and early March. Based on the information I have seen, the Trust’s treatment for Mr Z’s delirium was in line with the relevant guidance (NICE CG103 Delirium: prevention, diagnosis and management). The Trust’s Dementia and Delirium team reviewed Mr Z. He also received regular physiotherapy and occupational therapy to promote his mobility, which is a recognised way of preventing delirium. The NICE guideline also recommends reducing ward transfers, accommodating regular family visits, and treating or avoiding constipation and dehydration. The records indicate all of this was done during Mr Z’s admission and his delirium began to resolve.
29. By 1 March, it was documented that Mr Z’s delirium was lessening and he was having some better nights’ sleep, but “at home without overnight support, his confusion will present a falls risk”. The joint discharge team explored some options for managing this including use of falls sensors and temporary care by the family. The Trust also approached the local NHS Clinical Commissioning Group (CCG) about health funding for overnight support. However, this went no further as Mr Z still had social care-led rehabilitation goals. The option of a funded respite placement with rehabilitation support was also discussed, but Mr Z made it clear that he wished to return home. Mr Z’s preferred provider was unable to provide double handed care as it did not have capacity. The Council informed Ms Y of this. On 11 March, an alternative provider confirmed they had capacity to provide the double handed care package, and the Trust made a new referral to the rehabilitation and reablement team. However, shortly after this, on 15 March, Mr Z was treated for the unresponsive episode, but he was declared fit for discharge again on 22 March.
30. A discharge planning meeting involving Mr Z and Ms Y was initially planned for 22 March, but this did not go ahead. The records show the social work and discharge planning team, as well as occupational therapy and ward staff were present, but Ms Y was not there. It is documented that ward staff tried to contact Ms Y by telephone the day before the meeting. Emails from Ms Y dated 21 March say she had still not received confirmation of the meeting, and she received a call on the morning of the 22 March. However, by then it was too late for her to arrange time off work to attend.
31. It is not clear why it then took some time to arrange a further discharge planning meeting. One was scheduled for 11 April, but this was also cancelled. The records indicate the social worker and family were present, but the Trust notes say the meeting was “suspended due to ongoing legal process”. The Council said it was not party to the decision to cancel this meeting. The meeting was rearranged for 17 April, where it was agreed that Mr Z would not need overnight care and would now need only single handed care during the day. Discharge was aimed for by the following week. However, the occupational and physiotherapy team were not present at this meeting and their view, when they later reassessed Mr Z on 1 May, was that in fact he still would not be safe with single handed care. However, this had been known as early as February, so this should not have contributed to any delay.
32. As noted above, the Department of Health guidance states that discharge should not be an isolated event but rather an ongoing process that starts from admission. This is so that any problems can be anticipated in advance and appropriate support put in place. In Mr Z’s case, discharge planning began in January, and it was known then that discharge was complex and that he would need a double handed social care package. The Council said it tried to accommodate Mr Z’s wish for his previous carer, but this was not possible because they did not have capacity. The case notes indicate that on 8 March, the Council told Ms Y they were seeking an alternative agency, although Ms Y said no alternatives were discussed with them at that time. The Council also explored other possibilities, including bringing in an additional provider to support Mr Z’s preferred provider in the short term. This could not go ahead because the preferred provider did not have capacity. An alternative provider was identified on 11 March, but the referral was closed shortly after this, owing to Mr Z’s unresponsive episode on 15 March.
33. The records show there were reasons for the earlier discharge delays (periods of delirium, treatment on the coronary care unit for the unresponsive episode). However, it is not clear why it then took almost a month to arrange the initial discharge planning meeting: Mr Z was fit for discharge on 22 March, but the meeting did not take place until 17 April. While the records refer to the earlier discharge planning meeting being cancelled because of “legal process”, the Trust did not refer to this as a cause for delay in its response to the complaint. There was then a delay after the 17 April meeting. Mr Z was reassessed by therapists on 1 May but a re-referral was not made to the rehabilitation and reablement team until 9 May. The rehabilitation and reablement team felt the goals in this referral were not achievable. A re-referral was sent and accepted on 13 May, but a care provider was not confirmed until 30 May. The Council said it could not keep the care package open from March while discharge kept being pushed back for reasons including ensuring care was arranged around dialysis and Mr Z’s property not being ready. While both of those issues arose and were discussed by the Trust, Council and Ms Y at a meeting, the records indicate this was not until the end of Mr Z’s admission in June. Therefore, I cannot see that these factors contributed to any delays from 22 March onwards.
34. Taking into account the delays in arranging the discharge planning meeting, and the re-referral to rehabilitation, this amounts to a preventable delay to discharge of four weeks and six days. The medical records include extensive documentation showing Mr Z was medically fit for discharge for most of his admission, other than the episodes of delirium and the brief occasion when he had an unresponsive episode in March. While that is not to say that he was completely fit and well, it means that after he was treated for the unresponsive episode, his care (personal care, physiotherapy and dialysis) could have been delivered outside a hospital setting.
35. Ms Y says the prolonged admission had a detrimental effect on her father’s health and quality of life, and meant he missed important social interaction. Based on the information I have seen, I am not able to make a direct link between the delayed discharge and a deterioration in Mr Z’s health. However, I recognise the uncertainty this causes Ms Y, and the impact that supporting Mr Z with his discharge from hospital had on her. I have recommended the Trust and Council take action to address this.

Communication with Ms Y

36. Regarding communication with the family, it is clear the Trust and Council consulted and discussed Mr Z’s care and discharge plan with them on numerous occasions throughout his admission. Ms Y specifically complained the Council failed to tell her when it carried out a capacity assessment of Mr Z. The records show the assessment was done on the day of the cancelled discharge planning meeting and discussed with Ms Y the same day.

Personal care and isolation

37. Ms Y complained that Mr Z was wrongly placed in isolation as he was thought to have candida auris, a type of infection that can affect hospital patients. Ms Y says being in isolation had a significant impact on her father as he was disabled, and partially blind and deaf. She says being nursed in a side room meant Mr Z was socially isolated and did not get the care he should have had, as he could not ask for help.
38. In its response to Ms Y’s complaint, the Trust said that Mr Z had tested negative for candida auris at the dialysis unit. However, the Trust did not update his records, so the ward team thought he still had the infection. The Trust accepted this meant Mr Z was wrongly placed in isolation on two occasions. The Trust apologised to Mr Z and his family and updated Mr Z’s records.
39. We saw the Trust took steps to correct the information it held. However, we also looked at Ms Y’s concerns about the impact on Mr Z of being wrongly placed in isolation. During his admission, Mr Z needed nursing staff to support him in all areas of care, including hygiene, nutrition, hydration and skin integrity. This included regular changes of position to avoid pressure sores.
40. Mr Z had a care plan in place, setting out the level of care he needed on a daily basis. This was in line with the Nursing and Midwifery Council Code (the NMC Code). Nurses also carried out ‘intentional rounding’, which is checking the patient’s needs regularly. This means that even if the person is unable to use a call bell to ask for help, their needs will be checked on regularly. How frequently this happens depends on the individual, but is typically between every one and four hours. The records show that Mr Z had a pressure relieving mattress and was repositioned regularly. He also had a pressure relieving cushion on his chair. Mr Z wore pads to aid continence. The nursing evaluations indicate that Mr Z’s needs were met and that his pressure areas were intact for much of his admission. He did have a grade 2 pressure sore for one week in January, although this is recorded as healed by 25 January. The nursing records indicate his skin was intact for the remainder of his time in hospital.
41. Regarding communication, Ms Y was concerned that as Mr Z was partially blind and deaf, being placed in isolation meant he was unable to ask for help when he needed it. As noted above, nursing staff undertook intentional rounding to check on Mr Z regularly and it is documented that his needs were being met. It is also recorded in the nursing notes that he was able to express his needs.
42. The records indicate that Mr Z received the nursing care he needed while placed in isolation. The Trust corrected its records and offered appropriate apologies to the family. I do not consider there is anything further the Ombudsmen could add on this point.

Dialysis

43. Ms Y complains that during his admission, Mr Z was not given the dialysis he needed because staffing issues meant he could not be transported to the dialysis unit from the ward. The Trust carried out a Serious Incident Report into this matter. It acknowledged that Mr Z did not get all the dialysis sessions he should have had while he was an inpatient. The Trust also accepted that Mr Z was not weighed at the beginning and end of many of the sessions, “leading to sub-optimal fluid assessment”. The Trust said Mr Z had gained some weight due to fluid accumulation, which contributed to worsened blood pressure control and increased potassium levels. The Trust acknowledged care in the dialysis unit could have been better. However, it said “there were no significant clinical effects of the reduced HD [dialysis] duration, intermittently raised potassium, or raised blood pressure”.
44. The Trust calculated that Mr Z received 93% of the dialysis he should have had during his admission. Based on the information I have seen, it was reasonable for the Trust to conclude there were minimal or no longer-term consequences for Mr Z as a result of this.
45. The Trust said it would take action to improve the dialysis service for inpatients, including extending opening hours, training staff on risks of under-dialysis and fluid balance, and ensuring regular consultant-led dialysis review. This is an appropriate action plan to improve services. It covers the issues identified in the Serious Incident Report, in particular ensuring the involvement of renal teams where people admitted for other conditions require continuing dialysis as an inpatient. The Trust has taken appropriate steps to improve the service.

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Recommendations

46. I recommend that within one month of the final decision:

• the Trust and Council apologise to Ms Y for the impact of the delayed discharge on her and Mr Z;
• the Trust and Council to make a payment of £300, shared between them, to Ms Y in acknowledgement of the distress and difficulty the delayed discharge from hospital caused her, as well as uncertainty over how the delay may have affected her father.

47. Within three months of the final decision:

• the Trust and Council to review their policies and processes to determine what led to the delays in discharge, and what steps they could take to prevent recurrence.

48. The Trust and Council will provide the Ombudsmen with evidence they have completed this work.

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Final decision

49. Based on the evidence I have seen, there was fault by the Trust and Council leading to a preventable delay to Mr Z’s discharge from hospital. I have made recommendations to the Trust and Council to remedy the injustice caused to Ms Y.
50. I have now completed my investigation on this basis.

Investigator’s decision on behalf of the Ombudsmen

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Investigator's decision on behalf of the Ombudsman