The Ombudsman's final decision:
Summary: We found fault with the way a Council and NHS Trust handled the discharge planning process for Mr Y after his admission to hospital in April 2019. The Council and Trust agreed to apologise to Mr Y’s daughter and pay a financial sum in recognition of the distress this caused her. They will also review relevant policies and procedures to prevent similar problems occurring in future. We found no fault by another NHS Trust that cared for Mr Y during later hospital admissions in July 2019 and April 2020. Similarly, we found no fault by a GP Practice that provided care to Mr Y in the community.
- The complainant, who I will call Mrs X, is complaining about the care and treatment provided to her father, Mr Y, between April 2019 and April 2020. This care was provided by Essex County Council (the Council), Princess Alexandra Hospital NHS Trust (the Princess Alexandra Trust), Mid and South Essex NHS Foundation Trust (the Mid Essex Trust) and Felstead Surgery (the Practice).
- I have considered Mrs X’s specific complaints in more detail below in the ‘analysis’ section of this decision statement. In the interests of brevity, I have not set these out in full here.
- However, in summary, Mrs X complains that:
- The Princess Alexandra Trust failed to provide Mr Y with appropriate care during a hospital admission in April 2019.
- The Princess Alexandra Trust and Council discharged Mr Y to an unsuitable care home that could not meet his needs.
- The Council charged Mr Y for the care home placement, having initially told him it would be free.
- The Council delayed in beginning the Continuing Healthcare (CHC) process for Mr Y.
- The Mid Essex Trust discharged Mr Y in July 2019 without proper consultation with his family.
- The Practice failed to provide Mr Y with proper care when March 2020 when he was near the end of his life.
- The Mid Essex Trust failed to provide Mr Y with appropriate care during his admission in March and April 2020.
- Mrs X says these events caused Mr Y significant distress and placed her under unnecessary pressure. She says Mr Y lost his independence as a result of his extended stay in the care home and that he lost trust in the professionals supporting him. Furthermore, Mrs X says Mr Y was denied access to the CHC funding process as the professionals supporting him failed to ensure he was registered with a permanent GP.
- Mrs X would like the Council to fund Mr Y’s stay in the care home as it originally agreed to do. She would like the organisations involved in his care to apologise and take action to prevent similar failings occurring for other people in future.
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 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)
How I considered this complaint
- In making my final decision, I considered information provided by Mrs X and discussed the complaint with her. I also considered information and documentation provided by the organisations she is complaining about, including the health and social care records. In addition, I took account of relevant law and guidance. Furthermore, I considered comments on my draft decision statement from all parties to the complaint.
What I found
Relevant legislation and guidance
- The Department of Health produces guidance entitled Ready to go? Planning the discharge and the transfer of patients from hospital and intermediate care (March 2010) (the ‘Ready to go’ guidance). This 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 they can make informed decisions and choices that deliver a personalised care pathway and maximise their independence.
Discharge to assess placements
- The ‘discharge to assess’ care model is used for hospital patients who no longer need an acute hospital bed but still have short-term care needs. This care model allows for the discharge of a patient to a residential care placement on a short-term basis so a decision can be made about that person’s long-term care needs.
- A ‘discharge to assess’ placement can last up to six weeks. The Council funds the placement for this period. After four to six weeks, the Council will review the person’s care needs to decide whether they can return home or require 24-hour residential care.
Care Act 2014 – Charging
- The Care and Support (Charging and Assessment of Resources) Regulations 2014 (the Charging Regulations) and the Care and Support Statutory Guidance 2014 (the Statutory Guidance) set out the charging rules for residential care. When a council arranges a care home placement, it has to follow these rules when undertaking a financial assessment to decide how much a person has to pay towards the costs of their residential care.
- The rules state that people who have over the upper capital limit of £23,250 are expected to pay for the full cost of their residential care home fees. However, once their capital has reduced to less than the upper capital limit, they only have to pay an assessed contribution towards their fees.
- The council must assess the means of people who have less than the upper capital limit, to decide how much they can contribute towards the cost of the care home fees.
- Most people will have to pay something towards the cost of a care home even if they have capital of less than the lower capital limit of £14,250. Usually, a person is expected to pay all of their regular income towards their placement after deducting an amount for their personal spending which is known as their personal expenses allowance.
Mental Capacity Act 2005
- The Mental Capacity Act 2005 provides a statutory framework for people who lack capacity to make decisions for themselves. It describes when to assess a person’s capacity to make a decision, how to do this, and how to make a decision on behalf of somebody who cannot do so themselves.
- This Act is accompanied by statutory guidance entitled the Mental Capacity Act Code of Practice (the Code of Practice).
- The Act makes clear that a person must be presumed to have capacity to make a decision unless it is established that he or she lacks capacity. If there are doubts about a person’s capacity to make a specific decision, that person’s capacity should be assessed. This assessment should be specific to the decision to be made at a particular time.
- If a person is found to lack capacity to make a specific decision, a decision may be made on behalf of that person in his or her best interests.
- The Code of Practice allows for an Independent Mental Capacity Advocate (IMCA) to be appointed to support a vulnerable person who lacks capacity to make important decisions about his or her care and finances.
- Continuing Healthcare (CHC) is a package of ongoing care that is arranged and funded by the NHS where a person has been assessed as having a ‘primary health need’. For most people who may be eligible for CHC, the first step in assessment is for a health or social care professional to complete a CHC checklist. The threshold for meeting the CHC checklist is set relatively low.
- If the completed CHC checklist indicates the person may be eligible for CHC, the next step is a full multidisciplinary assessment. This assessment is completed using a decision support tool (DST). The DST is a record of the relevant evidence and decision-making. The DST should be completed within 28 days of the CHC Checklist unless there are ‘valid and unavoidable’ reasons for it taking longer.
- The decision on whether or not a person is eligible for CHC funding rests ultimately with the local Clinical Commissioning Group (CCG).
- In March 2020, in response to the emerging COVID-19 pandemic, the government published the COVID-19 Hospital Discharge Service Requirements. This guidance set out that CCGs would not be required to complete CHC assessments for individuals on the acute hospital discharge pathway or in community settings for the duration of the COVID-19 emergency period. This guidance remained in place until September 2020.
- Mr Y had a diagnosis of dementia, and several long-term physical health conditions, including lung and kidney disease. Mr Y also had haemorrhoids, which he attended to independently.
- Mr Y was admitted to hospital under the care of the Princess Alexandra Trust on 14 April 2019, having suffered a fall at home. X-rays revealed that Mr Y had sustained fractures to his right wrist and left shoulder.
- On 19 April, Mr Y was discharged to a temporary care home placement. This was a ‘discharge to assess’ placement.
- In May, a social worker advised Mr Y that the placement would become chargeable at the end of the six-week Intermediate Care period. Mr Y said he would be unwilling to pay anything towards his care.
- An Occupational Therapist (OT) completed a home assessment 25 June. The OT felt Mr Y may lack capacity to understand his needs and the support he would need to return home safely.
- A social worker completed a Mental Capacity Assessment the following day. This found Mr Y had capacity to decide to return home. However, Mr Y agreed to remain in the care home until he had fully recovered. The Council extended the placement again.
- Mr Y was admitted to hospital under the care of the Mid Essex Trust on 13 July with heart problems. Further investigations ruled out a heart attack.
- Mr Y was readmitted on 15 July with leg swelling. The Mid Essex Trust treated him with anticoagulant medication and discharged him back to the care home.
- A social worker visited Mr Y and Mrs X at the care home on 19 August to discuss his ongoing care. Mr Y was insistent that he wished to return home. However, he was unwilling to accept any support and refused to pay for care services.
- The social worker visited Mr Y and Mrs X again on 27 September. Mr Y said he felt he could no longer return home and needed ongoing residential care. Mrs X, with Mr Y’s consent, agreed to look for a suitable care home placement closer to her home.
- In October, Mrs X informed the social worker that she felt Mr Y’s heart condition was deteriorating and that he required a nursing home placement. However, the social worker advised Mrs X that the residential care home could meet Mr Y’s needs.
- On 2 October, Mr Y attended a cardiology outpatient appointment to discuss treatment options for his heart problems. Mr Y refused any surgical intervention.
- In November, a nurse assessor visited Mr Y at the care home to complete a CHC checklist. However, Mr Y refused to engage with the nurse and the process could not continue. A Council officer eventually completed a CHC checklist in January 2020. This identified that Mr Y required a full CHC assessment.
- On 22 April, Mr Y suffered a fall at the care home. He was admitted to hospital that day.
- Mr Y died in hospital on 24 April 2020.
Hospital admission – April 2019
- Mrs X complains that the Princess Alexandra Trust failed to provide Mr Y with appropriate care and treatment during a hospital admission in April 2019. Mrs X said the Princess Alexandra Trust did not call her in to support Mr Y during his initial examination. She says the Princess Alexandra Trust left Mr Y without analgesic medication and did not offer him a hot meal during his admission. Furthermore, Mrs X says the Princess Alexandra Trust failed to investigate the cause of Mr Y’s recurrent falls.
- In its response to my enquiries, the Princess Alexandra Trust admitted staff had not asked Mrs X to support Mr Y during his triage assessment. However, the Princess Alexandra Trust said Mr Y provided a full history, including the details of his fall. The Princess Alexandra Trust also said it had apologised to Mrs X for not including her in the assessment.
- In her complaint to the Ombudsmen, Mrs X explained that Mr Y refused to take pain relief medication in her absence. She said this meant he remained in pain while he waited for further treatment.
- The clinical records show the ambulance crew that transported Mr Y to hospital gave him pain relief medication at 4.50pm. Mr Y arrived at hospital at 5.25pm. At that stage, he declined further pain relief medication. The clinical evidence supports Mrs X’s complaint, therefore.
- I cannot say whether Mr Y would have taken pain relief medication even if Mrs X had been present. The clinical records show Mr Y sometimes did refuse pain relief medication during his admission. Nevertheless, I recognise this caused Mrs X uncertainty in terms whether Mr Y would have accepted pain relief if she had been present.
- I have reviewed the Princess Alexandra Trust’s letter to Mrs X of 9 January 2020 and found no evidence of an apology in response to this aspect of the complaint. I have addressed this in the ‘recommendations’ section of this decision statement.
- In its response to Mrs X’s complaint about nutrition, the Princess Alexandra Trust explained that the CDU is not intended to be an inpatient ward. It said the CDU is only used as one when insufficient ward beds are available. It acknowledged staff had not offered Mr Y a hot meal during his time on the CDU (around five days). This is evidence of fault by the Princess Alexandra Trust.
- The Princess Alexandra Trust apologised that Mr Y’s nutritional care had not been of an appropriate standard. It also explained that it had addressed this with the catering department and that it now offers hot meals to patients who experience a prolonged stay on the CDU.
- In my view, this is a proportionate remedy for the injustice caused to Mr Y by the Princess Alexandra Trust’s failure to provide him with appropriate nutritional care during his admission.
- In her complaint to the Ombudsmen, Mrs X explained that Mr Y was admitted to hospital twice in late 2018 having suffered falls. She complains that, despite this, the Princess Alexandra Trust made no effort to investigate whether there were any underlying factors that may explain Mr Y’s frequent falls.
- In response to my enquiries, the Princess Alexandra Trust said Mr Y reported having fallen over while chasing a cat. It said an electrocardiogram (ECG – a test that measures the electrical activity of the heart) showed Mr Y’s heart rhythm was normal. The Princess Alexandra Trust said that the clinicians treating Mr Y felt he did not require inpatient care at that time.
- It is clear from the clinical records that Mr Y had long-term health conditions that contributed to his general frailty. However, the records suggest the fall that caused Mr Y’s admission in April was a result of a trip rather than underlying health problems. Investigations undertaken during the admission (such as the ECG and a computerised tomography (CT) scan) revealed no significant acute illness. The clinical records support the Princess Alexandra Trust’s decision to discharge Mr Y. I found no fault on this point.
Hospital discharge – April 2019
- Mrs X complains that, in April 2019, the Princess Alexandra Trust and Council discharged Mr Y to a care home against his wishes and without proper consultation. She says the Princess Alexandra Trust used an inappropriate vehicle to transport Mr Y and that his medication was labelled incorrectly.
- The Princess Alexandra Trust took X-rays following Mr Y’s admission on 14 April 2019. These showed he had sustained fractures to his right wrist and left shoulder following a fall at home. The treating clinicians placed Mr Y’s left arm in a sling and put a backslab cast on his right arm.
- The Princess Alexandra Trust subsequently transferred Mr Y to the Clinical Decisions Unit (CDU) later that night for further assessment.
- An initial assessment of Mr Y’s mobility on the morning of 15 April found he was “usually mobile with a stick and was able to mobilise in the department with [the assistance of one person].” The assessment concluded “the plan is to discharge home with [a package of care]” and a referral for an outpatient appointment with the fracture clinic.
- A discharge nurse later called Mrs X to explain that Mr Y would be discharged into her care that day. However, Mrs X told the nurse she felt Mr Y should be discharged home with a proper package of care. The discharge did not go ahead.
- I found no evidence that staff discussed Mr Y’s care needs with Mrs X before deciding to discharge him. This is concerning given the discharge arrangements required Mrs X to support Mr Y.
- Furthermore, I found no detailed consideration at that stage of Mr Y’s ability to manage at home following his fall. The clinical records suggest Mr Y’s injuries would have prevented him from mobilising safely at home without support. This is because he was unable to bear weight on his left arm and had very limited use of his right arm. This would also have limited his ability to attend to his personal care.
- The available evidence shows the Princess Alexandra Trust failed to robustly consider Mr Y’s increased care needs and how these needs would be met prior to deciding to discharge him. This was contrary to the ‘Ready to go’ guidance and represents fault by the Princess Alexandra Trust.
- I am satisfied this did not cause Mr Y a significant injustice as the discharge did not ultimately go ahead. However, this situation caused Mrs X unnecessary concern and worry.
- The Council’s records show Mr Y remained keen to return home. He told a hospital social worker who visited him on the CDU on 15 April that Mrs X could support him without the need for a care package.
- The hospital social worker also spoke to Mrs X when she arrived at the hospital later that morning. Mrs X said she felt Mr Y needed a care package but that he would be unwilling to pay for one. Mrs X said she had no access to Mr Y’s funds and would be unable to arrange a care package on his behalf.
- There appears to be some confusion over whether Mr Y initially consented to a short-term discharge to assess placement.
- In her complaint to the Ombudsmen, Mrs X said the hospital social worker visited Mr Y on the CDU throughout his stay. She said Mr Y insisted he did not want to go to a care home and would prefer to remain in hospital until he could go home.
- The hospital social worker’s notes of her conversations with Mr Y and Mrs X on 15 April contradict this. The hospital social worker noted that “[t]he reason why he needs a [discharge to assess] bed is to establish whether he will be safe to return home at the end of his stay as [Mrs X] is worried that he will not cope with the fractures and he declines support from carers.” The hospital social worker also noted that “Patient and daughter agreed to [discharge to assess]/interim placement”.
- It is clear from the clinical records that Mr Y was keen to return home as soon as possible. However, Mr Y’s injuries meant he could not do so safely without a package of care, which he was unwilling to accept. A discharge to assess placement represented an appropriate way of preventing a protracted hospital admission, which would have carried its own risks for Mr Y (such as increased risk of infection). The contemporaneous records suggest Mr Y did consent to a short-term placement, therefore, albeit I appreciate Mrs X disputes this.
- On the afternoon of 15 April, the hospital social worker made a referral to the Council’s placements team for a discharge to assess placement. In a follow-up email on 16 April, the hospital social worker wrote that Mr Y “was declining support till late yesterday when I managed to convince him with the support of [Mrs X], to go to a [discharge to assess placement].
- The clinical records show the hospital social worker called the CDU on the afternoon of 17 April to report that she had arranged for Mr Y to be transferred to a local community hospital. The clinical records show CDU staff carried out a telephone handover with the community hospital and left Mrs X a message explaining the situation.
- When the transport arrived to take Mr Y to the community hospital later that afternoon, he became agitated and refused to go, despite the efforts of staff to persuade him.
- The case records show there was significant confusion surrounding this proposed transfer.
- The ‘Ready to go’ guidance stresses the importance of involving patients (and carers) in the discharge planning process to ensure they can make informed decisions about their care.
- I found no evidence in the case records of any discussion with either Mr Y or Mrs X about the proposed transfer, nor any evidence to suggest Mr Y consented to it. Indeed, the clinical records show Mr Y had personal reasons for not wanting to attend the community hospital. The handling of the proposed transfer was not in keeping with the ‘Ready to go’ guidance. This is fault by the Council and Trust.
- Although the transfer did not go ahead, the case records show the situation caused Mr Y and Mrs X unnecessary distress.
- The hospital social work team identified two possible short-term care home options for Mr Y and discussed these with Mrs X on the evening of 17 April. In her complaint to the Ombudsmen, Mrs X said she told the social worker to discuss the options with Mr Y but that the social worker left the CDU without doing so.
- I could not locate in the records a note of any discussion between the hospital social workers and Mr Y regarding the choice of care home. There is no record of Mr Y’s views, nor any indication that he agreed to this specific placement. Again, this is contrary to ‘Ready to go’ guidance and represents fault by the Council and Princess Alexandra Trust.
- I am satisfied this did not have a significant impact on Mr Y’s care. This is because the clinical evidence suggests that it was in Mr Y’s best interests to remain in a short-term placement while his injuries healed and his long-term care needs were assessed.
- Nevertheless, I recognise this situation caused Mr Y avoidable frustration and distress.
- In her complaint to the Ombudsmen, Mrs X said the Princess Alexandra Trust transferred Mr Y to the care home in a minibus rather than an ambulance and that this was not suitable for him. She said Mr Y’s haemorrhoid was not labelled correctly.
- The clinical records show Mr Y was suitable for non-emergency transport to the care home. He required minimal assistance to mobilise and could sit without assistance. I found no evidence to suggest the minibus was unsuitable for Mr Y or that he needed an ambulance. I found no fault by the Princess Alexandra Trust on this point.
- I understand the Princess Alexandra Trust discharged Mr Y on 19 April with the correct haemorrhoid cream. Nevertheless, the evidence suggests confusion later developed around the labelling of the medication. The hospital pharmacy labelled the tube rather than the box.
- When a district nurse visited Mr Y on the morning of 20 April, she found the box unlabelled and disposed of the medication, without noticing the tube had a label. This meant more of the cream had to be ordered. Mrs X reports that it took a week for the cream to arrive and for a district nurse to apply it and that Mr Y experienced significant discomfort during this time.
- The decision to label the tube rather than the box was in keeping with the Princess Alexandra Trust’s policy for labelling medication. This ensures that, if the outer packaging is lost or thrown away, the medication remains clearly labelled.
- I recognise this situation left Mr Y in pain and discomfort and that Mrs X found this understandably distressing. However, I am not persuaded this situation arose because of fault by the Princess Alexandra Trust. Rather, the confusion occurred as the district nurse was unfamiliar with the labelling policy.
- The Princess Alexandra Trust apologised that Mr Y was in pain and clarified its labelling policy with the district nursing team. I consider this an appropriate resolution to this part of the complaint.
Care home suitability
- Mrs X complained that the care home to which the Princess Alexandra Trust discharged Mr Y on 19 April was a residential care home and not suitable for someone with his complex care needs. As an example, Mrs X said staff at the care home could not help Mr Y with his haemorrhoid care. Also, she said the care home did not have suitable hospital riser bed for Mr Y. Mrs X said Mr Y’s lung disease meant he needed to be in an elevated position.
- The clinical records suggest the team treating Mr Y felt he was suitable for a social care placement and had only limited nursing needs. A manager from the care home visited Mr Y in hospital and found the care home could meet his needs. The Princess Alexandra Trust arranged a referral to the local district nursing service to support Mr Y with his haemorrhoid care. I found no evidence to suggest the care home placement was unsuitable for Mr Y based on his assessed needs at that time. I found no fault by the Council and Trust in this regard.
- In her complaint to the Ombudsmen, Mrs X said Mr Y required an adjustable hospital bed but that the care home did not provide him with one until February 2020. Mrs X said this demonstrated that the care home was unable to meet Mr Y’s needs.
- In its response to my enquiries, the Council explained that Mr Y could transfer in and out of an ordinary bed to go to the toilet. Nevertheless, the Council said the care home did provide Mr Y with an adjustable bed when Mrs X asked this. The Council acknowledged this allowed care home staff to placed Mr Y in an elevated position but said they could also do this using pillows. The Council said Mr Y was not at high risk of developing pressure sores and did not require a specialist mattress.
- It is important to be clear that my investigation has not considered the care provided to Mr Y by the care home. This is because Mrs X did not complain about that organisation. As a result, I have not reviewed the care home’s records.
- However, I have reviewed the records of both the Council and Princess Alexandra Trust on this point. The clinical team supporting Mr Y in hospital did not identify an adjustable hospital bed as a requirement based on his assessed needs at the point of his discharge from hospital. While I note Mrs X’s concerns, I accept the Council’s view that it was possible for care home staff to keep Mr Y in an elevated position using pillows. I found no fault on this point.
- Mrs X complains that the Council told her and Mr Y the placement would be free until he was ready to return home. However, Mrs X says the Council later claimed the placement was chargeable.
- The Council said a hospital social worker discussed charging with Mrs X and Mr Y in May 2019. It said the social worker explained the interim care home placement would be non-chargeable until 1 June, at which point it would become chargeable. The Council said another social worker discussed charging with the family again in August and on two further occasions in September. The Council said Mr Y disclosed that he had savings over the upper capital limit of £23,250 and owned a property. The Council said Mr Y and Mrs X refused to complete a financial assessment form, which resulted in Mr Y being charged full cost for the care home placement.
- The case records show that a hospital social worker spoke to Mr Y on 15 April 2019 when he was still an inpatient. She noted that Mr Y declined a care package as he said Mrs X could support him when he returned home.
- The social worker spoke to Mrs X later that day. Mrs X said she felt Mr Y would need a care package but that he would be unwilling to pay for this. The social worker later noted that, with Mrs X’s assistance, she had persuaded Mr Y to accept a temporary care home placement.
- The Princess Alexandra Trust discharged Mr Y to the care home on 19 April. This was a discharge to assess placement.
- On 23 May, a hospital social worker visited Mr Y and Mrs X at the care home. She noted “I discussed the charging policy with [Mr Y] and his daughter. [Mr Y] understands that he has to pay for his care and I informed her that the 6 weeks placement was non-chargeable to him but he will start paying after the interim placement lapses on the 30th of May 2019.” The social worker recorded that Mrs X told her Mr Y had significant savings. She also noted Mr Y felt he should not have to pay for his care but that Mrs X was worried about the prospect of Mr Y returning home without support.
- The social worker extended the placement. The care home manager discussed the extension with Mr Y and said he was content to remain in the placement while the Council arranged for him to return home. The social worker noted that “[Mr Y] has money over the threshold. This Placement is going to be a chargeable service from the 1st of June 2019…[Mr Y] understands that he has to pay for his care.”
- On 19 August, a social worker visited Mr Y and Mrs X at the care home to discuss Mr Y’s ongoing care arrangements. She noted that “I informed [Mr Y] wherever he decides he wants his care and support needs provided, he will have to pay, and the reason for this is having sufficient funds over the threshold and a property. [Mr Y] became very angry, telling me why should he pay for his care.”
- The social worker visited Mr Y and Mrs X again on 5 September to discuss charging arrangements. The social worker reiterated that, Mr Y would need to pay for his care, whether at home or in a care home placement. However, Mr Y again indicated that he would not do so. During this conversation, Mrs Y said the charging process had not been explained to them and the hospital social worker had simply advised them that Mr Y’s care would be funded by the Council until he was ready to return home.
- The care records show Mr Y was discharged to the care home under the ‘discharge to assess’ care model. This meant the Council would fund his care for up to six weeks. However, once this period of funded care ended, the Council was entitled under the Care Act 2014 to charge Mr Y for his care. As Mr Y had savings above the capital threshold of £23,250, he needed to pay the full cost of his residential care. I found no fault by the Council on this point as its decision to charge Mr Y was made in accordance with the Charging Regulations and the Statutory Guidance.
- In her complaint to the Ombudsmen, Mrs X said the social worker told her the Council would fund Mr Y’s care until he was ready to return home. The case records show social workers discussed the charging process with Mr Y and Mrs X in April, May, August and September 2019. I found no record of the discussion Mrs X describes, nor any other evidence that social workers misadvised Mr Y and Mrs X. I consider it more likely that this was simply a misunderstanding, therefore. I find no fault by the Council in this matter.
Discharge from care home
- Mrs X complains that a social worker tried to discharge Mr Y home even though he had not begun his course of physiotherapy and had no care package in place.
- The Council’s records show a hospital social worker visited Mr Y at the care home on 24 May. Mrs X was also present. The social worker noted that Mr Y’s backslab cast had been removed and that doctors had told him he could begin to use his arms again. However, she also noted Mr Y would need additional time for his arms to recover fully. She noted Mr Y continued to report pain in both arms. Mr Y remained keen to return home when the discharge to assess period ended on 30 May. However, the social worker noted that Mr Y “declined to have a care package and stated that he will not pay for his care. [Mrs X] tried to convince him but he declined.”
- Following further discussion with Mrs X, the social worker agreed to arrange for an Occupational Therapist (OT) to complete a home assessment. She extended the care home placement for a further four weeks to allow the assessment to take place.
- The case records show the social worker visited Mr Y to discuss discharge options with him as the ‘discharge to assess’ placement was ending. It is clear Mr Y was keen to return home as soon as possible. The Statutory Guidance emphasises the importance of ensuring that a person’s views are central to discussions about the care and support they receive. Therefore, it was appropriate for the social worker to explore whether Mr Y could return home safely.
- However, once it became clear that Mr Y would not consent to a package of care, the social worker agreed to extend the care home placement in consultation with Mrs X to allow further assessments to take place. The available evidence shows the social worker acted in accordance with the Statutory Guidance. I found no fault by the Council here.
- Mrs X complains that a social worker made an unannounced visit to Mr Y on 1 August when she was not present to support him. Mrs X says the social worker told Mr Y’s granddaughter that she (Mrs X) no longer wished to be involved in his care.
- An OT accompanied Mr Y and Mrs X on a visit to Mr Y’s home on 25 June. The OT felt Mr Y may lack capacity to make decisions about his care and support. As a result, she referred Mr Y for a capacity assessment. In addition, the OT made a referral for an Independent Mental Capacity Advocate (IMCA) to support Mr Y to make decisions.
- It appears an IMCA visited Mr Y at the care home on 1 August. A social worker was also present. In addition, Mr Y’s granddaughter, who was visiting him, attended.
- Based on the case records available to me, it seems that neither the IMCA nor the social worker kept a record of this meeting. As a result, I am unable to establish exactly what was discussed. This is evidence of poor record keeping and represents fault by the Council.
- I consider it unlikely, on balance of probabilities, that the social worker told Mr Y’s granddaughter that Mrs X no longer wished to be involved in his care. This is because I found no evidence elsewhere in the case records to suggest that Council officers were attempting to limit Mrs X’s involvement in the case or that they believed she did not wish to be involved.
- Nevertheless, I consider the failure to keep a record of the meeting on 1 August contributed to the confusion on this point. This caused Mrs X unnecessary distress and uncertainty.
- Mrs X complains that the Council delayed in initiating the CHC process for Mr Y and failed to ensure he was properly supported through this process.
- The Council’s records suggest Mrs X first raised the possibility of CHC funding with a social worker during a telephone conversation on 26 September.
- In October, the care home manager referred Mr Y to the local community integrated services team for a CHC assessment.
- On 13 November, a district nurse visited Mr Y to complete a CHC checklist. However, Mr Y would not consent to this process as he felt he did not need nursing or specialist care. The CHC process ceased at this point.
- On 17 January 2020, a social worker agreed to arrange a further CHC checklist for Mr Y. A Council manager visited Mr Y at the care home on 31 January to complete this. Mrs X and a social worker were also present. The completed checklist indicated that Mr Y may be eligible for CHC funding and that a full multidisciplinary assessment was needed.
- The Council manager submitted the completed checklist to the CCG on 11 February. However, the CHC assessment process was suspended in March due to the emerging COVID-19 pandemic.
- In her complaint to the Ombudsmen, Mrs X said she should have been invited to attend the visit in November 2019. She said Mr Y was generally unwilling to provide consent unless she was present to support him.
- While I appreciate Mrs X’s frustration, it was the responsibility of the district nurse who conducted the initial visited to establish who Mr Y wanted to be present to support him. I understand the district nurse was employed by a different NHS Trust that was not included within my investigation. As a result, I am unable to say why Mrs X was not invited to be present at the visit. However, I found no evidence of fault on the part of the Council in this regard.
- The case records show the Council subsequently completed a further CHC checklist at Mrs X’s request. While this process was not completed before Mr Y’s death in April 2020, this does not appear to have been the result of undue delay by the Council. Rather, the decision to suspend the assessment process was made by the CCG in keeping with the COVID-19 Hospital Discharge Service Requirements that were introduced in March 2020.
- Mrs X complains that the Council sent confidential bills for Mr Y’s care to her, even though she did not have Lasting Power of Attorney (LPA) for his finances and did not want to be involved with this aspect of his care.
- In response to my enquiries, the Council acknowledged Mrs X did not have LPA for Mr Y. However, the Council said Mrs X provided a social worker with her address so she could support Mr Y with correspondence relating to his care and support. The Council said this would include the financial assessment and care invoices.
- The case records show the Council referred Mr Y to the local IMCA service in July 2019. The referring officer noted that Mr Y’s capacity fluctuated and that he needed to be supported to decide where he wished to live. The officer noted that “[Mr Y] does not wish for his daughter to [manage] his finances, nor does she want [to].”
- A social worker discussed charging with Mrs X and Mr Y on 19 August. The social worker noted that Mr Y “informed me he deals with his finances, but when asked how much he has and information related to his financial affairs he looked at [Mrs X] for guidance, who explained she doesn’t have anything to do with his money, only on the occasions when [Mr Y] has asked her.”
- At a further meeting on 5 September, Mrs X told the social worker that she “doesn’t have access to her father’s finances…[Mrs X] does not want to play an active role with his finances and neither with the completion of the financial assessment form.”
- The case records contain clear evidence that shows Mrs X did not agree to support Mr Y with the financial assessment and care charging process. On this basis, I share Mrs X’s view that it was not appropriate for the Council to send Mr Y’s confidential financial information to her. This was fault.
- However, I am satisfied this did not result in a significant injustice to Mr Y. This is because the case records show Mrs X was otherwise actively involved in Mr Y’s care and that he welcomed her support and input.
Hospital discharge – July 2019
- Mrs X complains that, during a further hospital admission for Mr Y in July 2019, the Mid Essex Trust told her he would be moved to a ward. However, Mrs X says the Mid Essex Trust instead discharged Mr Y back to the care home without discharge information.
- The Mid Essex Trust said Mr Y was admitted on 13 July 2019 suffering from chest pain. The Mid Essex Trust said that observations and an ECG revealed no significant changes. The Mid Essex Trust said Mr Y took some pain relief medication and reported feeling well. He was then discharged back to the care home. The Mid Essex Trust added that it sent a discharge letter to Mr Y’s GP on the day of his discharge.
- The clinical records confirm that Mr Y was admitted to hospital on 13 July with a sudden onset of chest pain, radiating to his right arm and leg. An ECG carried out by the ambulance crew revealed that Mr Y had Atrial Fibrillation (a heart condition causing an irregular heartbeat). I was unable to locate a copy of this ECG in the clinical records.
- The clinical team arranged two further ECGs and took Mr Y’s observations. The ECGs revealed Mr Y had a normal heart rhythm and the clinical observations were recorded as within normal parameters. A reviewing doctor noted that Mr Y “feels well in himself” having taken paracetamol for pain relief.
- The clinical team also arranged blood tests for Mr Y. These revealed an elevated level of Troponin (a protein that can be released into the blood following a heart attack). However, the treating doctor felt this was likely linked to Mr Y’s long-term lung and kidney problems rather than a heart attack. The doctor made a diagnosis of non-cardiac chest pain.
- The doctor arranged a further blood test to measure Mr Y’s Troponin levels. He documented that, if there was no rise in Mr Y’s Troponin levels, he could be discharged back to the care home. The blood test revealed that Mr Y’s Troponin levels had dropped and he was discharged later that day.
- I was unable to identify any notes in the clinical records of conversations between the clinical team and Mrs X during Mr Y’s admission. As a result, I cannot comment further on Mrs X’s recollection that she was told Mr Y would be admitted to a ward. The records show the clinical team did not intend to admit Mr Y unless the second blood test revealed a rise in his Troponin levels. As the tests revealed the levels had dropped, the discharge proceeded.
- In summary, the ECG undertaken by the ambulance crew that transported Mr Y to hospital suggested initially that he may be suffering from Atrial Fibrillation. Subsequent tests completed by the Mid Essex Trust revealed no abnormalities. On this basis, the clinical evidence appears to support the decision to discharge Mr Y. I found no fault by the Mid Essex Trust in this regard.
- Mrs X was also concerned that Mr Y was discharged without any discharge information. I reviewed the clinical records and these confirm the Mid Essex Trust wrote to Mr Y’s GP with a discharge summary on the day of his discharge. Again, I found no fault by the Mid Essex Trust here.
Long-term health conditions
- Mrs X explained that Mr Y remained registered with his long-term GP surgery despite having been admitted to the care home, which was affiliated with the Practice. Mrs X said this meant Mr Y was not receiving care for his long-term health conditions as the original GP surgery could no longer support him and the Practice provided only limited care. Mrs X said Mr Y was not registered with the Practice until February 2020, despite her repeatedly requesting this be done.
- Mr Y was registered with the Practice as a temporary patient when he was initially admitted to the care home in April 2019. The case records show that, between April 2019 and February 2020, efforts were ongoing to make arrangements for Mr Y’s long-term care and where he wanted to live. This was evidently a long and complex process.
- There were various factors that contributed to this. The evidence I saw showed Mr Y’s capacity to make decisions fluctuated throughout this period. This meant it was not always possible for Council officers to obtain his views about his care and finances. The professionals supporting Mr Y felt he could not be safely discharged home without additional support in place. However, Mr Y remained consistently unwilling to pay for a home care package. In addition, there was an ongoing dispute between Mrs X and the Council as to whether Mr Y required a nursing home placement.
- In the meantime, Mr Y remained registered with the Practice as a temporary patient. The case records show Mrs X raised this as an issue with Council officers on several occasions. However, Mr Y did not become a permanent resident at the care home until February 2020. It would not have been appropriate to register Mr Y as a permanent patient until a decision had been made on his long-term accommodation needs.
- The evidence shows GPs from the Practice visited Mr Y regularly throughout his time in the care home. The clinical notes show the visiting GPs provided care for both acute illnesses (such as colds and coughs) and long-term health problems (such as Mr Y’s lung disease) during this period. Furthermore, Mr Y continued to receive medication for his long-term health conditions.
- In addition to the support provided by the Practice, Mr Y was visited regularly by the district nurses and also attended cardiology outpatient appointments.
- In summary, I found no evidence in the clinical records to suggest Mr Y was put at a significant disadvantage by remaining as a temporary patient of the Practice. I found no fault by the Practice in terms of the care it provided during this period.
End of life care
- Mrs X complains that the Practice failed to provide Mr Y with appropriate end of life care and did not send a GP to visit him when he became unwell in March 2020.
- The Practice acknowledged Mr Y had a diagnosis of aortic stenosis and that no further hospital intervention was to be undertaken. However, the Practice said Mr Y’s condition appeared stable and that he did not seem to be at the end of his life. The Practice said the COVID-19 pandemic lockdown restrictions meant GPs could not visit residents in person. Nevertheless, it said GPs continued to carry out consultations by telephone or video link. The Practice said GPs adjusted Mr Y’s medication as a result of telephone consultations and that his treatment would not have been any different if he had been seen face-to-face.
- In February 2020, Mr Y was briefly admitted to Broomfield Hospital under the care of Mid Essex Trust due to his ongoing aortic stenosis. The clinical team felt Mr Y was near the end of his life and that his care would be better managed in the community to avoid causing him unnecessary distress and disruption. The clinical team subsequently discharged Mr Y back to the care home.
- The clinical records show a GP from the Practice visited Mr Y on 18 March. The GP notes Mr Y had a slight cough but appeared generally well. However, the GP found Mr Y had slightly swollen ankles. The GP commenced Mr Y on Furosemide medication (a diuretic drug sometimes used to treat fluid build-up).
- Around this time, the care home went into lockdown as a result of a suspected outbreak of COVID-19. This was to reduce the spread of infection to and from the vulnerable residents.
- The Practice’s prescribing summary shows a GP prescribed antibiotic medication (Clarithromycin) for Mr Y on 24 March. I found no record in the clinical notes of the consultation that led to this prescription. However, subsequent entries in the clinical records lead me to believe this medication was intended to treat a chesty cough.
- On 6 April, a GP completed a telephone consultation. She noted that Mr Y’s swollen ankles had improved with the Furosemide medication. However, Mr Y’s cough had not improved. The GP prescribed an alternative course of antibiotics (Doxycycline) and a steroid medication (Prednisolone).
- A GP completed a further telephone consultation the following day as Mr Y was experiencing ankle pain. The GP discussed this with the care home manager, who advised there was no visible sign of injury. The GP prescribed pain relief medication.
- On 20 April, the care home reported that Mr Y was experiencing chest pain and breathlessness. Following a telephone consultation, a GP prescribed a Glyceryl trinitrate spray (a medication to treat chest pain).
- Mr Y had a fall at the care home on 22 April and suffered a cut to his head. As Mr Y was taking long-term anticoagulant medication, the wound continued to bleed. Mr Y was admitted to hospital that day for treatment. He subsequently returned a positive test for COVID-19.
- Mr Y died in hospital on 24 April.
- In March 2020, the NHS produced guidance for GPs entitled Guidance and standard operating procedures: General practice in the context of coronavirus (COVID-19).
- Section 6 of the guidance emphasises the importance of giving careful consideration to protecting staff and patients from the risk of infection. The guidance says clinicians are responsible for determining the most appropriate mode of consultation taking into account the patient’s needs, clinical circumstances and local COVID-19 risks.
- Mr Y was suffering from aortic valve stenosis and was considered to be very frail. Indeed, the clinicians who treated him during his admission in February 2020 considered him to be near the end of his life. However, the clinical records appear to show that his condition was relatively stable in March and April. I found no evidence to suggest Mr Y was significantly acutely unwell at that stage.
- In the circumstances, given the risk posed to the residents of the care home by the COVID-19 pandemic, I am satisfied the Practice's decision to conduct telephone or video consultations was appropriate and in keeping with the guidance.
- The notes of these consultations show the GPs recorded Mr Y’s presenting symptoms and clinical history and set out clear treatment plans. The evidence also suggests the GPs were responsive to changes in Mr Y’s presentation.
- Furthermore, it is important to note that, even if Mr Y had become acutely unwell, this would not have changed the course of his treatment. This is because it had already been decided that his care would be managed in the community. Indeed, it was only the bleeding caused by Mr X’s fall on 22 April that made an admission necessary.
- I consider the care provided to Mr Y by the Practice in March and April to have been appropriate and in keeping with good clinical practice.
Hospital admission – April 2020
- Mrs X complains that the Mid Essex Trust allowed Mr Y to become dehydrated during his admission. She says the Mid Essex Trust failed to keep her updated about Mr Y’s condition and would not let her speak to him. Furthermore, Mrs X said the Mid Essex Trust did not inform her for several hours that Mr Y had died.
- The Mid Essex Trust acknowledged Mrs X had overheard a healthcare assistant telling Mr Y that she was too busy to get him a drink. The Mid Essex Trust said it addressed this matter with the healthcare assistant involved and apologised to Mrs X.
- In 2012, the National Institute for Health and Care Excellence (NICE) produced guidance entitled Patient experience in adult NHS services: improving the experience of care for people using adult NHS services [CG138]. Section 1.2.1 of this guidance emphasises the importance of treating patients with “respect, kindness, dignity, compassion, understanding, courtesy and honesty”. The evidence shows Mid Essex Trust staff failed to observe these standards on this occasion. This is fault.
- This incident was understandably distressing for Mrs X. However, I am satisfied the Mid Essex Trust took appropriate action to put matters right by apologising to Mrs X and addressing the matter with the healthcare assistant.
- With regards to Mr Y’s hydration levels more generally, the Mid Essex Trust said it administered intravenous fluids to Mr Y on the evening of 23 April after Mrs X reported that Mr Y was dry. Nevertheless, the Mid Essex Trust said the results of blood tests taken prior to this did not indicate dehydration.
- I found no evidence in the clinical records, including the blood tests taken on Mr Y’s admission, to suggest he was dehydrated.
- The clinical records contain a note recorded by a nurse at 10.00pm on 23 April. She noted that she had spoken to Mrs X and that she “was very concern[ed] re care [Mr Y] is getting and stated that [he] was very dry in the morning not having enough fluid”. The nurse went on to note that the on-call doctor had prescribed intravenous fluids for Mr Y.
- The evidence suggests Mr Y was not dehydrated during this admission. However, the clinical team administered fluids to make Mr Y more comfortable. This suggest staff were trying to be responsive to Mr Y’s needs. I find no fault by the Mid Essex Trust on this point.
- Mrs X also complained that staff failed to keep her updated about Mr Y’s condition and delayed in notifying her when he died.
- The Mid Essex Trust said Mr Y had been admitted at the height of the COVID-19 pandemic and that this meant families could not visit. However, it said Mr Y’s family could speak to him on the phone. The Mid Essex Trust acknowledged there had been a delay in notifying Mrs X of Mr Y’s death but said this was because staff were required to prioritise the clinical needs of some of the patients on the ward whose condition were deteriorating. It apologised for this delay.
- The clinical records show staff provided Mrs X with updates on Mr Y’s condition on the evening of 22 April and the afternoon of 23 April. Shortly after this, Mr Y suffered a fall on the ward. A member of staff attempted to contact Mrs X at 6.20pm on 23 April to advise her of this. However, the call did not connect. The same member of staff made a further unsuccessful attempt to contact Mrs Y at 7.40pm that evening. At 10.00pm, a member of staff recorded that she had spoken to Mrs X.
- The records show staff tried to keep Mrs X updated during a very busy period in the hospital. There was some delay between Mr Y’s fall and a member of staff contacting Mrs X. However, there is evidence that staff attempted to speak to her during this time, albeit without success. I found no fault by the Mid Essex Trust in this matter.
- The clinical records show staff found Mr Y unresponsive at 3.00am on 24 April. The on-call doctor, who was present on the ward, pronounced Mr Y dead at 3.25am. I understand staff did not contact Mrs X until 6.30am to inform her of this. A consultant subsequently spoke to Mrs X at 10.30am to discuss her concerns about Mr Y’s care.
- The Mid Essex Trust accepted that staff should have contacted Mrs X as soon as possible to notify her of Mr Y’s death. The available evidence shows there was, in fact, a delay of around three hours before anyone did so.
- Nevertheless, I recognise the hospital was exceptionally busy at that time due to the COVID-19 pandemic. I also accept this meant staff were required to prioritise care for those patients who were seriously unwell or deteriorating.
- I understand this delay must have been very distressing for Mrs X. However, in the circumstances, I do not consider the delay to be so significant as to warrant a finding of fault by the Mid Essex Trust. In my view, the Mid Essex Trust’s apology to Mrs X represents a proportionate remedy for the distress caused to her by the delay.
- Within one month of my final decision statement, the Princess Alexandra Trust and Council will each write to Mrs X, apologising for the distress caused to her and Mr Y by:
- The Princess Alexandra Trust’s failure to ensure Mrs X was present to support Mr Y when he was initially triaged in the emergency department on 13 April 2019.
- The Princess Alexandra Trust’s failure to properly consider Mr Y’s care needs when planning his proposed discharge on 15 April 2019.
- Their shared failure to properly discuss with Mr Y and Mrs X the proposed transfer to the community hospital on 17 April 2019.
- Their shared failure to discuss the proposed care home placement with Mr Y and obtain his consent for this move.
- The Council’s failure to keep a record of the meeting of 1 August 2019 when Mr Y was visited at the care home by a social worker and IMCA.
- In addition, the Princess Alexandra Trust and Council will each pay Mrs X £100 in recognition of the distress caused to her by the fault I have identified.
- Within three months of my final decision statement, the Princess Alexandra Trust and Council will review all relevant discharge planning policies and procedures to ensure they reflect the key practises and principles set out in ‘Ready to go?’ and other relevant guidance. This should ensure that:
- Patients and carers are involved in the discharge planning process to enable them to make informed decisions about their care.
- Staff maintain clear and accurate records, including keeping notes of any discussions with patients and their carers.
- Staff robustly assess a patient’s health and social care needs as part of the discharge planning process and develop a clear care plan setting out how these needs will be met in the community.
- The Princess Alexandra Trust and Council will write to the Ombudsmen to explain the outcome of the review and any work they will be undertaking to improve practises and procedures in this area. They will also explain how they will ensure relevant staff are familiar with these practises and procedures.
- I found fault by the Princess Alexandra Trust and Council with regards to the handling of Mr Y’s discharge from hospital in April 2019.
- I am satisfied the actions these organisations have agreed to undertake represent a reasonable and proportionate remedy to the injustice caused to Mr Y and Mrs X by this fault.
- I found no fault by the Mid Essex Trust or Practice in terms of the care they provided to Mr Y.
- I have now completed my investigation on this basis.
Investigator's decision on behalf of the Ombudsman