Summary: Mrs B complained about nursing, personal care, and discharge planning provided to her mother, Mrs E. We found fault by the Trust, in personal care, record-keeping and moving and handling. We also found fault by the Council by not involving Mrs B in the discharge planning meeting. The Council and Trust have agreed to apologise to Mrs B and take steps to improve their services. They have also agreed to pay a financial remedy in view of the distress caused to Mrs B.

The complaint

1. Mrs B complains about the nursing and personal care provided to her late mother, Mrs E, while she was in hospital during June and July 2019, and about delayed discharge home. She said that Mrs E had cognitive impairment which meant she could not always communicate or consent to care. Specifically, Mrs B complains that while Mrs E was in hospital, her hair was cut without consent, she was left in soiled bedding, and she was not treated with dignity when transferring from bed to chair, leading to falls. She also raises concerns about dehydration and lack of nutrition. Mrs B says the Trust lost Mrs E’s dentures, further impacting her ability to communicate.
2. She says that Mrs E deteriorated as a result, and her care package had to be increased. She complains that even though she was medically fit, Mrs E’s discharge was delayed because of problems getting sufficient care in place to meet her increased care needs. Mrs B says she was not involved as she should have been in planning Mrs E’s discharge from hospital.
3. Mrs B says these events caused Mrs E unnecessary pain, anxiety and great distress. She says she was not treated with the respect or care she should have received during her final illness.

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The Ombudsmen’s role and powers

4. 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).
5. 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.
6. 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

7. During my investigation of this complaint, I considered information provided to us by Mrs B. I wrote to the Council and Trust to tell them what I intended to investigate, and request copies of relevant records. I considered the comments and documents they sent. I have also considered the law and guidance relevant to this complaint.
8. I also took advice from a clinical adviser, a nurse.
9. Mrs B, 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

10. Mrs E had a diagnosis of dementia. In June 2019, she was admitted to hospital with a possible stroke (right-sided weakness). She remained in hospital for just over five weeks before being discharged back to her sheltered housing with an increased package of care.
11. Mrs E’s daughter, Mrs B, raised several concerns about the care provided to Mrs E, and about the way her discharge was arranged by the Trust and Council. I have grouped these issues under separate headings, below.

Nutrition and dehydration

12. Mrs B said her mother did not receive adequate food or fluids during her admission to hospital. The Trust assessed Mrs E’s nutrition needs when she was admitted to hospital, and again on two further occasions during her admission. In doing so, the Trust used the Malnutrition Universal Screening Tool (MUST), which is used to identify adults who are malnourished or at risk of malnutrition. This showed that Mrs E was at low risk from malnutrition.
13. A plan was made for a weekly MUST screening to be done, and that nurses should refer Mrs E to a dietician if there were any further concerns. There was also evidence within the records that nursing staff were aware of the need to assist, encourage and prompt Mrs E with her food and fluid intake. Speech and language therapists were also appropriately involved in identifying the most suitable consistency of food and fluid for Mrs E.
14. The records indicate a food chart was completed appropriately and consistently throughout Mrs E’s admission. This recorded the amount and type of food taken. However, I have seen only one fluid chart for Mrs E’s admission. A fluid chart records the ongoing volume of fluid taken by mouth, intravenously or by any other route. Further fluid charts would have indicated whether Mrs E had achieved her fluid target of 1000mls every 24 hours. Fluid intake was documented regularly in the daily nursing records, but I have not seen an ongoing record of total input. Some documentation of correlation between renal function and fluid input would have indicated Mrs E’s level of hydration, but this was not available in the records I have seen. There is some evidence within the records that nursing staff escalated concerns about fluid intake to medical staff, and subcutaneous fluids were then started. However, based on the records I have seen, I am unable to say whether Mrs E received appropriate fluid input.

Hair cut without consent

15. Mrs B complained that Mrs E’s hair was cut without her consent, leaving a large bare patch of scalp. Mrs B also said nobody at the Trust discussed it with her beforehand, even though she had lasting power of attorney for Mrs E.
16. The Nursing and Midwifery Council Code (Professional standards of practice and behaviour for nurses, midwifes and nursing associates, 2017) states “You must… make sure that [patients’] dignity is preserved… encourage and empower people to share decisions about their treatment and care.”
17. During a meeting with Mrs B, the Trust accepted that Mrs E’s hair had been cut while she was on the ward, and said this was because it was tangled and causing her discomfort. The Trust said that its usual protocol is that staff ask the patient’s permission to cut their hair. However, if the patient lacks capacity to give consent, the Trust said it would ask the next of kin wherever possible. The Trust said if there is no next of kin available, a best interest assessment should be undertaken, and is documented in the nursing notes.
18. The Trust’s process as set out above seems reasonable. However, I have seen no documentation to indicate this process was followed in Mrs E’s case. Given that Mrs E was vulnerable because of her dementia diagnosis, and could not always communicate or consent to care, in line with its policy the Trust should have asked her next of kin or taken a best interests decision. However, there is nothing in the records to say that this happened. This was fault, leading to avoidable distress to Mrs E and Mrs B.

Loss of dentures

19. Regarding the loss of Mrs E’s dentures while she was on the ward, the Trust said it was possible they were lost among bed linen which was then changed, and the Trust was not able to search through it all to try and find them. The Trust apologised for this. Mrs B said losing the dentures had a significant impact on Mrs E, as she was not able to eat properly, it affected her smile, and she was not able to sing as she liked to. Mrs B explained it was not possible for Mrs E to be fitted for new dentures, as she was unlikely to have tolerated this because of her dementia diagnosis.
20. The Trust accepted staff could learn from Mrs B’s complaint in terms of the impact of loss of dentures on patients and their families. The Trust set out the steps it had taken to prevent patients losing dentures since Mrs B’s complaint. It introduced a pilot project where it purchased trays for patients, so all belongings (including spectacles, dentures and hearing aids) were kept together. However, the Trust found this did not improve loss of dentures because patients did not always place their dentures back on the tray. The Trust explained its current practice is that when admitted, all patients with dentures are given a denture pot labelled with their name and ward. A patient’s property sheet is also completed to show the patient has dentures, a copy given to the patient and another filed with the ward records and kept electronically.
21. I recognise the impact the loss of Mrs E’s dentures had on her, and on Mrs B. However, the Trust has accepted and appropriately apologised for this. The Trust has also taken reasonable steps to prevent recurrence, but will take further action in terms of monitoring and evaluating these changes to measure their impact.

Falls and mobility on the ward

22. Mrs B said Mrs E was unable to use a standing aid (called a “Re-Turn”) on the ward because she could not grip onto it as she had little function on her right‑hand side. Mrs B also said Mrs E could not follow the instructions given for using the equipment, and that she fell because of problems with transfers. In response to the complaint, the Trust said Mrs E was able to use the equipment safely while on the ward. The Trust added that Mrs E was assessed by the occupational therapy and physiotherapy teams for a different type of equipment to use once she was back home. However, Mrs B said this was not done soon enough, as she had raised concerns previously about transfers.
23. I have seen no evidence that a moving or handling assessment was done when Mrs E was admitted to hospital. This would have identified the most appropriate and safe mode of transfer for Mrs E. On 28 June, the physiotherapy team reviewed Mrs E, and documented that she usually used a walking frame. It was noted that since her admission to hospital, Mrs E had been unable to hold onto the frame and needed assistance from two people when mobilising.
24. A moving and handling assessment was done on 30 June. This said Mrs E’s mobility had deteriorated over the previous month, that she could not transfer by herself, and would usually use a wheelchair. However, the same day it was documented that the Re-Turn aid could be used. The nursing records say that Mrs E could become agitated when having to use the Re-Turn and could let go at times. This resulted in Mrs E having to be lowered to the floor on some occasions. On 8 July, an occupational therapist (OT) documented that Mrs E had fallen while using the Re-Turn. The OT asked the physiotherapy team to reassess Mrs E for suitability for a hoist for transfers. Another moving and handling assessment was done, and a hoist assessment followed.
25. The records I have seen do not suggest Mrs E was able to use the Re-Turn safely. The initial physiotherapy assessment documented Mrs E did not have the strength to hold onto a walking frame. The strength needed to hold onto the Re‑Turn is similar. It was already known that Mrs E’s level of compliance and agitation fluctuated, so it is likely that using the Re-Turn aid would have posed a risk. Furthermore, the moving and handling assessment lacked detail and did not appear to take Mrs E’s dementia diagnosis into account.
26. Therefore, the records indicate that Mrs E did not receive the care she should have done in terms of mobility and transfers on the ward, including the use of the Re-Turn aid.

Discharge from Hospital

27. 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.

28. Mrs B said she was not involved in discharge planning as she should have been. The hospital social work team arranged a discharge planning meeting, also involving Mrs E’s care provider and Trust staff. However, Mrs B could not attend. The Council said it contacted Mrs B after the meeting to update her with the outcome, but acknowledged it should have done more to include Mrs B. The Council apologised to Mrs B for this. The Council also accepted it did not send a copy of the care plan to Mrs B and apologised to her.
29. During our investigation, the Council apologised for any unnecessary distress caused to Mrs E and Mrs B, and said it would take steps to improve communication with people who use its services. The Council also offered to make a payment of £250 to Mrs B in recognition of the distress caused to her. My view is the Council has offered a reasonable remedy to Mrs B to address the failings it acknowledged. I have made a further recommendation in terms of improving its service in this area, below.

Care and support plan

30. 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.
31. 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”.
32. Mrs B complained Mrs E’s discharge was delayed because of a disagreement over the number of care hours required to meet her increased care needs. Mrs B also said the Council tried to change her mother’s previous care provider and it should not have done this.
33. The records indicate that Mrs E’s discharge was initially planned for 11 July 2019. However, this was cancelled because equipment requested by the occupational therapy team to aid Mrs E’s safety at home had not yet been delivered. The records indicate the social work team followed up with the ward to ask that they send a discharge notice as soon as a delivery date for the equipment was known. The records also show the social work team spoke to Mrs B to explain the reason for the change to the discharge date. The equipment was in place by 17 July and Mrs E was discharged the next day.
34. The Council said it did consider another care provider, and this was because it was not initially known if Mrs E’s previous care agency had capacity to provide the increased number of hours. The Council said it agreed with Mrs B that it was in Mrs E’s best interests to have carers who she was familiar with, and that in looking at other providers, it was trying to ensure her increased needs would be fully met on her return home. The records indicate the situation was resolved, as Mrs E’s previous provider confirmed it was able to provide the additional care calls once she returned home. Mrs B said she facilitated this by contacting the provider herself. The records show the Council also followed up with the provider after speaking to Mrs B.
35. I recognise that the possibility of using a different care provider may have caused distress to Mrs E and Mrs B. However, the Council has given a reasonable explanation for considering a new provider. There is no indication that this consideration caused a delay to Mrs E’s discharge from hospital. The records indicate that the query over the care provider was resolved prior to the equipment being ready, and Mrs E was then discharged as planned on 18 July. Therefore, I have not found fault with the Council’s actions on this point.

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Agreed Actions

36. Within one month of my final decision, the Trust will:

• Write to Mrs B to apologise for the distress caused to her by the faults identified above;
• Pay Mrs B £200 in recognition of the impact this had on her.

37. Within three months of my final decision, the Trust will:

• Take action to ensure learning from the complaint about staff cutting Mrs E’s hair without consent, making sure staff are aware of the Trust policy.
• Set out how it will improve record keeping for fluid intake;
• Explain how it will improve moving and handling assessments; and
• Explain how it has or will monitor and evaluate the impact of changes to its policy on patients’ property (dentures).

38. The Trust will also send a copy of its action plan on the points above to NHS Improvement.
39. As referred to above, during our investigation the Council offered an apology and financial remedy to Mrs B of £250 in recognition of any unnecessary distress caused. The Council has agreed to contact Mrs B directly to make this payment within one month of my final decision.
40. Within three months of my final decision, the Council will:

• Take action to improve its communication with and involvement of patients’ families in the discharge process.

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Final decision

41. I found fault by the Trust in terms of not following procedures for cutting patients’ hair, failings in moving and handling, and in record-keeping.
42. I also found fault by the Council in terms of not involving Mrs B in a discharge planning meeting.
43. I am satisfied the actions the Trust and Council have agreed to take represent a reasonable and proportionate remedy for the injustice caused to Mrs B by the failings identified.
44. I have now completed my investigation on this basis.

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Investigator's decision on behalf of the Ombudsman