The Ombudsman's final decision:
Summary: We find fault with an NHS Trust and Council regarding the discharge planning process for the late Mr Y when he left hospital. The NHS Trust also failed to ensure Mr Y continued to receive treatment for a fungal infection. The Council failed to assess Mr Y’s care needs and its care provider failed to properly assess and meet Mr Y’s needs. The Council failed to properly investigate the safeguarding concern raised when Mr Y was readmitted to hospital and did not notify Mr Y’s daughter, Ms X, of the outcome. This meant Mr Y did not receive the care and support needed after his hospital discharge. The organisations have agreed to apologise to Ms X and make a symbolic payment to acknowledge the distress this caused her. The organisations have also agreed to take action to prevent a recurrence of the faults identified.
- Ms X complained about faults in the way Princess Alexandra Hospital NHS Trust (the Trust) and Essex County Council arranged her father Mr Y’s discharge from hospital on 12 November 2019. She says this meant he was discharged in the morning when his care package was not due to start until that evening, leaving him without care for the day. She also complained the Council’s care provider, ECL (the care provider), failed to provide her father with adequate care, so her father was re-admitted to hospital with no dignity and in pain, with a moisture lesion in his groin and faeces on his bottom. Ms X is seeking an apology and financial payment to acknowledge the time and effort she was put to in having to check Mr Y was being properly cared for. She is also seeking service improvements to prevent the same thing happening to others.
The Ombudsmen’s role and powers
- 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,as amended, and Health Service Commissioners Act 1993, section 18ZA)
- 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 reaching this decision, I considered information provided by Ms X, including the care provider’s daily records 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.
- I invited comments on a draft of this decision statement from all parties to the complaint and considered what they said before I made a final decision.
- Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share the decision on this complaint with CQC.
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 care worker in your decision; and
- involve patients and care workers so they can make informed decisions and choices that deliver a personalised care pathway and maximise their independence.
The Gold Standards Framework
- The Gold Standards Framework approach provides practical guidance for clinicians to help recognise when a patient is declining and considered to be in the final years of life. It aims to enable better assessment of their needs and more proactive planning for care in line with the patient’s needs and wishes.
- 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 care worker or any other person they might want involved.
- The Care and Support Statutory Guidance (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”.
- Intermediate care and reablement support services are for people after they have left hospital or when they are at risk of having to go into hospital. They are time limited and aim to help a person to preserve or regain the ability to live independently.
- A council must make necessary enquiries if it has reason to think a person may be at risk of abuse or neglect and has needs for care and support which mean he or she cannot protect himself or herself. It must also decide whether it or another person or agency should take any action to protect the person from abuse or risk. This is a safeguarding enquiry. (Section 42, Care Act 2014)
The fundamental standards of care
- The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards those registered to provide care services must achieve. The Care Quality Commission (CQC) has issued guidance on how to meet the fundamental standards below which care must never fall.
- Regulation 9 requires care and treatment to be appropriate and person-centred based on an assessment of their needs and preferences.
- Regulation 10 sets out that service users must be treated with dignity and respect. Staff must respect people’s personal preferences, lifestyle and care choices.
- Regulation 14 is about meeting nutritional and hydration needs. Providers must make sure people have enough to eat and drink to meet their nutrition and hydration needs and receive the support they need to do so.
- Regulation 17 is about good governance. This includes keeping accurate, complete and detailed records about people receiving care, including records of care provided and decisions made relating to care.
- Mr Y had a number of physical health conditions including lung disease, heart issues and cellulitis in his legs. He was hospitalised several times in 2019 related to his health and breathing difficulties. He lived in sheltered accommodation. In September 2019 he had previously received reablement support from the provider of two calls a day following a hospital discharge. The care provider assisted him with meal preparation and applying creams but not with personal care. This ended when Mr Y was admitted to hospital again. The following is a summary of the key events relevant to this complaint.
- In October 2019 Mr Y was admitted to hospital due to chest pain, shortness of breath and increased pain in his legs.
- The nursing notes record Mr Y was alert, on oxygen, tolerated eating and drinking and was able to use the commode at his bedside. The Trust started to wean Mr Y off the oxygen.
- The Trust spoke with Mr Y and his grandson. It noted he needed assistance with his care needs. Mr Y’s grandson was concerned about his repeated hospital admissions. The Trust advised it planned to refer Mr Y for physiotherapy/occupational therapy (PT/OT) input and to look at increasing Mr Y’s care package. The PT/OT assessed Mr Y and noted he required oxygen when mobilising and at present did not use oxygen at home. Previously he had reported he could walk 20 metres at home. They agreed to reassess after a week at which point Mr Y was able to mobilise with a frame and could transfer from bed to chair.
- Over the following days the Trust stopped Mr Y’s oxygen therapy and noted he was ‘fine on room air’.
- The Trust spoke to Mr Y later that week. Mr Y said he took his medication every day as per the Dossett box (where medicines are organised by day of the week and time of day). The Trust noted that in the Dossett box issued on 20 September 2019 only one morning dose was taken out of the box. So it appeared Mr Y had not been taking his medication.
- On 18 October 2019 the nursing notes record Mr Y was alert and orientated, still on room air, was eating and drinking fine and taking his medication. They questioned whether he was approaching being medically fit for discharge. However, Mr Y’s condition deteriorated the next day and Mr Y later started needing oxygen therapy again. On 22 October a nurse also noted Mr Y appeared to have thrush around the groin area.
- Over the following week, Mr Y required assistance with personal care and had increasing episodes of incontinence. He was assisted to use a commode and also used continence products which were regularly changed. On 29 October the Trust assessed Mr Y required assistance from one person with all transfers and he would need carer support on discharge.
- On 31 October 2019 the Trust noted Mr Y had a moisture lesion on his groin.
- On 1 November 2019 the Trust noted Mr Y required assistance from one person with transfers and recommended he received an increased package of care when he returned home. The Trust noted it needed to reduce the amount of oxygen Mr Y needed and noted he still had thrush in his groin which it treated with an anti-fungal cream.
- The Trust completed a referral for care and support to the Council which gave an estimated discharge date of 8 November. The referral noted Mr Y was not independent with medication. He needed the assistance of one with washing and dressing, he could mobilise but needed the assistance of one member of staff to do so. The referral listed Mr Y’s next of kin as Ms X and Mr Y’s son.
- The Trust met with Mr Y’s grandson and Mr Y’s partner on 7 November. It explained it planned to discharge Mr Y the next day once oxygen was delivered and a care package was in place. Mr Y’s grandson was concerned how Mr Y would cope between care calls as he was now only able to transfer from bed to his chair with assistance. The Trust apologised for not informing them of the planned discharge earlier. It advised 24 hour supervision usually meant a nursing home admission. Mr Y did not have care before admission, and it would usually trial care at home first. Mr Y’s grandson said Mr Y was very independent and would not want a nursing home.
- The care provider advised it could accept the referral for reablement with the first visit starting at tea time on 11 November. The Council updated the Trust. The Trust’s notes record Mr Y still had thrush and the Trust continued to apply anti-fungal cream to his groin. On 11 November 2019 the Trust’s notes record Mr Y was due to be discharged but it had changed his medication and he needed a Dosett box preparing so the discharge was delayed to the following day.
- The Trust’s nursing notes of 12 November noted Mr Y required the assistance of two with his care. He was doubly incontinent and eating and drinking fine. The Council advised the Trust Mr Y’s care package would start that evening.
- Later that morning the Trust discharged Mr Y with long term oxygen therapy, that is for Mr Y to have oxygen at home for use 18 hours a day. The discharge summary noted ‘mobility declined during his long hospital admission and he now requires assistance to transfer from bed to chair. He is being discharged home with a package of care. At present [Mr Y] is not keen on the idea of a care home. He is at very high risk of re-admission due to frailty and multiple co-morbidities’.
- There were around 25 different medications listed on Mr Y’s records. He was discharged with one week’s medication in a Dossett box. The medication list does not include anti-fungal cream and there is no reference to Mr Y having thrush in the discharge summary.
Following Mr Y’s discharge
- On 12 November the Trust informed the hospital social care assessment team that Mr Y was discharged that day.
- Ms X lives some distance from Mr Y. Her son visited that day and found Mr Y incontinent and in a state of undress. Ms X contacted a friend who attended and assisted Mr Y to get showered and changed.
- The care provider carried out an assessment of Mr Y in the evening of 12 November 2019. It noted Mr Y had capacity and had no problem communicating his needs. It noted Mr Y:
- used a walking frame.
- managed his own medication but needed help creaming his legs.
- needed support to have a shower or full body wash if he was ‘having a bad day’.
- needed support to get dressed and undressed
- needed support with meal preparation
- needed the commode emptying.
The safeguarding investigation
- The Council allocated a social worker to consider the safeguarding referral. The records show they spoke to the care provider. They noted the care provider did not complete a body map when it started the care package. The social worker considered the concern met the threshold for a safeguarding enquiry. The social worker noted they contacted Mr Y’s wife who did not want to get involved. There is no evidence they contacted Ms X or Mr Y’s son who were listed as Mr Y’s next of kin on the hospital referral to the Council.
- The safeguarding enquiry noted the care provider did not have the daily care records as they were at Mr Y’s property. They noted the support plan showed Mr Y was independent with personal care and the care workers only provided support with getting up and getting dressed. As Mr Y had died they could not obtain his input. The social worker concluded the concern was not substantiated. They noted Mr Y had capacity to make decisions around how he wanted his care and support needs met. They noted Mr Y was deceased and ‘all efforts made to feedback to Mrs Y and daughter to no avail’.
The complaint response
- In December 2019 Ms X complained to the NHS Trust. The NHS Clinical Commissioning Group (CCG) responded in April on the Trust’s behalf. It accepted that as the care package was starting in the evening Mr Y should have been discharged after lunch and not in the morning. It said it was unacceptable Mr Y was left on his own for a longer period with no provision made for lunch. The first visit by a care worker was at teatime to assess his needs but personal care should have been carried out that evening.
- The Trust said the medical records show Mr Y’s grandson was spoken to on 7 November regarding his pending discharge home. It noted Mr Y’s grandson said Mr Y would not have wanted to go to a care home and would prefer to be discharged home. It said there was no evidence to suggest Mr Y was included in the conversation or asked regarding his preferred place of care.
- It noted Mr Y was admitted to hospital six times in the last year of his life and staff failed to recognise he may be approaching the last year of his life. It said it should have followed the Gold Standard Framework and discussed his medical treatment and preferred place of care.
- In its response the CCG said the Trust had agreed with the Council that it would respond directly to Ms X. Ms X did not receive any response from the Council. Ms X remained unhappy and complained to the Ombudsmen.
Council response to my enquiries
- In response to my enquiries the Council said it had not been previously aware of the concerns in this case. It had reviewed the case notes and found shortcomings in the management of Mr Y’s case. It did not complete a robust assessment at the point of Mr Y’s discharge and the reablement offer did not appear appropriate for Mr Y. The Council offered to apologise and pay Ms X £250 to acknowledge the distress caused to the family.
- The ‘Ready to go’ guidance stresses the importance of involving patients (and care workers) in the discharge planning process to ensure they can make informed decisions about their care. While records show discussions took place with Mr Y on 29 October and 1 November there is no record of a detailed discussion with Mr Y about the practicalities of the plans for his actual discharge between 2 November and his discharge date of 12 November. The Trust spoke with Mr Y’s grandson and partner on 7 November but, as acknowledged in the CCG’s complaint response, there was no evidence Mr Y was included in the discussion. The Council failed to meet with Mr Y or to contact the Trust for further information on Mr Y’s care needs. The Council has accepted it did not complete a robust assessment of Mr Y’s needs before his discharge. The failure to properly assess Mr Y and to coordinate his discharge was fault by the Council and the Trust. This meant he was discharged early before his care package started and the package in place was not appropriate to meet his needs.
- The Trust has already acknowledged that given Mr Y was admitted to hospital six times that year, staff failed to recognise he may be approaching the last year of his life. It said it should have followed the Gold Standard Framework and discussed his medical treatment and preferred place of care. Its failure to do so was fault.
- Mr Y was keen to go home, and it is likely he would still have chosen to do so rather than go into a care home. However, if further discussion had taken place Mr Y may have had a more realistic appreciation of his care needs and would have been able to express his wishes for future care and support moving forward.
Mr Y’s care package
- The hospital discharge noted Mr Y could mobilise with the assistance of one, he also needed assistance with washing and dressing. The Trust’s records from during his hospital admission show:
- Mr Y had frequent episodes of incontinence
- Needed assistance from a care worker with all transfers
- Needed assistance from a care worker with personal care
- Had thrush and at one point had a moisture lesion
- Had not been taking his medication regularly prior to his hospital admission
Mr Y’s treatment for a fungal infection
- The Trust’s records show Mr Y had a moisture lesion on 31 October and had thrush on his groin on 11 November which was being treated with an anti-fungal cream. There is no reference to this in the discharge summary or list of discharge medication and there is no anti-fungal cream listed on his medications when he was discharged. It is likely Mr Y’s groin area was still affected with thrush at his point of discharge. The failure to ensure he continued to receive treatment for thrush is fault by the Trust. This is likely to have contributed to the poor condition of Mr Y's groin on his hospital readmission and is likely to have caused him significant discomfort.
- The care provider failed to complete a body map when it started supporting Mr Y. This is fault. On this basis I cannot know whether Mr Y still had a moisture lesion at the point of discharge or if this developed over the next few days. Had it done so it may also have noticed Mr Y’s thrush and taken action to ensure it was treated.
The safeguarding investigation
- The Emergency Department raised a safeguarding alert with the Council based on Mr Y’s presentation when he was re-admitted to hospital. The social worker spoke to the care provider but did not see a copy of the daily records as these remained in Mr Y’s property. The records show they spoke to Mr Y’s ‘wife’ who I believe may have been his partner who did not live with Mr Y and did not want to be involved. They were also unable to speak with Mr Y as he had died.
- The social worker found the allegation unsubstantiated. This was based on the care provider’s needs assessment and support plan and that Mr Y was independent with his personal care. They did not see a copy of the daily records as they said these were at Mr Y’s property. Ms X has found these and provided me with a copy. The Council and its care provider failed to show due regard to regulation 17 of the fundamental standards of care. It was the Council and care provider’s responsibility to ensure they kept accurate and complete records of Mr Y’s care and they did not do so.
- There is no evidence the social worker considered the hospital referral to social care or sought Ms X or Mr Y’s son’s input who were listed on the hospital referral as Mr Y’s next of kin. They had noted no body map was completed but did not refer to this in the outcome. The Council has also accepted the referral to reablement was not appropriate given Mr Y’s condition. The failure to properly investigate the safeguarding allegation was fault.
- The notes record the social worker tried to contact Ms X with the outcome although I have seen no evidence to support this. It was also open to the Council to write to Ms X with the outcome of the safeguarding enquiry but it did not do so. Had it done so it is likely Ms X would have communicated her concerns to the Council. The failure to notify Ms X of the outcome of the safeguarding enquiry was fault.
Summary of injustice
- Mr Y had a number of serious health conditions and his condition was deteriorating throughout the year with several hospital admissions. Mr Y was also very independent and so I cannot know to what extent he would have accepted more support had it been more clearly identified and offered. However, the faults identified impacted upon Mr Y’s dignity and meant he did not receive the care and support he needed before his final admission to hospital. Mr Y has died and therefore the injustice caused to him by the faults identified cannot be remedied. However, Ms X was caused distress by the faults identified and has been left with a sense of uncertainty over what would have happened had the faults not occurred. The injustice of distress cannot generally be remedied by a payment, so we seek a symbolic amount to acknowledge the impact of the fault.
- Within one month of the final decision on this complaint the Council and Trust have agreed to write to Ms X to apologise for the distress caused to her and the family by the faults identified which in summary were:
- The Trust and Council’s failure to properly coordinate Mr Y’s hospital discharge;
- The Trust’s failure to follow the Gold Standard Framework;
- The Council’s failure to properly assess Mr Y’s needs and the Council’s care provider’s failure to properly assess and meet Mr Y’s needs;
- The Trust’s failure to ensure Mr Y continued to receive treatment for thrush; and
- The Council’s failure to properly investigate the safeguarding concern and to advise Ms X of the outcome.
- remind its care provider of the need to complete a body map at the start of a care package.
- ensure its care provider maintains copies of records in line with regulation 17 and that it has procedures in place to retrieve records when service users have died.
- remind officers of the need to ensure they consider which next of kin to consult as part of a safeguarding investigation and to notify them of the outcome.
- provide guidance or training to relevant Council staff of the need to investigate safeguarding enquiries in line with relevant law and guidance.
- Patients and care workers 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 care workers.
- 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.
- I have completed my investigation. There was fault by the Council, its care provider and the NHS Trust. The organisations have agreed to take action to remedy the injustice the faults caused.
Investigator's decision on behalf of the Ombudsman