Summary: Mr A has complained about a Trust and a Council in relation to his father’s discharge from hospital. We found fault with the Trust but not the Council.

The complaint

1. Mr A complains about the care and treatment and the handling of a hospital discharge of his late father, Mr B, by Northumbria Healthcare NHS Foundation Trust (the Trust) and Northumbria County Council (the Council) in October and November 2022.
2. Specifically Mr A complains:

• staff did not carry out a Magnetic Resonance Imaging (MRI) scan when his father was in hospital in October 2022 which led to a delay in diagnosing mini strokes which caused his father’s death,
• staff did not properly assess his father’s ability to make decisions about his care despite his confusion,
• his father was unsafely discharged home instead of being transferred to another hospital (the General Hospital); and
• a doctor misinformed Mr A that his father would make a recovery only to call back and say his father only had hours to live.

3. Mr A believes the Council and the Trust made mistakes which led to his father’s death. In addition, Mr A believes due to these mistakes, his father’s last few weeks were needlessly distressing and painful.
4. Mr A has suffered depression due to the circumstances of this complaint and had to close his business while he recovered.
5. As a result of this complaint Mr A would like compensation for the loss of his father and for the impact on Mr A and his business.

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The Ombudsmen’s role and powers

6. The Local Government and Social Care Ombudsman and Health Service Ombudsman have the power to jointly consider complaints about health and social care. (Local Government Act 1974, section 33ZA, as amended, and Health Service Commissioners Act 1993, section 18ZA). The Local Government and Social Care Ombudsman investigates complaints about adult social care providers. (Local Government Act 1974, sections 34B, and 34C, as amended).
7. The Health Service Ombudsman investigates complaints about ‘maladministration’ and ‘service failure’ in the delivery of health services (Health Service Commissioners Act 1993, section 3(1)).
8. We investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, we 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).
9. If it has, we 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.
10. 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

11. During my investigation I have considered information from the Council, the Trust and Mr A.
12. I also took advice from an independent clinical adviser, and I considered the relevant legislation and guidance.
13. I shared my draft decision with Mr A, the Council and the Trust and gave them the opportunity to comment. Mr A provided comments and I considered those comments before making this final decision.

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What I found

Background

14. In October 2022 Mr B went into hospital with Chronic Obstructive Pulmonary Disorder (COPD) symptoms. COPD is a common lung disease causing restricted airflow and breathing problems. Mr B was confused and the hospital admitted him for four days.
15. Mr B left hospital and went home after his admission. However, he fell that night and an ambulance transported him to hospital the following morning. Mr B had scans which revealed that he had suffered mini strokes. Mr B died a few days later in hospital in early November.

Lack of MRI during first admission

16. Mr A said that his father had suffered mini strokes but these could have occurred before his first admission. He says his father was confused and unsteady on his feet and doctors should have ordered an MRI to diagnose the mini strokes at this time.
17. The Trust said that the plan was to monitor Mr B for a few days in hospital, then a transfer to the General Hospital to see if he improved. If it did not, then it would have looked at other methods to diagnose Mr B’s confusion.
18. The Trust said Mr B was confused on admission but an assessment of confusion which doctors made two days later found there was no objective evidence of confusion.
19. The Trust said there was no clinical reason for an MRI during that first admission.

Analysis

20. The records show the hospital carried out tests to find the cause of Mr B’s confusion and none of these indicated a stroke as the cause. On admission staff carried out a Glasgow Coma Scale test in which Mr B scored 15 out of 15. The Glasgow Coma Scale (GCS) is used to objectively describe the extent of impaired consciousness in all types of medical patients including those who have suffered a fall. The scale assesses patients according to three aspects of responsiveness: eye-opening, motor, and verbal responses. Reporting each of these separately provides a clear picture of a patient.
21. In addition, his confusion had improved after a couple of days. The records also state that after a couple of days, Mr B seemed a lot better.
22. Taking this into account, I do not find fault with the hospital for not sending Mr B for an MRI as it was not indicated by the tests the hospital carried out.

Assessment of capacity

23. Mr A said his father was very confused in hospital and staff should have properly measured his mental capacity to make decisions before following his wishes for his treatment and for his discharge arrangements.
24. The hospital said that never had concerns that he lacked capacity to make his own decisions.

Analysis

25. The Mental Capacity Act 2005 (the MCA) applies to people who may lack mental capacity to make certain decisions. Section 42 of the MCA provides for a Code of Practice (the Code) which sets out steps organisations should take when considering whether someone lacks mental capacity.
26. Both the MCA and the Code start by presuming individuals have capacity unless there is proof to the contrary. The Code says all practicable steps should be taken to support individuals to make their own decisions before concluding someone lacks capacity. The Code says people who make unwise decisions should not automatically be treated as not being able to make decisions. Someone can have capacity and still make unwise decisions.
27. The Code says, at paragraph 2.11, there may be cause for concern if somebody repeatedly makes unwise decisions exposing them to significant risk of harm or exploitation. The Code says this may not necessarily mean the person lacks capacity but further investigation may be required.
28. The hospital records show Mr B advised staff about his capabilities and that he may require some assistance when he went home in relation to shopping.
29. The records also show Mr B wanted to go home and that hospital staff had no concerns about his ability to make these decisions.
30. In accordance with the legislation and guidance, staff did not have concerns over Mr B’s ability to make decisions and so there was no reason to carry out a formal test of his capacity. Therefore, I have not found fault with the Trust in relation to this aspect of the complaint.

Mr B’s discharge

31. Mr A said that the hospital originally planned to send his father to the General Hospital following his first hospital stay. This was for him to recover and for the Trust or Council to organise some care for Mr B at home following his discharge.
32. Mr A said he received a call from the hospital on the morning of his father’s discharge that his father would be transferred to the General Hospital that afternoon. However, at 4pm the discharge lounge rang him and said that in fact his father would be discharged home.
33. Mr A said he was told that a discharge team at the hospital called Home Safe had decided his father was fit to be discharged home and had cancelled his transfer to the General Hospital.
34. Mr A only agreed to this discharge reluctantly as his father had been sat in the discharge lounge all day and was desperate to go home. Mr A said his father returned home at 8pm that evening and he put his father to bed. When he returned in the morning his father had fallen in the night and was in pain and distress. Mr A called an ambulance and Mr B went to hospital where he died several days later.
35. Mr A questioned what he felt was an unsafe discharge without medical approval. He had a complaint meeting with the hospital and at this meeting the doctor in charge of his father’s care said he did not sanction the discharge and was unsure why Mr B did not go to the General Hospital to recover.
36. Mr A felt his father should not have been discharged home as he was still unwell and could barely walk. He also criticised a lack of support for when his father returned home.
37. The Home Safe Team is a social care team working for the Council at the Hospital. It does not make the decision to discharge a person but supports the discharge process by arranging care for those patients who have been assessed as needing help leaving hospital.
38. As appropriate, Home Safe will raise concerns with the clinicians prior to discharge if, for example, the family is concerned the person may not manage.
39. The Council said the Home Safe team first visited Mr B when he was on the ward and he declined care and support. The team had no concerns about his ability to make this decision himself. It provided him with a list of domestic carers and requested that a physiotherapist assess him as Mr A was concerned about his father’s mobility.
40. A physiotherapist assessed Mr B and found that he could move around.
41. The Council said that on the afternoon of Mr B’s discharge it was informed by the Hospital that it had rejected the transfer to the General Hospital as he was medically fit and safe from a physiotherapy view to go home.
42. The Council said that Home Safe staff spoke to Mr B in the discharge lounge on the day of his discharge and he expressed a wish to return home and that he understood his son's concerns. He also consented to a visit from the Home Safe Support Team (HSST) the next morning. As previously, there were no concerns regarding his capacity. The Council said it passed on Mr A’s concerns about whether his father was medically fit to return home to the nurse overseeing his father’s care.
43. The Trust said Mr B was planned for transfer to the General Hospital. However, the Home Safe team assessed him in the discharge lounge and after discussion with Mr B, who wanted to go home, they had no concerns from a social or physiotherapy point of view.
44. The Trust went on to say the Home Safe team informed the nursing team of this decision and at this point the nursing team should have spoken to the ward medical team to see if they still wanted a hospital transfer from their medical aspect. The discharge lounge team did not speak to the clinicians and instead arranged the discharge.
45. As a result of this error, the Trust said it discussed the case at its Patient Flow Governance meeting to highlight the issues that led to the discharge. This meeting was attended by all grades of nursing staff from both the bed management and discharge lounge team.

Analysis

46. The records show that the plan was to transfer Mr B to the General Hospital and that the Trust changed this decision.
47. The transfer to the General Hospital may have allowed him to recover and provide more support for when he went home.
48. However, Mr B had declined support and the Hospital discharge and community support guidance states:

‘Even where a professional (including medical professionals and social care professionals) disagrees with a person’s choice, in most cases a person who has mental capacity to decide what care and support they would like on discharge, will make the final decision. If an individual with the relevant capacity refuses the provision of care, then ultimately this decision should be respected.’

49. Although the Trust said that a nurse did not check the discharge decision with the ward which Mr B had been on, there is evidence he was assessed on the morning of his discharge as medically fit to be discharged.
50. In view of this I have not found that this was an unsafe discharge. However, there was confusion between staff on the day of discharge which led to uncertainty and frustration for Mr A. This was a fault on the part of the Trust.
51. I have not found fault with the Home Safe team as it spoke to Mr B and Mr A and offered support which Mr B declined but it was due to visit him at home the morning after discharge.

A doctor misinformed Mr A

52. Mr A said that when his father was taken back to hospital he spoke to his father’s doctor. This doctor gave him the impression that his father would make a recovery.
53. However, Mr A said the doctor then called him back five minutes later saying they had only now checked his father’s notes and he did in fact only have hours to live which was distressing for Mr A.
54. The Trust said it could not find a record of this misunderstanding in the hospital records.

Analysis

55. We could not find evidence of this misunderstanding or misrepresentation in the hospital notes.
56. There is one note of a doctor meeting with Mr A a few days after his father’s admission. This doctor told him they would check Mr B’s notes and speak to him again. The next day Mr A returned to the hospital and a doctor told Mr A that his father was most likely reaching the end of his life.
57. However, I have not found further evidence of the sequence of events as Mr A describes it and so do not find fault with the Trust in relation to this matter.

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Recommendations

58. I would normally make recommendations of the Trust apologising to Mr A and taking action to prevent a recurrence in relation to the confusion about his father’s discharge. However, the Trust has already apologised to Mr A for this and taken action to prevent it happening to other patients. Therefore, I do not propose to make recommendations in this case.

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Final decision

59. I found fault with the Trust in relation to Mr B’s discharge but that it has taken appropriate remedial action. I did not find fault with the Trust or the Council in relation to the other issues in this complaint.

Investigator’s decision on behalf of the Ombudsmen

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Investigator's decision on behalf of the Ombudsman