Summary: Mrs X complained the NHS Trust and the Council discharged her father from hospital into an unsuitable care home. We found fault by the NHS Trust, but we could not say this would have led to a different outcome. The NHS Trust has already accepted the fault, but we recommended it apologises to Mrs X for the uncertainty caused. We did not find fault by the Council’s actions, but we did find fault with how it dealt with Mrs X’s complaint. We made recommendations to address this.

The complaint

1. Mrs X complains about the way Leicestershire County Council and University Hospitals of Leicester NHS Trust dealt with discharge arrangements from hospital for her father, Mr Y. She says the Council and the Trust failed to update discharge information when Mr Y’s discharge was delayed, and his needs changed. Mrs X says this meant Mr Y moved to an inappropriate residential care home placement which could not meet his needs. Mrs X says the failings caused her and her family distress during the final days of Mr Y’s life.
2. Mrs X also complains the Council did not deal with her complaint effectively. She says this added to her overall distress and frustration.

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The Ombudsmen’s role and powers

3. 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).
4. 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).
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 we are satisfied with the actions or proposed actions of the organisations that are the subject of the complaint, we can complete our 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. I considered evidence provided by Mrs X, the Council and the Trust, as well as relevant law, policy and guidance.
8. Mrs X, the Council and the Trust had an opportunity to comment on my draft decision. I considered any comments before making a final decision.

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What I found

Background

9. Mr Y went into hospital in February 2023 after a fall and head injury. During his hospital admission, Mr Y discussed how he would manage when he left hospital with the medical team. Mr Y recognised he was unsteady on his feet and did not feel he would manage at home. Medical records noted Mr Y was a high risk of falling.
10. When the hospital considered Mr Y was ready to leave hospital (did not need medical treatment in hospital). It made a Home First referral in March 2023. This was so a discharge to assess (D2A) placement could be arranged. However, Mr Y tested positive for Covid-19, so this discharge did not go ahead.
11. When Mr Y’s isolation period ended, the hospital completed a further Home First referral in early April 2023. A D2A bed was not immediately available and Mr Y remained in hospital until the start of May 2023. Mr Y then moved to a D2A bed within a residential care home (the Care Home). His health deteriorated quickly and he died a few days later.

Relevant guidance and regulations

Discharge policy

12. The Trust’s “Discharge and Transfer of Care Policy (Going Home Policy)” and its “Criteria Led Discharge Policy” set out the process for safe and timely transfer of care from hospital.
13. Patients with on-going healthcare needs should be considered for Discharge to Assess in their own home or a Discharge to Assess placement in a Nursing/Residential Home. The Trust staff should refer using a “Home First Form”.
14. A patient’s progress against their discharge criteria and plan must be clearly documented in their medical records and handover documentation.
15. If a patient fails to meet specific discharge criteria but remains medically stable, their criteria should be discussed with the Clinical Lead to consider if they need to make any changes.

Complaint handling

16. The complaints procedure for councils and NHS organisations is set out in the Local Authority Social Services and NHS Complaints (England) Regulations 2009 (the Regulations). There is a duty for organisations to investigate complaints properly and in a way that will resolve them efficiently. There is also a duty to cooperate when a complaint is made to one organisation and contains material relevant to the other.
17. The Council’s own Adult Social Care Complaints Policy sets out how it handles complaints based on the Regulations. This includes complaints involving other organisations, such as the Council and an NHS Trust. In these cases, there is a duty to co-operate in seeking to resolve the complaint. This should include a co‑ordinated response. The policy also states there should be clear signposting to the Local Government and Social Care Ombudsman (or other appropriate organisation) following a response.

Analysis

Discharge to residential care home

18. Mrs X complains the Council and the Trust failed to update discharge information when Mr Y’s discharge was held up and his needs changed. Mrs X says this meant Mr Y moved to an inappropriate residential care home placement which could not meet his needs. She considers Mr Y should have moved to a Nursing Home.
19. The Trust completed a Home First referral form when Mr Y was first ready to leave hospital. It updated this after Mr Y tested positive for Covid-19 which delayed his discharge from hospital. However, Mr Y did not leave hospital for another three weeks.
20. The hospital continued with clinical observations during this time. The records show Mr Y’s condition was stable. The records also show the Care Home completed a pre-admission assessment a few days before Mr Y moved. This included discussion with clinical staff and provided up-to-date information about Mr Y’s health and needs.
21. The hospital prescribed Mr Y with anticipatory end-of-life care medication (medication prescribed to patients with a terminal illness in advance, so the person has access to them as soon as they are needed). However, Mr Y did not need this medication at the point he left hospital. The records show Mr Y’s condition was stable and he was aiming to improve his mobility with rehabilitation. Mr Y had some pressure sores, but these were being managed with a pressure relieving mattress and regular turning. There was no medical sign at this point that Mr Y needed nursing care.
22. The Trust’s policy states staff should complete the Home First referral form before the date a patient is expected to be ready to leave hospital. Its use is one part of discharge planning. The Care Home also completed an assessment before accepting Mr Y. This assessment included a review of records and input from clinical staff at the hospital to ensure they could meet Mr Y’s needs based on up‑to‑date information. I have therefore found no fault with how the Trust completed the Home First referral or with how the Care Home reached its decision that it could meet Mr Y’s needs.
23. However, the hospital records from the day Mr Y left hospital note indicate a pressure sore to Mr Y’s sacrum (lower spine) had worsened. In response to the Ombudsmen’s enquiries, the Trust said it had reviewed Mr Y’s records and noted he had a “significant pressure sore” on the day of discharge. It accepted this could potentially mean a nursing care placement would have been suitable.
24. If Mr Y’s condition had changed, the Trust should have ensured he still met the discharge criteria in line with its discharge policies. The Trust has accepted there was fault by not clarifying the situation with Mr Y’s pressure areas on the day he left hospital. This could have changed the discharge destination if Mr Y’s pressure areas were so bad that nursing care was indicated.
25. I have considered the records from the Care Home. These show the Care Home completed an assessment of Mr Y’s needs on the day he moved. This included pressure care. It noted Mr Y’s pressure sores were “superficial” (skin not broken) and was happy it could manage his pressure sores. The records do not show there were any issues with pressure care or that the Care Home did not adequately manage Mr Y’s pressure areas. I therefore do not consider we could say the outcome would have been different, but I accept this does leave some uncertainty.
26. Mr Y’s health deteriorated quickly after he moved to the Care Home. Clinical staff anticipated this would happen at some point, but did not necessarily expect it would have been so soon after he left hospital. This does not mean the Care Home was unsuitable or could not meet his needs. This was also not linked to the potential reason nursing care could have been considered on the day Mr Y left hospital.
27. The Trust has told us that since Mrs X complained, it has introduced a new procedure. Patients who have waited longer than seven days for a discharge destination are reviewed regularly by multiple members of the discharge specialist nurse team. This should help identify any changes and ensure the discharge destination is still appropriate where there have been changes to a patient’s health or needs.

Complaint handling

28. Mrs X also complains the Council did not deal with her complaint effectively. She says this added to her overall distress and frustration.
29. Mrs X complained to the Council by letter in May 2023. The Council responded by email in July 2023. It advised that part of the complaint related to NHS care and said Mrs X would need to send her complaint to the Trust so this could be considered. Mrs X complained to the Trust the same day and received a response in September 2023. The Trust response signposted Mrs X to the PHSO if she remained unhappy with the outcome.
30. Mrs X then complained to the PHSO. As her complaint related to health and social care services, the PHSO and LGSCO decided to consider this jointly.
31. In response to our enquiries, the Council acknowledged that best practice would have been to collaborate with the Trust rather than referring Mrs X to make a separate complaint. The Council said it would remind officers of the Joint working protocols.
32. The Council did not follow the Regulations or its own policy in not considering the complaint in collaboration with the Trust. I have also noted the Council did not signpost Mrs X to the LGSCO in its final response for the parts of the complaint it had responded to. This is fault. This meant Mrs X’s complaint potentially took longer to be considered. It was also only received by LGSCO following a referral from PHSO. The Trust had provided appropriate signposting for the health part of the complaint.

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Agreed actions

33. Within one month of the date of the Ombudsmen’s final decision statement, the Trust has agreed it will:
• Apologise in writing to Mrs X for any distress from the uncertainty caused by the fault identified with updating Mr Y’s discharge information.
34. Within one month of the date of the Ombudsmen’s final decision statement, the Council has agreed it will:
• apologise in writing to Mrs X for the distress and inconvenience caused by the faults with complaint handling;
• confirm the steps taken to remind staff about the need to follow the steps in its complaints policy, particularly about working with other organisations and with signposting to the Ombudsman.
35. We publish guidance on remedies which sets out our expectations for how organisations should apologise effectively to remedy injustice. The organisations should consider this guidance in making the apologies.
36. The organisations should provide us with evidence they have complied with the above actions.

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Decision

37. I have found fault by the Trust and with the Council’s complaint handling. The organisations have agreed actions to remedy the injustice. I have therefore completed my investigation.

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Investigator's decision on behalf of the Ombudsman