Summary: Mr X complains about the lack of information he received when his father was discharged from hospital. We found fault by the Council and the NHS organisation responsible for coordinating hospital discharges with their communication. This led to a loss of opportunity for Mr X to make informed decisions about his father’s care. The organisations have agreed to apologise to Mr X and pay a financial payment in recognition of the loss of opportunity and distress, and make service improvements.

The complaint

1. Mr X complains about Wiltshire Council (the Council), Wiltshire Health and Care (WHC) and NHS Bath and North East Somerset, Swindon and Wiltshire Integrated Care Board (the ICB). He complains about the lack of consultation about discharge arrangements for his father, Mr Y, following a hospital admission in March 2024.
2. Mr X says hospital staff told him his father’s care would be free for 4-6 weeks, but the funding ended after two weeks, without any prior notice. He also says he was told a social care assessment would be completed within two weeks, but this did not happen.
3. Mr X says if he (as Power of Attorney) had known about the discharge plan, he would have arranged to move his father to a care home sooner. He says this caused his father and his family distress and they have had to pay for home care they did not think they were liable for.
4. Mr X wants acknowledgement of the failings and apologies for the effect of this on his father and family. He also wants 2-4 weeks of extra fees repaid for care he understood would be free.

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The Ombudsmen’s role and powers

5. 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).
6. 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).
7. 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.
8. If we are satisfied with the actions or proposed actions of the bodies 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

9. I have considered information from Mr X, the Council, the Trust and WHC. This includes relevant health and social care records for Mr Y. I have also considered relevant guidance and policies.
10. All parties had an opportunity to comment on a draft of my decision.

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What I found

Relevant law and guidance

Mental Capacity Act

11. 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.
12. 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.
13. The Mental Capacity Act 2005 introduced the ‘Lasting Power of Attorney’ (LPA). An LPA is a legal document which allows people to choose one person (or several) to make decisions about their health and welfare and/or their finances and property, when they become unable to do so themselves. The decision must be made in the person’s best interests.

Hospital discharge pathway

14. Patients are entitled to return home on a Home First pathway. This provides patients with support at home or intermediate care (short-term support to help recovery and increase independence). Wherever possible, patients should be supported to return to their home for assessment. WHC coordinate the hospital discharge along with input from the hospital staff and the Council.
15. For patients with a delirium (a change in mental abilities resulting in confusion and a lack of awareness of surroundings), extra care is needed. Based on national outcomes, within two weeks the patient should show health improvements once they are home and in familiar surroundings. In these cases, the ICB will fund up to two weeks care to allow the delirium to settle. However, if the patient does not improve, the discharge Multidisciplinary Team (MDT) will agree a social care assessment and Adult Social Care should then liaise with the family about meeting future care needs.

Care Act 2014

16. Sections 9 and 10 of the Care Act 2014 require councils to carry out an assessment of any adult who appears to need care and support. They must assess anyone, regardless of their finances or whether the council thinks they have eligible needs. The assessment must be of the adult’s needs and how they impact on their wellbeing and the outcomes they want to achieve. It must involve the individual and where appropriate their carer or any other person they might want to be involved.
17. An assessment should be carried out over an appropriate and reasonable timescale taking into account the urgency of needs and a consideration of any fluctuation in those needs. Councils should let the individual know of the proposed timescale for when their assessment will be conducted and keep the person informed throughout the assessment process.
18. Section 4 of the Care Act sets out how local authorities should provide information and advice. It states a local authority must provide information and advice on matters including:
• the choice of types of care and support, and the choice of providers, available to those who are in the authority's area;
• how to access the care and support that is available;
• how to access independent financial advice on matters relevant to the meeting of needs for care and support; and
• how to raise concerns about the safety or well-being of an adult who has needs for care and support.

Local discharge arrangements

19. In this case, WHC had responsibility for coordinating Mr Y’s hospital discharge. The ICB provided funding for the hospital discharge pathway and contributed to the discharge MDT reviews while it provided funding. The Council brokered the care agency and were responsible for assessing care needs following discharge from hospital.

Brief background

20. Mr Y went into hospital in early 2024. He could not make decisions himself about discharge arrangements because he had dementia and had difficulty understanding decisions about this.
21. Mr X held LPA for Mr Y and was involved in decision-making for his father’s care, including his hospital discharge in March 2024.
22. Mr X says hospital staff told him that Mr Y would receive 4-6 weeks of funded care when he left hospital. He says a social worker also said to expect an assessment of Mr Y’s needs during this time, following which decisions would be made about his ongoing care.
23. Mr Y returned to his own home with home care workers providing support. The ICB funded this initially under a pathway to allow time for a delirium to resolve before the Council completed an assessment of Mr Y’s needs. The discharge MDT reviewed Mr Y’s condition every few days. After two weeks Mr Y’s condition had not improved significantly. Health professionals considered this was his new “base line” (a point where professionals do not consider someone is likely to improve any more) and passed the care over to adult social care. The health funding ended and Mr Y funded his own care after this.
24. Mr Y moved to a care home shortly after. Mr X then contacted the Council to ask for support. He said Mr Y’s savings had been used up on care fees.
25. The Council completed an assessment of Mr Y’s needs in July 2024.

My findings

Communication about discharge from hospital

26. The records show Mr Y could no longer manage at home without increased support. He was experiencing a delirium following his hospital admission. The records show WHC and the Council considered discharge choices. They agreed a plan for Mr Y to return home with live-in carers so his needs could be assessed once he was settled in a familiar environment.
27. The social worker contacted Mr X to discuss the discharge plan and check there was enough room at Mr Y’s home for a live-in carer. The social worker recorded they explained a financial assessment would be needed for longer term care needs. The social worker explained a discharge MDT meeting would take place in the next few days to confirm arrangements. There was no recorded discussion about the short-term funding for care on discharge from hospital. However, the social worker made a separate entry in the records. This was to clarify Mr X was told the care would be free for up to 28 days and continuation of care would be subject to financial assessment.
28. The MDT meeting agreed 24-hour live-in carers to allow Mr Y’s delirium to settle. An email from the discharge team to the Council confirmed this was for two weeks. It also noted that “family are happy to take over funding and self-fund” when the health funding ended. Mr X was not part of these discussions or email exchanges. The Council confirmed the arrangements with Mr X, but I have not seen evidence it clarified the funding arrangements or that these differed from their previous conversation.
29. In response to the Ombudsmen’s enquiries as part of this investigation, WHC advised us the Council had provided the information about the family being happy to pay for Mr Y’s future care.
30. The Council told the Ombudsmen it considered the ICB was responsible for explaining the discharge plan, including the funding arrangements, to Mr X. The ICB told us it would be the discharge team. WHC explained that as the social worker already knew Mr Y, in this case the Council took this role on.
31. WHC was responsible for coordinating the discharge and would usually have discussed the arrangements with Mr X. However, it advised us that because the social worker already knew Mr Y, they took on this role. I have seen no records specifically stating the Council had agreed to take on this role or that it was unhappy in doing so. The records do show its social workers discussed discharge arrangements with Mr X and passed on information from health services.
32. The Council’s complaint response to Mr X states it asked “the ICB” to discuss funding arrangements with him. I have seen no evidence of the Council making this request and in any event, the ICB would not be responsible for discussing discharge arrangements with the family. As noted above, this would usually fall to WHC.
33. The Council has accepted some fault with communication. It agreed that given there was a lot of information and the situation was quickly changing, it would have been helpful to provide written information about the relevant discharge pathway. It said it would discuss this with its staff.
34. There may have been a misunderstanding or lack of clarity between the Council and WHC about what information would be shared and who would do this. Either way, this was not made clear, particularly if this differed from normal practice. If the organisations had arrangements outside of the usual process, they should have been clear about these and recorded it. As a result of the fault, Mr X did not receive clear information about the discharge arrangements for Mr Y or about meeting his future care needs. This is fault by the Council and WHC.

Communication by the MDT

35. When Mr Y left hospital and was receiving health funding for his care, there were regular MDT meetings to check Mr Y’s progress. These did not however include Mr Y or his family. In response to the Ombudsmen’s enquiries, the Council and ICB have accepted Mr X should have been included in decisions about Mr Y’s care. As Mr X was not involved in discussions and the outcome was not shared with him, this is fault. Had the organisations included Mr X in discussions during this time, this may have clarified the funding sooner. The Council has confirmed that since Mr X made his complaint, along with health organisations, a process is now in place to ensure families are involved in such discussions.

Communication about ending health funding

36. When the MDT decided that Mr Y’s health funding should end, the records show the ICB sent communication to the Council. This confirmed the funding was ending and asked the Council to allocate a social worker to support a longer-term plan and ensure any decisions made about future care were properly informed.
37. The records show the social worker telephoned Mr X and explained the health funding was ending. They said the expectation would be for Mr Y to pay for his own care given his savings were above the threshold. The records show Mr X questioned the funding because he understood it would last longer. The social worker recorded they discussed with Mr X that funding was for two weeks. The records do not support this. As noted above, previous records of conversations between Mr X and the Council say funding was for 28 days.
38. Mr X says he would have considered a care home placement for Mr Y earlier had he been aware of the limited funded care at home. The reason for the health‑funded care was to allow Mr Y’s delirium to settle so his needs could then be properly considered. There were no assessment places available in a care home and a return home with increased care was the least restrictive option. Health professionals explained that Mr Y’s delirium would be more likely to resolve quicker in a familiar environment. Mr X agreed with this plan, although I recognise the exact time frames and funding may not have been clear. I do not consider we can say if the outcome would have been different. However, there is a loss of opportunity for Mr X to have considered the options and avoidable frustration at not having all the relevant information to make an informed decision.
39. I have seen no records of any further action until Mr X contacted the Council in July 2024 asking for help. He said Mr Y had used up his savings paying for his care and could no longer pay his care fees.
40. At the point health funding ended, Mr Y had not recovered to the level he was before his hospital admission. Health professionals considered he had reached a point where he was unlikely to improve significantly. The Council said it did not receive a referral from health. However, it was party to the MDT discussions and outcomes. The ICB was also clear in its communication to the Council that it should assess Mr Y’s needs and consider his options for future care.
41. It should have been clear to the Council that Mr Y’s needs had changed after he left hospital. However, I have seen no indication the Council considered completing an assessment of his needs until July 2024. Neither is there any record of discussions about the choices available to Mr Y or his family. The records of discussions between the Council and Mr X show he did not fully understand how care planning and funding worked or if there were other choices available. This indicates the Council was happy to accept Mr Y would pay for his own care without discussing alternatives or whether this was suitable to meet his needs. This is not in line with the Care Act and is fault.
42. The fault meant Mr X could not properly consider choices for Mr Y’s future care or the cost implications of this. This left Mr X to find and arrange carers and then a care home placement for Mr Y when the live in care was no longer working. I do not consider we can say if Mr X would have made different decisions had the Council assessed Mr Y or made Mr X aware of alternative care available. However, this has led to a loss of opportunity for Mr X to consider available options and make an informed decision about Mr Y’s care. It has also caused Mr X distress and inconvenience from having to manage Mr Y’s care planning, unsupported and without a proper assessment of needs.

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Agreed actions

43. Within one month of the date of the Ombudsmen’s final decision, the Council and WHC have agreed to:
• Send Mr X a written apology for the faults and injustice identified in this investigation. 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 apology.
• Pay Mr X £250 (£125 each) in recognition of the avoidable uncertainty and frustration identified in this decision because of faults with communication about the hospital discharge arrangements.
44. Within one month of the date of the Ombudsmen’s final decision, the Council should:
• Pay Mr X an additional £250 in recognition of the avoidable uncertainty, distress and frustration caused by the fault in not completing an assessment or sharing information about Mr Y’s care options when the health funding ended.
• Remind social care staff of the need to communicate care options and complete an assessment when there has been a change of needs.
45. Within three months of the date of our final decision statement, the Council has agreed to:
• Take action to ensure there is a process in place to clarify who has responsibility for sharing information relevant to a patient’s hospital discharge and funding arrangements, and record where there is a variance to standard practice.
46. Since this complaint was made WHC no longer provides hospital discharge services. Therefore any service improvements relating specific to its involvement in hospital discharge coordination are no longer relevant. However, the ICB has agreed to support the Council and local health services with making improvements about discharge planning.
47. The Council and WHC should provide us with evidence they have complied with the above actions.

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Final decision

48. I have found fault by the Council and WHC. I have made recommendations to the organisations to remedy the injustice caused by the fault. I did not find fault by the ICB.
49. The Council and WHC have agreed actions to remedy the injustice caused by the faults identified in this complaint. I have therefore completed my investigation.

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Investigator's decision on behalf of the Ombudsman