Summary: Miss H complains about what happened when her mother, Mrs D was discharged from hospital. We found no fault by the Trust or Council in the way Mrs D was discharged from hospital, or in how they communicated with Mrs D and her family about the discharge process.

The complaint

1. Miss H complains about what happened when her mother, Mrs D, was discharged from hospital to a care home. Specifically, she says:
2. Discharge from hospital was rushed;
3. The care plan was missing important information;
4. There was a lack of communication with Mrs D and her family about discharge planning and decisions, and there was no discharge planning meeting;
5. The family were not supported or involved in assessments of Mrs D’s needs; and
6. Reasonable adjustments were not made which would have allowed Miss H to contribute to discussions and decisions.
7. Miss H says the family should have been consulted because Mrs D’s capacity fluctuated, she needed support with communication, and she was confused about what was happening. Miss H says that if the family had been involved, the care plan may not have been missing important information, and would have prevented an unsuitable care home being chosen at first. She also says it may have prevented Mrs D eventually being discharged to a care home without seeing it first, and which was difficult for the family to visit.

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The Ombudsmen’s role and powers

8. 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).
9. 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.
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 of this complaint, I have considered information provided to us by Miss H. I wrote to the Council and Trust to tell them what I intended to investigate and requested copies of relevant records. I considered the comments and documents they sent. I have also considered the law and guidance relevant to this complaint. I also took clinical advice from a nurse.
12. Miss H, the Council and Trust had an opportunity to comment on my draft decision.

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What I found

13. Mrs D was admitted to hospital with slurred speech and facial droop after she fell at her residential care home. She had a history of stroke and falls. However, she was found to have had a seizure rather than a further stroke. Mrs D remained in hospital for treatment, and she also had physiotherapy and occupational therapy. As part of planning her discharge from hospital, the care home where Mrs D had been living came to assess her. They found her needs had increased and the care home was no longer suitable for her. A new placement at a nursing home was sought as part of discharge planning.
14. The Council identified a potentially suitable nursing home placement for Mrs D. The Council discussed this with Mrs D, and contacted her family to tell them the nursing home manager was coming to assess Mrs D in hospital. The family then visited the nursing home to see if they felt it would be suitable for her. However, on assessing Mrs D, the nursing home decided it was unable to meet her needs. Another potential nursing home was identified, and they then came to assess Mrs D. This second nursing home was able to meet Mrs D’s needs and the family was then informed so they were able to go and visit before Mrs D was discharged.

Hospital Discharge

15. Miss H said her mother’s discharge from hospital was rushed, and this meant the care home initially suggested for her was not suitable as her needs were not taken into account. 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.

16. Miss H also queried how Mrs D’s risk of falls was managed, and whether this was properly considered when planning her discharge from hospital. In line with national guidance, ‘Falls in older people: assessing risk and prevention’ (NICE CG 161), all patients over the age of 65 should be considered ‘at risk’ of falls and have targeted falls interventions aimed at reducing their personal risk factors. The guidance states that falls interventions should “promptly address the patient's identified individual risk factors for falling in hospital and take into account whether the risk factors can be treated, improved or managed during the patient's expected stay”.
17. Falls are not always representative of poor care or neglect. Research has shown that interventions tailored to individual patients can reduce falls by 20 to 30%, but cannot prevent them (Royal College of Physicians Audit Report 2015). If a person has had a fall, interventions should be reviewed and amended if appropriate (National Patient Safety Agency, ‘Essential care after an inpatient fall’, 2011).
18. The Trust held a meeting with the family where falls management was discussed, and the Trust explained the actions it was taking to prevent further falls. It was confirmed that Mrs D had fallen twice prior to this meeting: once from bed and once from a chair. This prompted an occupational therapy (OT) assessment for a specialist chair. The meeting also discussed intentional rounding. This is when nurses check on patients at specified times to ensure that they are comfortable and that there are no outstanding nursing needs.
19. OT input was also in line with the relevant guidance, the Royal College of Occupational Therapists Professional Standards. The records show that Mrs D’s needs were assessed and clearly documented. The rationale for nursing home placement, rather than returning to her residential home, is documented in the OT notes. The OT was also involved in ensuring Mrs D had the equipment she needed (a specialist chair) on discharge to the nursing home. The OT also prepared an individualised seating guideline for the nursing home, to promote Mrs D’s safety on discharge. There is also evidence of OT communication with Mrs D’s family.
20. As part of discharge planning, the physiotherapy team assessed and reviewed Mrs D’s mobility and falls risks. A ‘high-low’ bed was discussed. This is a bed to minimise the harm sustained by falling from bed and it is kept on the lowest setting when the patient is in bed. Following the family meeting, the high-low bed versus a bed with sides and bumpers was discussed to identify which would be the best option for Mrs D’s individual needs. Mrs D’s consent was gained prior to interventions, and the treatment plan and goals are clearly documented. These steps indicate the Trust considered and implemented interventions tailored to Mrs D, to prevent falls. This was in line with the guidance referred to above.
21. Mrs D was at high risk of falls, and the records indicate the Trust and Council considered this when planning discharge. In the continuing healthcare (CHC) assessment, it is documented that Mrs D had had multiple falls. The OT, physio and social care records also make numerous references to her risk of falls.
22. The information available indicates that falls prevention and management while Mrs D was in hospital was in line with national guidance. Consideration of falls risk as part of Mrs D’s discharge planning was also in accordance with the relevant standards.

Care plan

23. Miss H complained the care assessment and care plan were missing important information about Mrs D’s medical background, including her stroke in 2016 and risk of falls. She said that this meant an unsuitable nursing home was initially chosen for Mrs D, leading to the family making an unnecessary visit to the nursing home. She said this caused the family expense and inconvenience, as in the end Mrs D was not able to move there as it could not meet her needs.
24. It is noted in the care assessment that Mrs D had a stroke in 2016. As noted above, the nursing and therapy records document a high risk of falls, and this information was included in the care assessment. It was also highlighted that Mrs D had fallen twice in hospital, and included details of the OT seating assessment referred to above. The physiotherapist assessed Mrs D as being “at very high risk of falls and this is likely to remain this way”, and that she needed support from two people to mobilise. Therefore, relevant details about Mrs D’s history of stroke and risk of falls were taken into account when planning Mrs D’s discharge, as well as information from Mrs D’s family about her communication.
25. The Council acknowledged that the family had “made considerable effort to visit [the first potential nursing home] only to find following the visit that they did not feel they could meet your Mum’s care needs”. The Council said it had no record of Miss H raising concerns about difficulties visiting at the time. The Council asked Miss H to provide further information such as receipts for costs incurred related to her travel to the first nursing home, in order to address this. Therefore, Council has offered a reasonable solution to Miss H’s concern that they went to unnecessary expense to visit the first nursing home.

Communication with family

26. Miss H says Mrs D needed support from her family with discharge planning because her capacity fluctuated, and her communication was impaired. She also said that as Mrs D’s first language was not English, it was more important for her family to be involved in discussions about discharge so they could help with communication. Miss H said that instead, a friend of Mrs D’s who had been visiting her in hospital, was asked to be involved and support Mrs D.
27. 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.
28. 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.
29. The records show that Mrs D’s capacity fluctuated. A capacity assessment was done in relation to decisions about discharge planning. Mrs D was assessed as having capacity to make a decision about her care needs and accommodation. The records also show Mrs D was given the information she needed about moving to a nursing home, and the choices available. The Trust and Council communicated with her about discharge planning, and she was supported by a friend during assessments and discussions.
30. Mrs D received support with communication from the speech and language therapy (SALT) team. The hospital social work team also sought advice from SALT about how best to communicate with Mrs D. It was noted that she was better able to communicate after she had taken her medication, and that care staff tried to optimise those times to discuss decisions with her. The records also indicate that Mrs D asked for a friend to be involved in discussions. A capacity assessment was carried out, and Mrs D was assessed as having capacity to make decisions about her housing and support needs.
31. Regarding communication with the family, the records do not show a specific discharge planning meeting was held. However, the records show engagement with Mrs D’s family at a CHC assessment meeting that took place on the ward. This involved Mrs D, Miss H and Mrs D’s other daughter, a social worker, a CHC assessor and nursing staff. The notes indicate that discharge arrangements were discussed at this meeting. Mrs D’s daughters provided information about her background and her future needs, and it was agreed Mrs D would need a nursing home on discharge. Mrs D’s daughters were also given written information about the discharge process at this meeting.
32. Miss H later contacted the social work team as the leaflets she had received at the meeting were not accessible for her, and she requested them on coloured paper or in audio format. Miss H raised additional questions about the discharge process and how the family would be involved. She also requested phone calls after 10am only.
33. The case notes show that the social work team sent written information to Miss H about choice of nursing homes, charging, and making decisions about care, as well as how to access further information. The social work team also spoke to Miss H after 10am on several occasions, to explain the mental capacity and care assessments, and to provide information about the nursing home assessments. They also sent Miss H a copy of the draft support plan for her additions or amendments, and it is noted that some changes were made as a result. Although the notes do not specify whether the written information was sent on coloured paper, the social worker recalled that she communicated with Miss H as requested.
34. The records show that ward staff and the hospital social work team discussed discharge planning with the family and sent them written information. Mrs D was assessed as having capacity to make a decision about her choice of nursing home. The Council offered to address any inconvenience caused to the family by the first nursing home visit.

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Final decision

35. I found no fault by the Council or Trust in the way Mrs D was discharged or in communication with her family. I have now completed my investigation on this basis.

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Investigator's decision on behalf of the Ombudsman