Summary: Mr D complains about the way his mother, Mrs E, was discharged from hospital, and that communication with him was poor. The Trust accepted its communication with Mr D about Mrs E’s condition while she was in hospital was lacking, meaning he did not have all the relevant information. The Trust has apologised to Mr D and taken steps to improve communication. We did not find fault by the Trust or Council with regard to the other matters we investigated.

The complaint

1. Mr D complains that his mother, Mrs E, was discharged from hospital without adequate care in place. He says that health and care assessments done in hospital did not reflect Mrs E’s needs. He also complains the Trust lost documents showing he had Lasting Power of Attorney (LPA) for his mother, meaning he was not involved in discussions about her care even though he says she did not have capacity to make decisions about this. He also says the Trust did not explain how severely ill Mrs E was, and that the Trust’s complaint handling was poor.
2. Mr D also complains an assessment for continuing NHS healthcare (CHC) was not accurately completed. He also says some of Mrs E’s records were incorrect, and that the Trust did not supply him with these when he requested them.
3. Mr D says he has not been given a full answer to his concerns. He said his mother was let down by the Trust and Council who arranged her discharge from hospital, as she did not get the care she needed afterwards. He also said this had an impact on him as his mother’s carer. He said the family lost opportunities to spend time with Mrs E because they were not told how seriously ill she was, and that having to pursue the complaint took him away from spending time with his mother towards the end of her life.

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What I have investigated

4. I have investigated Mr D’s complaint about the health and care assessments done prior to Mrs E’s discharge from hospital, that the Trust lost the LPA documents, communication and complaint handling.

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The Ombudsmen’s role and powers

5. 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, and Health Service Commissioners Act 1993, section 18ZA)
6. 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)).
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 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)
9. The Ombudsmen cannot investigate late complaints unless they decide there are good reasons. Late complaints are when someone takes more than 12 months to complain to the Ombudsmen about something an organisation has done. (Local Government Act 1974, sections 26B and 34D, as amended, and Health Service Commissioners Act 1993, section 9(4).) In Mr D’s case, I decided to consider his complaint now, because it took a longer time than usual for the local responses to his complaint to be completed.

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How I considered this complaint

10. During my investigation of this complaint, I have considered information provided to us by Mr D and discussed the complaint with him. I wrote to the Council and Trust to tell them what I intended to investigate, and request copies of relevant records. I considered the comments and documents they sent. I have also considered the law and guidance relevant to this complaint.
11. Mr D, the Council and Trust had an opportunity to comment on my draft decision. I have taken their comments into account before making a final decision.

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What I found

Applicable legislation and guidance

Hospital Discharge

12. 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

Medically fit for discharge

13. Department of Health guidance: Definitions – Medical Stability and ‘Safe to Transfer’ (2003) (the ‘Safe to transfer guidance’) gives guidance on when a patient can be safely considered to be ‘medically fit for discharge’. This lists three key criteria for making this decision and stresses professionals should address them at the same time, if possible. According to the protocol, a person is considered to be safe for discharge when:

• a clinical decision has been made that the patient is ready for transfer;
• a multidisciplinary team decision has been made that the patient is ready for transfer; and,
• the patient is safe to discharge/transfer.

14. A patient can be defined as clinically or medically stable if tests (such as blood tests and observations) are considered to be within the normal range for the patient. A patient is ‘fit for discharge’ when all relevant physiological, social, functional, and psychological factors have been taken into account. This can require a multidisciplinary assessment.

Care and support

15. 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 carer or any other person they might want involved.

Mental Capacity

16. 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.
17. 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.

What happened

18. Mrs E had been living at home with a self-funded care package of three carer visits a day. Mr D also provided care for her. Mrs E had a diagnosis of Alzheimer’s disease.
19. In June 2018, Mrs E was admitted to hospital after developing symptoms of confusion and a urinary tract infection (UTI). While in hospital, Mrs E was treated for a UTI with intravenous antibiotics and fluids, and was also given medication for confusion. A chest X-ray and blood tests were done, and Mrs E was given some additional medication as test results indicated another infection, thought to be community-acquired pneumonia.
20. Mrs E was assessed by the physiotherapy and occupational therapy teams. Her mobility was found to be at a similar level as it had been before her admission to hospital, and it was decided no additional therapy was required. A plan for discharge involved further assessment of Mrs E’s mobility and safety while moving from bed to chair and standing. She was found safe to do so and to be discharged home, pending a care needs assessment.
21. The hospital social work team contacted Mr D to offer support with care planning and assessment, as the hospital had told them Mrs E might need an increased care package. The social work team said that as the care had been privately funded previously, the family could arrange this themselves, or they could ask the Council for support with this. Mr D responded that Mrs E would like a needs assessment to determine what support she would need. The social work team’s assessment recommended that Mrs E’s care package be increased, to four 30-minute calls per day.
22. On 25 June, a checklist for NHS continuing healthcare (CHC) was completed on the ward. The checklist is a screening tool to identify individuals who may need referral for a full assessment of CHC eligibility. On completion of the checklist, Mrs E was not referred for a full CHC assessment. Mrs E was discharged home with an increased care package, which remained self-funded.

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Analysis

23. I have set this section out under separate headings of the complaint for ease of reading.

Discharge from hospital

24. Mr D complained that Mrs E was discharged with no notice, no care plan, and no discharge letter. He said there should have been a document available to him that explained what would happen on discharge, the results of assessments and what Mrs E’s needs were. He said this would have helped prepare him for her needs after discharge.
25. The records show that Mrs E was declared medically fit for discharge on 12 June, which is when discharge planning began. Discussions with Mr D about discharge plans took place during this time. On 19 June, a doctor discussed Mrs E’s condition with Mr D, explaining that she was medically fit for discharge. The doctor noted Mr D was having a discussion with a social worker the same day, as Mrs E needed care in place before she could go home. Mrs E was discharged a week later on 27 June, indicating Mr D had sufficient notice of discharge. Therefore I have not found fault in how the Trust gave Mr D notice that Mrs E was going to be discharged.

Communication about discharge planning

26. Each hospital should have its own discharge policy in line with the national guidance from the Department of Health. Mr D said he could not find a copy of the Trust’s discharge policy, and therefore he did not know what to expect. I note that there is a current version of the Trust discharge policy is on its website, although I recognise Mr D may not have been able to access this at the time.
27. In its response to Mr D, the Trust said every patient discharged should have a discharge plan in line with the policy. This includes basic information such as ensuring the patient and/or their carer or relative has been informed of the discharge plan, whether transport is needed, medicines and pain management, services and equipment, and any specialist referrals. The Trust said it shares this information with patients and carers/relatives if involved. In its meeting with Mr D, the Trust said that details for other referrals (such as OT) could be held separately, so there may not be one single document that sets out everything the person needs.
28. Although Mr D may not have received a single document explaining all Mrs E’s needs, the records show the Trust and Council communicated with him about discharge planning and the assessments that were done as part of this. On 17 June, the integrated discharge team (managed by the Trust and Council) contacted Mr D at Mrs E’s request to “discuss [her] home situation”. As noted above, Mr D spoke to a doctor about Mrs E’s discharge on 19 June. On 21 June, ward staff contacted Mr D to explain Mrs E would not need physiotherapy on discharge, and that the social work team would assess her care needs. The next day, 22 June, the OT telephoned Mr D to discuss “some slight changes” to Mrs E’s needs, and on 25 June, went over the content of the OT assessment with Mr D on the telephone. Mr D raised concerns about whether Mrs E would be able to manage stairs on her return home, and he was advised that she had been assessed for this and found to be steady on the stairs with no issues noted.
29. The Trust acknowledged that Mr D was not informed of the time of some of the assessments, which would have enabled him to be present for them. The Trust apologised to Mr D for this. However, as set out above, he was updated about the assessments shortly afterwards. I found the Trust’s actions to be in line with its discharge policy in terms of keeping patients and families informed of discharge planning, and this was explained to Mr D in its response to his complaint.

Communication about pneumonia

30. Mr D complained the Trust’s communication about Mrs E’s illness was poor, and that it was not explained to him how severely ill she was. He said he had not been informed Mrs E had pneumonia, and if he had known, he and other members of the family, would have wanted to spend more time with her.
31. The Trust explained that after an X-ray and blood tests, there were indications that Mrs E had another infection, as well as the UTI she was admitted with. The Trust began to treat her with additional antibiotics for community-acquired pneumonia, but said that primarily, she was being treated for a UTI. The Trust accepted it should have communicated better with Mr D about this, and that it would have been best to set out a plan at the start for how and when they would communicate with him about Mrs E’s clinical condition. Therefore while there was fault in the way the Trust communicated with Mr D about Mrs E’s pneumonia, the Trust appropriately apologised to Mr D for this and for any distress it may have caused.

Care Act assessment

32. Mr D said that no proper care plan was made when Mrs E was discharged from hospital, and that the care assessment done by the social work team did not reflect her needs. He said when it became evident that Mrs E did not have sufficient support at home, he then had to arrange more care himself, and that this should not have happened.
33. The social work team visited Mrs E on the ward on 17 June. The notes indicate she was able to tell them that she had carers at home and when they usually called, but that initially she was not sure if she would need increased care and asked the social work team to speak to Mr D about it. The social work team left Mr D telephone messages on 17 and 18 June, and on 19 June spoke to him about care arrangements, including his concerns that Mrs E would need help with personal care on discharge.
34. Mrs E’s care was self-funded but, as noted above, at the family’s request the Council carried out a Care Act assessment before discharge. This included information about Mrs E’s care and support needs. As Mrs E self-funded her care, the Council did not put a care plan in place, but the assessment recommended an increase in care calls from three to four per day.
35. Mr D’s concerns about help with personal care were reflected in the care assessment, which states the reason for referral was “bathing, showering and hyg[iene], dressing and grooming, personal ADLs [activities of daily living]”. The assessment also says “if left without support, Mrs [E] would be at risk of repeated UTIs and infections”. Mrs E was assessed as requiring the second highest level of support, “I often need support/encouragement with my personal care”, in this category. Therefore, I have not found fault on this aspect of the complaint as the assessment reflected the concerns raised by Mrs E and Mr D about personal care needs after discharge. The records also show the hospital social work team held further discussions with Mr D on 22, 25 and 26 June. The records show these discussions covered the type and amount of care Mrs E should have after discharge, as well as the Care Act assessment, self-funding care, and discharge planning.
36. The records also indicate Mrs E agreed to the increased care package and understood she would continue to fund the care herself. Her previous provider was able to continue. No formal capacity assessment was done, the social worker documenting: “no concerns regarding capacity to make decisions ie care and accommodation needs upon discharge”. The Care Act assessment states “Mrs [E] does have mental capacity and is capable of making her wishes and feelings known but does have problems retaining information therefore, her son (who is also her main carer) is in attendance for any appointments.” Although when she was admitted, it was noted that Mrs E did not have capacity to make decisions about her medical and nursing care, in its meeting with Mr D, the Trust also said Mrs E would have understood some things but not others, and therefore the Council and Trust consulted Mr D and involved him in discussions about therapy and care assessments. Therefore I have not found any fault with the way the Trust and Council communicated with Mr D about the care assessments.

Complaint about records including missing Lasting Power of Attorney Document

37. Mr D complained that the Trust lost a document showing he had Lasting Power of Attorney (LPA) for health and welfare for Mrs E. He said he gave the original document to administration staff, who made a copy and placed it in Mrs E’s file, then returned the original to him. He said that because of this, and reference to the LPA during Mrs E’s previous hospital admissions, the Trust should have been aware there was an LPA. Mr D said the absence of the LPA document during this admission meant Trust staff were not aware he held that role. Mr D said because of this he was not involved in discussions about discharge planning as he should have been.
38. In its response to Mr D’s complaint, the Trust acknowledged that he held LPA for Mrs E. During its investigation into the complaint, it reviewed Mrs E’s records and found no copy of an LPA within her records. The Trust also said it had no record of an LPA being shown to or viewed by Trust staff during Mrs E’s admission, and it was unable to identify or find the staff member Mr D recalled speaking to. The Trust said the usual process for handling LPAs at the time was that the original document would be checked and verified, and a signed copy placed at the front of the patient’s records. However, it confirmed there was no copy in Mrs E’s records, and apologised for this.
39. The Trust said that since Mr D’s complaint, it is increasingly using electronic records, and is looking at how to incorporate electronic versions of LPAs into patient records. The Trust also said handling of LPAs is included in the Trust’s mandatory adult safeguarding training for all employees.
40. Based on the information available, I am not able to say what happened to the copy of the LPA and why it was not in Mrs E’s records during this hospital admission. I am unable to add to the response Mr D has already received from the Trust in terms of whether the LPA was shown to or seen by the Trust during this admission, and therefore cannot conclude whether or not there was fault in the LPA not being included in the records.
41. Regarding the impact of the LPA not being included in the records, Mr D said this meant he was not consulted as he should have been about Mrs E’s discharge from hospital. He said this was because staff were not aware he held LPA. As noted above, the records show that Mr D was involved in several discussions about Mrs E's care and discharge planning. I have not found fault with the Trust on this point because this was in line with the Department of Health guidance referred to in paragraph 12, which states discharge planning should involve patients and carers so that they can make informed decisions and choices. Therefore, although the LPA was missing from the records, I have not seen any evidence that Mr D was not involved in discharge discussions as a result of this.
42. Mr D also complained that Mrs E’s patient-held records went missing, and said this meant the Trust did not refer to these when treating Mrs E. The Information Commissioner’s Office has already considered Mr D’s complaint that the patient-held records went missing. In its response to the complaint, the Trust said it had referred to the information in the patient-held records when Mrs E was admitted.

Trust complaint handling

43. Mr D said there were delays in the Trust’s handling of his complaint and that a proper investigation was not carried out. Mr D first complained in August 2018, and attended a meeting in October 2018. The Trust sent a written response in June 2019 and a final response in November 2019. The Trust acknowledged delays in completing its consideration of the complaint, and remedied this by appropriately apologising to Mr D. Based on the information I have seen, the Trust investigated the concerns raised by Mr D in his complaint and I have not found fault with this aspect of its complaint handling.

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Final decision

44. I found fault by the Trust in its communication with Mr D about Mrs E’s pneumonia, leading to distress to Mr D. The Trust has offered an appropriate remedy to Mr D by apologising to him for this. However, I found no fault by the Trust or Council regarding the other matters I have investigated, and I have completed my investigation on this basis.

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Parts of the complaint that I did not investigate

45. There were two issues of Mr D’s complaint that I did not investigate, which are set out below.

NHS Continuing Healthcare checklist

46. Mr D complained about the completion of the NHS funded continuing healthcare (CHC) checklist, a screening tool to determine eligibility for NHS funded continuing healthcare. After the checklist was completed, Mrs E was found not eligible for CHC.
47. Mr D complained the checklist was not accurately completed and did not reflect Mrs E’s needs. In its response to Mr D’s complaint, the Trust accepted the checklist did not appear to correlate with Mrs E’s medical history. The Trust also acknowledged consent was not sought for the checklist to be completed. It said the family should have been involved when the checklist was done, and the rationale for the assessment discussed with them. The Trust apologised to Mr D and said that since Mr D’s complaint, staff completing CHC checklists were monitored and supported by senior staff. It also said they were provided with guidance and ongoing training to ensure checklists were completed properly with the correct supporting evidence.
48. Mr D then approached the responsible NHS clinical commissioning group (CCG), to carry out a retrospective review of Mrs E’s CHC eligibility. As this review is ongoing, I have not investigated this part of Mr D’s complaint.
49. However, Mr D still has an opportunity to complain about this matter in future should he remain dissatisfied after receiving the outcome of the CHC review. It would then be open to him to complain about this directly to the CCG.

Further concerns about records

50. Mr D complained that the Trust lost Mrs E’s patient-held records, altered some of her records, and withheld copies of assessments that he requested. Mr D has already complained to the Information Commissioner’s Office (ICO) about these matters, and it has considered and responded to his concerns. Therefore, I have not included them in this investigation.

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Investigator's decision on behalf of the Ombudsman