Summary: We found fault with the Trust’s handling of Mrs D’s hospital discharges in March 2020. We also found fault with the handling of the subsequent complaint from Mrs D’s daughters by the Trust and Surrey Downs. We recommend the Trust and Surrey Downs apologise for this fault and pay a financial remedy to Mrs D’s daughters in recognition of their distress, time and trouble.

The complaint

1. The complainants, who I will call Mrs B and Mrs C, are complaining about the care provided to their late mother, Mrs D by Surrey County Council (the Council), Surrey Downs Health and Care (Surrey Downs) and Epsom and St Helier University Hospitals NHS Trust (the Trust). In addition, Mrs B and Mrs C complain these organisations failed to provide them with appropriate support.
2. Mrs B and Mrs C complain that the Council, Trust and Surrey Downs:

• discharged Mrs D from hospital on two occasions (on 26 and 30 March 2020) when she was not clinically fit and without appropriate care and support to meet her needs;
• failed to support them to secure care for Mrs D prior to her discharge on 30 March 2020, despite their request for assistance;
• failed to provide Mrs D with support at home following her discharge, despite her vulnerability; and
• failed to work together effectively to address their complaint.

3. Mrs B and Mrs C say these failings meant Mrs D was left vulnerable and in pain in the community. They found this situation deeply stressful and distressing and this was compounded by the subsequent poor handling of their complaint.

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The Ombudsmen’s role and powers

4. 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).
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 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

7. In making my final decision, I considered information provided by Mrs B and Mrs C and also discussed the complaint with Mrs B. In addition, I considered relevant documentation from the Council, Trust and Surrey Downs, including the case records. I obtained further information from a local ambulance Trust. I also considered comments from all parties on my two draft decision statements. Furthermore, I obtained clinical advice from an independent clinical adviser (a consultant physician).

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What I found

Relevant legislation and guidance

Intermediate Care and Reablement

8. Intermediate care and reablement support services are usually provided for people after they have left hospital, or when they are at risk of having to go into hospital. They are time-limited and aim to help a person to preserve or regain the ability to live independently. The National Audit of Intermediate Care lists four types of intermediate care:

• crisis response – services providing short-term care (up to 48 hours);
• home-based intermediate care – services provided to people in their own homes by a team with different specialties but mainly health professionals such as nurses and therapists;
• bed-based intermediate care – services delivered away from home, for example in a community hospital; and
• reablement – services to help people live independently which are provided in the person’s own home by a team of mainly care and support professionals.

9. Regulations require that intermediate care and reablement be provided without charge for up to six weeks. This is for all adults, whether or not they have eligible needs for ongoing care and support. Councils may charge where services are provided beyond the first six weeks but should consider continuing providing them without charge because of the preventive benefits. (Reg 4, Care and Support (Preventing Needs for Care and Support) Regulations 2014)

COVID-19 pandemic

10. In response to the COVID-19 pandemic and the need to keep hospital beds free, the Government introduced the COVID-19 Hospital Discharge Service Requirements (‘Discharge Today’). This guidance came into effect on 19 March 2020.
11. Discharge Today set out that patients must be discharged from hospital as soon as it was clinically safe. It introduced a “discharge to assess” model consisting of four care pathways. Pathway 0 applied to patients undergoing a simple discharge, with no input from health or social care services. Pathway 1 applied to people who required some support from health and/or social care services to recover at home.
12. Discharge Today also set out that the NHS would fully fund the cost of new or extended social care support for a limited time for people who started a care package between 19 March and 31 August 2020. This was to enable care to continue until a person’s longer-term care needs had been assessed, at which point the person’s care would move to normal funding arrangements.

Key facts

13. Mrs D underwent bowel surgery in 2015 and had a stoma bag. She was admitted to hospital on 24 February 2020 with severe back pain caused by twisting awkwardly. She was also constipated. Mrs D was discharged the following day with a package of reablement care. This involved a carer visiting Mrs D at home two times per day to assist her with washing and dressing.
14. Mrs D’s reablement care package was initially planned to end on 27 March. However, as she made good progress in her rehabilitation, Mrs D received her final care visit on 20 March.
15. Mrs D suffered a fall at home on 25 March and aggravated her back injury. She was admitted to hospital that day with back pain and constipation.
16. The clinical team treated Mrs D with pain relief medication. A physiotherapist from Surrey Downs’ @Home service assessed Mrs D on 26 March. The physiotherapist concluded Mrs D was independently mobile and independent with most tasks. The Trust discharged Mrs D later that day with additional pain relief medication.
17. On 27 March a member of the @Home service made a follow-up call to Mrs D. Mrs D reported that she was managing well with pain relief medication and did not raise any concerns.
18. A member of the @Home service spoke to Mrs D again on 28 March. Mrs D said she continued to experience pain and constipation, for which she was taking medication. The @Home officer noted that she would speak to Mrs D the following day to see whether her constipation had resolved and her pain was easing.
19. At Mrs B’s request, a physiotherapist and nurse from the @Home service visited Mrs D later that day. They noted Mrs D was able to move around her home, but that this was painful for her.
20. On 29 March, Mrs D spoke to an @Home nurse and a GP. She reported that she remained constipated and was struggling. The GP noted that Mrs D was taking a stool softener and that he would review her in 48 hours.
21. On 30 March, Mrs D was admitted to hospital. She was again noted to be suffering from constipation and back pain.
22. An @Home service nurse assessed Mrs D that morning. She noted Mrs D was able to mobilise independently with her walking frame and could change her stoma bag without assistance. However, she continued to experience pain.
23. A social worker spoke to Mrs B and Mrs C later that day. The social worker noted they felt Mrs D would require reablement care on discharge. However, the social worker advised that Mrs D would not be eligible for reablement care as her needs were long-term in nature.
24. Mrs B and Mrs C arranged a temporary respite care home placement for Mrs D. Mrs D was discharged on 31 March and transferred to the care home.
25. On 9 April, Mrs D moved to a community hospital placement arranged by her GP.

Analysis

Hospital discharge – 26 March 2020

26. Mrs B and Mrs C say the Trust discharged Mrs D from hospital on 26 March 2020 when she was not clinically fit. Furthermore, they say Mrs D was discharged without appropriate care and support to meet her needs in the community.
27. The clinical records show Mrs D was admitted on 25 March with back pain and constipation, having suffered a fall at home.
28. A lumbar (lower spine) X-ray showed Mrs D had a historical vertebral fracture. However, the clinical team found no evidence of any injuries related to Mrs D’s recent fall.
29. The clinical team also noted that Mrs D had a raised C-Reactive Protein level (CRP – a blood protein that indicates inflammation). The clinical team undertook a chest X-ray and a urine dip stick test to rule out infection. These investigations did not identify any significant abnormalities. The clinical team noted that blood tests confirmed Mrs D had a normal white blood cell count. They concluded that there were no clinical indications of infection.
30. It is clear Mrs D did have significantly raise CRP levels at the time of her admission. There are many potential causes for this. For example, rheumatoid arthritis (which Mrs D suffered from) and constipation can contribute towards a raised CRP. It is unclear what was causing the raised CRP levels in Mrs D’s case. However, I am satisfied the clinical team conducted appropriate examinations to exclude the possibility of an infection.
31. Mrs D had a history of constipation and had undergone surgery in 2015 due to a perforated bowel. She had recently (in February 2020) been admitted to hospital with constipation. Furthermore, Mrs D was at increased risk of constipation due to the pain relief medication she was taking for her back.
32. An abdominal X-ray found sections of Mrs D’s bowels were distended, with significant faecal loading (a build-up of faeces in the bowels). However, there was no evidence of a bowel obstruction. The radiologist who reported on the X-ray recommended further evaluation via a Computerised Tomography (CT) scan of the area.
33. The clinical team’s examination found Mrs D was able to eat and drink normally and was not experiencing abdominal pain. For that reason, the clinicians concluded a CT scan was not needed.
34. The clinical team treated Mrs D with suppositories and noted that her stoma bag contained “watery bowel contents”. I note the discharge summary for this admission records that Mrs D’s “stoma [was] working with normal output”. However, I found no evidence in the clinical or nursing records to support this statement. Indeed, I found no evidence to suggest Mrs D had passed any stools (beyond that noted above).
35. In my view, Mrs D should not have been treated as medically fit for discharge until her severe constipation had been relieved. This was significant given her history of constipation. I found no evidence this was the case. This was fault.
36. It is not possible, given Mrs D’s history of constipation, to say whether her subsequent readmission would have been prevented even if she had remained in hospital until her constipation resolved. However, I consider the decision to discharge Mrs D placed her at greater risk of readmission and caused Mrs B and Mrs C significant distress.
37. It is important to note that the @Home service was working on information provided to it by the treating clinical team. By the following day, the clinical team had concluded that Mrs D was medically fit for discharge. I have set out my concerns about this above. However, I will now go on to consider whether the discharge planning carried out by the @Home service was appropriate.
38. A physiotherapist from the @Home service assessed Mrs D on the ward on 26 March. He noted Mrs D was able to transfer independently from her chair to her bed and could mobilise with the use of her walking frame. Mrs D told the physiotherapist that she lived at home in a ground floor property without steps and was supported by her daughter. The physiotherapist noted “[p]atient managing well at home independently, feeling well supported by daughters.” He concluded Mrs D was at her functional baseline and could return home with a planned follow-up call from the @Home service.
39. I am satisfied the @Home service completed an appropriately thorough assessment of Mrs D’s needs and I found no fault by Surrey Downs in this respect.
40. In response to my enquiries, the Trust confirmed that Mrs D was discharged under Pathway 1 as defined in the Discharge Today guidance. This was the care pathway used for patients who could be discharged home with some additional health or social care support. In Mrs D’s case, this was to be provided by the @Home service.
41. I was unable to find a record of this in the clinical notes. This should have been clearly recorded in Mrs D’s discharge summary so other professionals involved in her care could access this information. This omission represents fault by the Trust.
42. Nevertheless, I am satisfied this did not have a significant impact on Mrs D’s care. This is because Mrs D did receive the follow-up care required under Pathway 1 from the @Home service.
43. In summary, I consider the @Home service completed an appropriate assessment. However, my view as set out above, is that Mrs D should not have been treated as medically fit for discharge at that point.

Hospital discharge – 30 March 2020

44. Mrs B and Mrs C said the Council, Trust and Surrey Downs discharged Mrs D without appropriate care and support to meet her needs in the community, Furthermore, they said these organisations failed to provide Mrs D with support at home, despite her vulnerability.
45. On 27 March, a physiotherapist from the @Home service called Mrs D to check how she was coping. She noted that Mrs D “reports managing well with regular analgesia – Nil concerns raised by patient.” The physiotherapist gave Mrs D a contact number for the @Home service and advised her to make contact if her condition changed.
46. A nurse from the @Home service called Mrs D again on 28 March. Mrs D reported that she was still in pain but taking regular pain relief medication. She also explained that she remained constipated and was taking laxative medication and drinking fluids. Mrs D said she “has very supportive daughters who are visiting daily to help.”
47. Later that day, the @Home service received a call from one of Mrs D’s daughters. It is unclear whether this was Mrs B or Mrs C. Mrs D’s daughter reported that Mrs D was “not managing at home, not able to get in/out of bed due to pain and slept in chair last night.” The @Home service agreed to visit Mrs D.
48. A nurse and physiotherapist visited Mrs D at home during the afternoon of 28 March. They took Mrs D’s observations and noted these were within normal ranges. They noted Mrs D was able to stand from her chair and move to her bedroom and the toilet, albeit with some pain.
49. The nurse called Mrs D again on 29 March. Mrs D said she remained constipated, with abdominal pain and bloating. The nurse noted Mrs D was “struggling”. The nurse said she would ask a GP from the @Home service to review Mrs D.
50. The GP called Mrs D later that day and spoke to her daughter. He noted Mrs D had poor appetite and remained constipated. The GP recommended Mrs D use a stool softener and planned to review her in 48 hours.
51. In the early hours of 30 March, Mrs D was admitted to hospital. She reported continued constipation and back pain. The ambulance crew that transported Mrs D recorded in her patient care record that she was “not safe to be discharged home without [a package of care]”. The evidence shows the ambulance crew completed a handover with the Trust’s Emergency Department and provided a copy of the patient care record.
52. Despite this, I was unable to locate this document in the clinical notes. Similarly, I found no evidence in the clinical records to suggest Trust clinicians or the @Home service were aware of this information. This was important information that should have been available to the professionals treating Mrs D. This omission represents fault by the Trust.
53. It is not possible to say whether the handling of Mrs D’s discharge would have been different even if this information had been available to the clinical team or @Home service. However, I recognise this has caused uncertainty for Mrs B and Mrs C.
54. The ambulance crew also completed a safeguarding referral for Mrs D on 29 March. This was sent to the Council the following day. The case was allocated to a social worker on 31 March, by which point Mrs D had been discharged.
55. The hospital clinical team arranged further X-rays and blood tests. The blood tests revealed a further rise in Mrs D’s CRP levels. This was again suggestive of possible infection. Furthermore, Mrs D’s mental test score had dropped to 2/10 (from 10/10 at her previous admission).
56. The clinical team took further blood tests that revealed a normal white blood cell count. They could not identify any clinical signs of infection and found Mrs D did not have a fever. However, I found no evidence to suggest the clinical team arranged a further urine dipstick test to exclude the possibility of a urine infection. Furthermore, while the clinical team did arrange a chest X-ray for Mrs D, there is no evidence in the notes to show this was considered for signs of infection.
57. Furthermore, the clinical records for the evening of 30 March show Mrs D receive three unsuccessful enema treatments. I have been unable to identify any further clinical evidence to show that Mrs D’s constipation had resolved at the point of her discharge on 31 March.
58. In summary, I consider the Trust failed to carry out the necessary clinical investigations to determine whether Mrs D was suffering from an infection. Mrs D should not have been treated as medically fit for discharge until further investigations had been carried out. This was particularly important given the significant rise in her CRP levels since her previous admission. In addition, there is no clear clinical evidence to show that Mrs D’s constipation had resolved. Again, this should have prevented her being treated as medically fir for discharge. This was fault by the Trust.
59. In my view, the decision to discharge Mrs D at that point placed her at greater risk of readmission. It also caused Mrs B and Mrs C significant distress and concern.
60. As with Mrs D’s previous admission, the @Home service was working on the understanding that Mrs D was medically fit for discharge. A nurse from the @Home service assessed Mrs D during the morning on 30 March. She noted Mrs D was able stand from her chair to her walking frame independently. The nurse noted Mrs D mobilised to the toilet and was able to change her stoma bag and wash her hands without assistance.
61. The nurse spoke to Mrs D’s daughters. She noted they were concerned Mrs D would be unable to cope at home overnight without support. The nurse advised Mrs D’s daughters that she would not be eligible for reablement support. She explained that Mrs D could be supported on discharge by the @Home team but that this would not include overnight care. The nurse noted Mrs D’s daughters felt she would need a respite placement if she was not going to receive proper support at home. However, the nurse explained that any respite care or additional support would need to be arranged privately.
62. A social worker from the @Home service spoke to Mrs B and Mrs C that afternoon. She explained that Mrs D would be discharged that day. The social worker reiterated that Mrs D would not be eligible for reablement care as her ongoing constipation and back pain were long-term needs. The social worker told Mrs B and Mrs C that there were no community hospital beds available and advised that they would need to arrange a private package of care for Mrs D if they felt she needed additional support.
63. One of Mrs D’s daughters spoke to a nurse again shortly after this. She explained that Mrs D’s GP had advised a community hospital bed. The nurse explained that she did not consider Mrs D to be suitable for a community hospital bed. Furthermore, she said no such beds were available at that time.
64. The @Home social worker subsequently identified a home care agency that could provide night care visits. She provided Mrs D’s daughters with the agency’s contact details. However, Mrs B and Mrs C were able to arrange a private care home placement and Mrs D was discharged there on 31 March.
65. In response to my enquiries, the Trust confirmed that Pathway 0 was applied to Mrs D on this occasion. This was because Mr s D’s family had arranged a private respite placement for her. Again, this is not clearly recorded in the clinical notes. This was fault. However, I do not consider this had a significant impact on Mrs D’s care as she was not ultimately discharged home at that point.
66. The case records show Mrs D’s care needs were a matter of significant dispute. Mrs D’s family and her GP were concerned that she would be unable to cope at home. This was also the view of the ambulance crew that transported Mrs D to hospital on 30 March. However, the professionals from the @Home service remained of the view that Mrs D was able to manage independently and did not require additional support.
67. The professionals from the @Home service assessed or reviewed Mrs D three times (either in person or over the telephone) between 27 and 30 March. These assessments incorporated input from a nurse, physiotherapist and GP. The case records show the @Home service were concerned about Mrs D’s ongoing pain and constipation. Nevertheless, they did identify the need for an ongoing package of care. Rather, the professionals were satisfied they could support Mrs D at home.
68. In my view, this was ultimately a matter of professional judgement for the officers concerned. The evidence I have seen suggests the @Home service completed an appropriate consideration of Mrs D’s needs. I found no fault by the Council or Surrey Downs in this regard.
69. It is understandable Mrs B and Mrs C wanted to ensure Mrs D was appropriately supported in the community. This led them initially to explore whether a community hospital bed would be available for Mrs D as recommended by her GP. However, the assessment undertaken by the @Home service did not identify the need for a community hospital bed.
70. This placed Mrs B and Mrs C in a difficult position. They had very little time to identify a suitable respite care home placement for Mrs D before her planned discharge on 30 March. Indeed, Mrs B told me they made over 20 calls to different care agencies and providers that day.
71. The case records show the social worker offered only very limited support with this process. Nevertheless, it is important to note that the assessments undertaken by the @Home service did not identify the need for a package of care or a respite placement. This was a matter of choice for Mrs D and her family.
72. Given the pressure faced by frontline health and social care services during this exceptionally busy period, I consider it appropriate for the social worker to inform Mrs B and Mrs C that they would need to secure this care privately. I found no fault by the Council in this regard.

Complaint handling

73. Mrs B and Mrs C complained that the Council, Trust and Surrey Downs failed to work together effectively to respond to their complaint. They said this led to unnecessary delay and meant not all their concerns were addressed.
74. Under The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 (the ‘complaints regulations’), health and social care providers have a duty 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 another.
75. Section 9 relates to the duty to cooperate to address complaints that concern more than one responsible body. It states that, in these circumstances, the responsible bodies must co-operate in handling the complaint. This includes a shared duty to: establish who will lead the complaint process; share relevant information; and provide the complainant with a coordinated response.
76. The case records show Mrs B and Mrs C first complained to the Trust in May 2020. However, the complaint appears not to have reached the Trust’s complaints team until 16 June. This was a delay of over a month.
77. On 6 July, the Trust wrote to Mrs B and Mrs C to request their consent to share details of the complaint with the other organisations involved in Mrs D’s care. Despite not having received consent, the Trust shared the complaint with all parties on 13 July. Confusingly, the Trust complaints officer was still chasing consent from Mrs B and Mrs C in late July. By this point, around two months had passed without progress.
78. The Council agreed to lead on coordinating a joint response. It acknowledged the complaint on 30 July. The acknowledgement letter detailed each of the issues and which agency would respond. Mrs B and Mrs C responded to the Council on 2 August with one small amendment.
79. On 2 and 8 August, Mrs B and Mrs C submitted further complaints to the Trust about Mrs D’s care and its handling of the complaint to that point. They noted the Trust had shared the complaint with the Council even without their consent and queried why it could not have done so in June when it first became apparent the complaint involved the Council.
80. On 12 August, the Council shared a copy of its response with the Trust and Surrey Downs. This set out each of the complaints as agreed in the Council’s summary of 30 July along with the outstanding issues to be addressed. However, the Trust and Surrey Downs did not use the Council’s suggested format. Instead, they provided a separate letter from the Trust’s chief executive for inclusion with the Council’s response. The Council sent the responses to Mrs B and Mrs C on 9 September.
81. On 12 October, Mrs B and Mrs C sent a further detailed complaint to all parties. In addition to seeking responses to further points of complaint, they pointed out that many of their original complaints remained unaddressed.
82. The Council provided a further response on 9 December, setting out its response to each of the social care complaints. The Council also clarified which issues the Trust and Surrey Downs would respond to. However, the subsequent Trust/Surrey Downs response of 23 December again used a different format.
83. The complaints records show the Trust and Surrey Downs were primarily responsible for the delay in responding to the complaint. This was partly because the Trust took over a month to handle the initial complaint letter. The subsequent confusion surrounding the consent to share information then caused further delay.
84. In my view, the evidence shows the Council did attempt to coordinate a joint response to the complaint. It agreed a full summary of complaint with Mrs B and Mrs C and shared this with the Trust and Surrey Downs to facilitate a response that would address each point in turn. However, the Trust and Surrey Downs elected not to use this format. This caused confusion and meant that not all of their concerns were addressed. It also made the course of the correspondence harder to follow. Furthermore, it put Mrs B and Mrs C to time and trouble as they were required to correspond separately with each organisation.
85. In summary, I consider there was fault by the Trust and Surrey Downs with regards to their handling of this complaint. This was acknowledged in their response of 15 March 2021. In that response, the Trust acknowledged that “the information provided was not as clear as we would like and there was little explanation as to which organisation was responsible for specific services”. In my view, this situation would likely have been avoided if the Trust and Surrey Downs had used the Council’s complaint summary as a basis for their responses.

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Agreed actions

Trust

86. Within one month of my final decision statement, the Trust will:

• apologise to Mrs B and Mrs C for its decision to treat Mrs D as medically fit for discharge on 26 March even though her severe constipation had not resolved;
• apologise for its failure to retain relevant clinical information from the ambulance crew that transported Mrs D to hospital on 29 March;
• apologise to Mrs B and Mrs C for its decision to treat Mrs D as medically fit for discharge on 30 March without having carried out the necessary clinical investigations to exclude the possibility of an underlying infection and without having ensured her constipation had resolved;
• pay Mrs B and Mrs C £400 each. This recognises the distress and uncertainty caused to them by the fault I have described above; and
• ensure it has an appropriately robust process in place for storing and accessing relevant clinical information from third-party organisations.

Trust and Surrey Downs

87. Within one month of my final decision statement, the Trust and Surrey Downs will:

• apologise to Mrs B and Mrs C for their shared failure to address their complaint effectively and in accordance with the complaints regulations; and
• each pay Mrs B and Mrs C £50 (a total of £100 for each complainant) in recognition of the time and trouble they were put to us as a result of this poor complaint handling.

Council, Trust and Surrey Downs

88. Within three months of my final decision statement, the Council, Trust and Surrey Downs will complete a joint review of their complaints procedures. This review should seek to agree a clear process for handling joint complaints that reflects their duty to cooperate as set out in the complaints regulations. The review should also agree a standardised format for joint responses.
89. The Council, Trust and Surrey Downs should write to the Ombudsmen to confirm they have completed the above actions.

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Final decision

90. I found fault by Trust with regards to its handling of Mrs D’s hospital discharges on 26 and 30 March.
91. I also found fault with the handling of Mrs B’s and Mrs C’s complaints by the Trust and Surrey Downs.
92. In my view, the actions the Trust and Surrey Downs have agreed to undertake represent a reasonable and proportionate remedy for the injustice caused to Mrs B and Mrs C by this fault.
93. I have now completed my investigation on this basis.

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Investigator's decision on behalf of the Ombudsman