Summary: We uphold Mrs X’s complaint about the way her husband, Mr X, was discharged from hospital and the care he received in a care home. We found fault with how Leicestershire County Council and Leicestershire General Hospital NHS Trust discharged Mr X. We also found fault with some aspects of Mr X’s care. As a result, Mr X did not always receive appropriate care and Mrs X was caused distress and uncertainty. The Council and the Trust will apologise to Mrs X and pay her a total of £400. The Council will also make some systemic improvements. We did not find fault with Queens Road Surgery.

The complaint

1. Mrs X complains about the way Leicestershire County Council (the Council) and Leicestershire General Hospital NHS Trust (the Trust) discharged her husband, Mr X, from hospital to a Discharge to Assess placement at Stoneygate Ashlands (the Care Home). Mrs X says the discharge was rushed and failed to properly involve her in the process, as Mr X’s main carer and health and welfare attorney. She says Mr X was discharged to an unsuitable placement which was too far away from her. She further complains about poor communication between the organisations, including failure to ensure the Care Home had the correct information about Mr X’s needs.
2. Mrs X is unhappy with the care provided by the Care Home. She says the Care Home refused to listen to her, despite being her husband’s attorney. She says the Care Home fed Mr X inappropriate food and drink, provided excessive pressure care and failed to recognise his pain. She also complains Queens Road Surgery (the Practice) failed to address Mr X’s pain.
3. She also complains the Council’s social worker did not act on her concerns or help to return Mr X home. Further, the social worker told Mrs X she had no power as attorney and matters would go to court if she disagreed with the professionals.
4. Mrs X says her husband was inappropriately discharged to a care home which could not meet his needs. As a result, he received poor care which contributed to his premature and painful death. Mrs X says she was caused significant distress by her husband’s poor care and struggled to visit him due to distance.
5. Mrs X would like carers to be listened to and to ensure people’s needs are met by care homes. She would also like a financial remedy.

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The Ombudsmen’s role and powers

6. 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).
7. 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).
8. 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.
9. 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

10. I have considered the information Mrs X provided in support of her complaint. I have also received information from the Council, the Trust and the Practice. I have carefully considered all the written and oral evidence submitted, even if it is not all mentioned within this decision statement.
11. I shared this draft decision with Mrs X, the Council, the Trust and the Practice and they had an opportunity to comment. I have carefully considered the comments I received.

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What I found

Key legislation and guidance

NHS Quick Guide: Discharge to Assess

12. Definition of ‘Discharge to Assess – ‘Where people who [no longer need hospital treatment], but may still require care services, are provided with short term funded support to be discharged to their own home (where appropriate) or another community setting. Assessment for longer-term care and support is then undertaken in the most appropriate setting and at the right time for the person.
13. Principles for Discharge to Assess model include:
• Putting people and their families at the centre of decisions, respecting their knowledge and opinions and working alongside them to get the best possible outcome.
• Take steps to understand both the perspectives of the patient and their carers… [and] their needs…’

Hospital Discharge

14. 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:

• involve patients and carers so that they can make informed decisions and choices that deliver a personalised care pathway and maximise their independence.’

Hospital discharge and community support guidance – July 2022

15. Section 2 ‘Planning for discharge from hospital should begin on admission…This will enable the person and their family or carers to ask questions, explore choices and receive timely information to make informed choices about the discharge pathway that best meets the person’s needs.’
16. Section 3 ‘Health and care professionals who are facilitating hospital discharges should work together with individuals, and – where relevant – families and unpaid carers, to discharge people to the setting that best meets their needs. This process should be person-centred, strengths-based, and driven by choice, dignity and respect.’
17. Section 11 ‘Planning and implementation of discharge should respect an individual’s choices and provide them with maximum choice and control possible from suitable and available options. While NHS organisations should seek to offer choice to patients where such choice exists, in practice, there may be limited situations where an NHS organisation may decide to reduce the choice of services offered to people on discharge. Such situations include times of extreme operational pressures, for example, for the duration of the UK COVID-19 Level 4 National Incident. A record should be produced of the considerations of the relevant discharging body in deciding to offer that patient a reduced choice, setting out all of the material considerations for and against doing so, and the balancing exercise between the patient choice duty in the NHS Act 2006, and relevant competing duties and countervailing factors.’

The Care and Support and Aftercare (Choice of Accommodation) Regulations 2014

18. The Care and Support and Aftercare (Choice of Accommodation) Regulations 2014 set out what people should expect from a council when it arranges a care home place for them. Where the care planning process has determined a person’s needs are best met in a care home, the council must provide for the person’s preferred choice of accommodation, subject to certain conditions. This also extends to shared lives, supported living and extra care housing settings.
19. The council must ensure:

• the person has a genuine choice of accommodation;
• at least one accommodation option is available and affordable within the person’s personal budget; and,
• there is more than one of those options.

What happened

20. Mr X lived at home with his wife, Mrs X. Mr X had advanced dementia and was mostly unable to communicate verbally. Mrs X was his main carer and his appointed health and welfare attorney. This gave Mrs X the legal power to make decisions about Mr X’s health and personal welfare on his behalf, such as day-to-day care, medical treatment, or where he should live.
21. Late October 2023, Mr X was admitted to Leicester General Hospital, following a fall at home where he hit his head. A few days later, Mrs X had a full knee replacement surgery.
22. In mid-November 2023, Mr X was deemed medically fit for discharge. Mr X moved to a ‘virtual ward’ at The Ashtons Care Home (the Nursing Home). The virtual ward allowed Mr X to continue receiving hospital care in a community bed while his discharge was arranged.
23. Mental capacity is the ability to make an informed decision based on understanding a situation, the options available, and the consequences of the decision. A mental capacity assessment found Mr X was not able to make decisions around his discharge destination. This meant a decision would need to be made on his behalf. A key principle of the Mental Capacity Act 2005 is that any act done for, or any decision made on behalf of a person who lacks capacity must be done, or made, in that person’s best interests.
24. The Council records state Mrs X felt unable to continue caring for Mr X at home due to her own health conditions. Mrs X disputes saying this. The Council began to source a Discharge to Assess placement in a care home where Mr X’s care needs could be fully assessed before deciding on where he would live long term. Mrs X wanted Mr X to remain in the local area so she could visit him daily and advocate for him. Mrs X felt he should remain in The Nursing Home.
25. In early December 2023, when Mr X still had not been discharged, Mrs X started to ask about the possibility of Mr X coming home. However, she remained concerned that she may not be able to meet his needs.
26. Mrs X spoke with a social worker manager about her concerns. She explained she had her own complex needs and was also supporting her daughter who was unwell. Mrs X’s recollection of this call is the manager agreed not to place Mr X far away from her.
27. On 14 December 2023, the Council referred Mr X for a residential care home placement. All the local care homes were full. However, the Care Home was able to accept him.
28. On 15 December 2023, Mr X was discharged to the Care Home. The Care Home had a Care Quality Commission (CQC) rating of ‘Requires Improvement’ at the time.
29. Mrs X was not told about Mr X’s discharge. She visited the Nursing Home later that day and was distressed to find Mr X was not there and staff were unclear where he had gone. Mrs X was unhappy Mr X had been moved out of the area. Mrs X complained to the Council and asked for Mr X to be moved locally or back to the Nursing Home.
30. The Council spoke with the Nursing Home, however its care fees were significantly higher than the usual Discharge to Assess placement rate. The matter was escalated to the Head of Service, who advised to keep Mr X at the Care Home. Mrs X was unhappy about this and asked for Mr X to come home.
31. In late December 2023, the Council’s social worker visited Mr X at the Care Home, along with Mrs X, as part of his longer term care needs assessment.
32. In January 2024, a Continuing Healthcare (CHC) checklist was completed. CHC funding is a package of ongoing care that is arranged and fully funded by the NHS where a person has been assessed as having a ‘primary health need’. Mr X was scheduled to have a full CHC assessment in mid-February 2024 to see if he was eligible for CHC funding.
33. Mrs X repeatedly raised concerns the Care Home was giving Mr X inappropriate food and drink. In early February 2024, the Care Home received a copy of a report from a Speech and Language Therapist (SALT). This report recommended Mr X be offered a combination of normal and thickened fluids and pureed food. A SALT review was scheduled for 6 February 2024.
34. On 5 February 2024, the GP from the Practice visited Mr X. He was red faced and sweating, with a hot leg. The GP diagnosed Mr X with cellulitis and prescribed antibiotics and paracetamol.
35. On 6 February 2024, Mr X collapsed unexpectedly during the SALT review and died. Mr X’s death certificate lists cause of death as septicaemia, chest infection, cellulitis and dementia.

Analysis

Hospital discharge

36. Mrs X complains Mr X’s discharge to the Care Home was rushed and failed to listen to her views. Mrs X says the out of area placement was not discussed with her. She also says the organisations also failed to communicate properly between themselves.
37. I have found poor communication between the Trust and the Council, regarding Mr X’s discharge which caused a delay. The Council was initially confused as it was unclear that Mr X’s placement at the Nursing Home was part of the Trust’s ‘virtual ward’ rather than a Discharge to Assess placement. This meant the Council did not begin actively searching for a placement for Mr X until late November 2023. This is fault. This caused Mrs X uncertainty about whether there was a missed opportunity to find a local placement, had the searching not been delayed.
38. Mr X was discharged via the Discharge to Assess Pathway 2. This pathway is for people who need a short-term care placement while longer term care options are considered. Once the Trust decides a person is medically fit for discharge, it contacts the Council to request support to find a suitable discharge location.
39. Mrs X clearly expressed her wish for Mr X to remain in the local area, ideally at the Nursing Home. Mrs X was repeatedly directed to talk to different teams about the discharge location, without any single point of contact taking overall responsibility for the discharge. This was understandably frustrating for Mrs X. There was additional confusion about whether Mr X should have been placed in a residential or nursing home. This led Mrs X to feel that Mr X had been inappropriately placed.
40. The Council told me it tries to place people in their preferred area but placements also need to represent good value. The Council said it was unable to source a placement in the local area, therefore needed to conduct a wider search to find an available placement that could meet Mr X’s needs. While I acknowledge the lack of placements, all relevant factors for each individual person still need to be properly considered.
41. The Council told me it arranges the placements and the Trust’s ward staff arrange the discharge and notify the family of the discharge plans. The Council accepted it should have notified Mrs X that a placement had been sourced and provided her with the details of that placement.
42. The Council did not discuss the placement with Mrs X. The Trust’s ward staff did not contact Mrs X discuss the discharge date. The Council and the Trust have failed to act in line with the ‘Ready to Go’ guidance which is clear that family members and carers should be involved in discharge decisions. Further, Mrs X was also Mr X’s health and welfare attorney which means she had additional legal powers to make discharge decisions on his behalf. Mrs X was denied the opportunity to consider the suitability of the proposed placement at the Care Home. The placement at the Care Home was clearly contrary to Mrs X’s wishes, yet the discharge proceeded without any discussion with her. This is fault. The communication failure caused distress and frustration for Mrs X.
43. Both the Trust and the Council has already accepted Mrs X was not told Mr X was being discharged to the Care Home. The Trust has shared this as a learning point with staff and put several systemic improvements in place including additional staff and training. However, there is more that can be done to address this failing.
44. The Council panel and the Head of Service considered Mrs X’s wish for Mr X to be placed at the Nursing Home. The outcome is recorded to accept the ‘most cost effective’ placement. The Head of Service’s reasons for choosing the Care Home is not clearly recorded. However, this appears to be because the Care Home was within the Council’s usual rate.
45. The Council complaint response says it was unable to source a suitable bed in the area which was affordable in Council’s rate and could meet Mr X’s needs. The Council is obliged to spend public money wisely. However, it must also have regard for a person’s wishes and individual circumstances. The decision about how best to meet a person’s needs should take into account all relevant information including wishes, benefits and risks, least restrictive options and finances for that particular person. Mr X was unable to express his wishes. This made Mrs X’s views particularly important as she was advocating on his behalf, not only as his main carer and his wife, as his health and welfare attorney. Mrs X feels the Council did not have a proper conversation with her about the financial options available to her for topping up Mr X’s care fees to enable him to move to the Nursing Home.
46. The Council had not provided any reason the Nursing Home was rejected as a placement option, aside from cost. Mrs X raised several reasons why Mr X staying in the local area was important for them. Mrs X felt strongly that Mr X should remain in the local area so she could support him properly, including with her communication. Mrs X’s views, as Mr X’s attorney, were not given sufficient weight. Mrs X also struggled to travel due to her recent surgery. There is no evidence the Council considered Mrs X’s needs as Mr X’s main carer.
47. Mrs X’s views are noted in the Council’s records, but I have not seen any meaningful consideration of her views when making the decision about discharge location. This is not in line with the hospital discharge and community support guidance (July 2022) which states ‘A record should be produced of the considerations of the relevant discharging body in deciding to offer that patient a reduced choice, setting out all of the material considerations for and against doing so, and the balancing exercise between the patient choice duty in the NHS Act 2006, and relevant competing duties and countervailing factors.’ The failure to offer Mr and Mrs X a choice of discharge locations, or to clearly record why this could not be offered, is contrary to the relevant guidance. This is fault.
48. Had the Council fully considered Mrs X’s views, we cannot know what the discharge outcome would have been or whether it would have been different. However, I have found that the decision was not taken properly. As a result, Mrs X experienced significant frustration. Mrs X did not feel heard. This was distressing for her.
49. Even though this was intended to be a short-term placement, it was still important the discharge decision was taken properly. As can be seen from Mr X’s case, people can be in Discharge to Assess placements longer than anticipated. Mr X was at the Care Home for seven weeks and his long-term placement had not been resolved. This time in the Care Home turned out to be his final weeks with Mrs X.
50. Mrs X is unhappy that Mr X was placed in a Care Home with a CQC rating of ‘Requires Improvement’. Care homes rated ‘Requires Improvement’ by the CQC are generally still able to accept new referrals. Care homes may be rated ‘Requires Improvement’ for various reasons. This does not automatically mean they are unsafe or provide poor care. There is a high demand for beds and limited availability. Due to a shortage of placements, it is sometime necessary to discharge people to care homes with a ‘Requires Improvement’ rating. However, as noted above, the placement should have been discussed with Mrs X and she should have had the opportunity to raise concerns about the choice prior to Mr X’s discharge location being chosen.
51. Mrs X says the Council social worker manager lied to her by promising Mr X would not be moved out of the area. The records note this conversation but does not mention any agreement that Mr X would remain local. In the absence of any independent evidence, I cannot say what was discussed.
52. Mrs X remains concerns that the Care Home was unable to meet Mr X’s complex needs as it was not a nursing home. However, the Trust and the Council found Mr X did not have any specific nursing needs on discharge. A District Nurse also said nursing care was not required. Mrs X had previously been told Mr X would need a nursing placement and it was not properly explained to her why this was not necessary. This caused confusion and worry for Mrs X.

Care provided by Care Home

Incorrect information

53. Mrs X complains there was no proper handover when Mr X moved to the Care Home. She says the Care Home had incorrect information recorded about him and did not know some important information about his care. Mrs X says she arrived at the Care Home, on the day of discharge, to find Mr X sitting alone, without the TV on and without his comfort toys. She also says the Care Home did not know about Mr X’s modified diet or that he was unsafe to sit out in a chair.
54. The Care Home’s pre-admission assessment notes Mr X’s enjoyment of TV and his toys, so it was aware of this information. The Care Home’s complaint response apologised to Mrs X for how she found Mr X and said this is not usual. I appreciate this was upsetting for Mrs X, however the Care Home has already addressed this point and we cannot achieve anything further.
55. Mrs X said Mr X needed a pureed diet but the Care Home fed him inappropriate food such as hard fried chicken. She also says he was left unsupervised with drinks. The Care Home’s pre-admission assessment noted Mr X needed assistance to eat and drink but wrongly recorded he had a normal diet and ‘no’ for SALT input. The Care Home complaint response said the information shared with them did not contain anything about an amended diet and it can only go on information from medical professionals. The Care Home says it had not witnessed Mr X having any trouble swallowing.
56. The Trust’s nursing records shows the Trust was aware Mr X was on a soft diet. There is also a note of previous SALT involvement, although it is incorrectly recorded that SALT gave no advice. It is unclear why the contents of Mr X’s SALT report were unknown. There was a missed opportunity for Mr X to have a SALT review while he was on the ward, given his known swallowing issues.
57. The Council’s brokerage form notes ‘Mrs X says sloppy food only, can struggle with swallowing, has a SALT assessment and identified with slow swallow’.
58. The Trust and the Council were aware of Mr X’s modified diet. I have not been able to establish why the Care Home did not identify Mr X’s modified diet when it completed the pre-admission assessment. This was important information which should have been clearly recorded. This Care Home’s failure to identify this important information was fault. This placed Mr X at increased risk. I will address later the Care Home’s actions around providing Mr X food and drink.
59. Mrs X also complains that the Care Home did not know Mr X needed to be nursed in bed. The pre-admission assessment records that Mr X was nursed in bed in hospital and had not been out of bed since he arrived. I have not seen anything to suggest the Care Home was unaware of this. I will address the Care Home’s decision to sit Mr X in a chair later.

Mrs X not listened to

60. Mrs X complains the Care Home did not listen to her concerns about Mr X’s care, despite being his main carer and health and welfare attorney.
61. It has been difficult to establish what concerns Mrs X raised with the Care Home at the time. The Care Home records that I have seen contain almost no information about Mrs X, except to note that she visited regularly. There are no written records of any concerns Mrs X might have raised during her visits.
62. I consider the lack of documentary evidence is likely down to poor record keeping, rather than Mrs X not raising any concerns. When considering complaints, we make findings based on the balance of probabilities. This means that we look at the available relevant evidence and decide what was more likely to have happened. Mrs X has raised her concerns with several other professionals and I am satisfied that, on the balance of probabilities, she was also raising her concerns directly with the Care Home.
63. Mrs X informed the Trust and the Council that Mr X was on a modified diet. She also mentioned the need for soft foods on the Care Home’s ‘Getting to know you’ form which she completed. I have no reason to doubt that she would have raised concerns about inappropriate foods being given to Mr X.
64. However, it was not until Mrs X was able to provide a copy of Mr X’s SALT report that the Care Home took any action to review Mr X’s diet. Mr X had been in the Care Home several weeks at that point. I have seen nothing to suggest the Care Home listened to Mrs X’s concerns, which should have carried weight as she had been his main carer for many years and his health and welfare attorney. The Care Home should have been more proactive about checking Mr X’s diet as soon as Mrs X raised concerns. The Care Home did not listen to Mrs X as carefully as it should have. This caused Mrs X frustration and increased risk to Mr X, for example by providing an inappropriate diet.

Food and drink

65. Mrs X complains the Care Home fed Mr X inappropriate food and drink and failed to act on her concerns. She says this contributed to his death from sepsis and a chest infection, which she suspects was caused by aspiration. I have addressed this point above to some extent. I will address the outstanding point on this issue.
66. The Care Home complaint response says there was no sign of swallowing issues while Mr X was resident, or they would have sought SALT input.
67. However, the Care Home completed a care plan for Mr X which noted he had a delayed swallow. Further, the Care Home completed a choking risk assessment. The outcome of this was Mr X was identified as medium risk for choking and noted that referral to SALT should be considered. Mr X was noted as having difficulty swallowing, and the checklist states that this fell into a risk category which should trigger an immediate referral to SALT for assessment. This did not happen.
68. I have identified multiple occasions where the Care Home could and should have acted earlier to clarify Mr X’s diet and involve SALT input. Failure to do so is fault. Again, this increased risk to Mr X, by providing an inappropriate diet over the course of several weeks.
69. However, there is nothing in the records I have seen to confirm Mr X’s chest infection was due to aspiration, or any record of Mr X having a known aspiration episodes at the Care Home. We are unable to speculate over whether Mr X’s inappropriate diet contributed to his death.

Overnight pressure care was excessive

70. Mrs X complains Mr X’s pressure care was excessive. She says Mr X was turned every two hours, even through the night, which significantly disrupted his rest.
71. Pressure area management is an important part of a person’s care. Pressure sores (also called pressure ulcers or bed sores) are wounds caused by pressure on part of the body interrupting the blood supply to the skin. People with mobility difficulties are more at risk. Without proper pressure care, pressure sores can develop quickly. These can be very uncomfortable and bring a risk of infection or, in extreme cases, death.
72. As Mr X had little mobility and spent most of his time in bed or a chair. He needed regularly repositioning to reduce his risk of developing pressure sores as he was unable to do this himself. However, I have not seen any evidence that Mr X required two-hourly turning.
73. Mr X was being repositioned every three to four hours in hospital. The Care Home’s pre-admission notes his Waterlow Score as 8. The Waterlow Score calculates the risk of pressure ulcers developing on an individual basis through a simple points-based system. Scores over 10 indicate a risk of developing a pressure ulcer, with higher scores indicating a higher risk. Mr X’s skin was intact and his Waterlow Score did not place him in a risk category.
74. The information was recorded on the Trust’s Discharge referral form, which says Mr X was receiving continence checks every two hours with repositioning to maintain his skin integrity. This information fed into the Council’s brokerage form which states Mr X required two-hourly turning due to high risk of pressure sores. Again, the basis for this statement is unclear as the Mr X’s inpatient records note him as three to four hourly turning and continence checks.
75. The National Institute for Health and Care Excellence (NICE) guidance for pressure ulcers: prevention and management (April 2014) says ‘1.1.8 Encourage adults who have been assessed as being at risk of developing a pressure ulcer to change their position frequently and at least every 6 hours. If they are unable to reposition themselves, offer help to do so….1.1.9 Encourage adults who have been assessed at being at high risk of developing a pressure ulcer to change their position frequently and at least every 4 hours’.
76. I accept Mr X was at risk of pressure sores due to his reduced mobility and required repositioning. However, his skin was intact and his Waterlow Score did not put him in a risk category. As such, there was no clear basis to reposition him as often as every two hours. The unnecessary additional turning has caused Mrs X worry and likely impacted on Mr X’s sleep. This has also caused Mrs X uncertainty about whether the two hourly turning requirement created an unnecessary barrier to Mr X returning home.

Sitting in a chair

77. Mrs X complains about the Care Home’s decision to regularly sit Mr X out in a chair. She says Mr X was primarily nursed in bed in hospital and was too weak to sit safely in a chair. Mrs X witnessed occasions where the staff needed to use a hoist to lift Mr X back to bed.
78. The Trust records show that Mr X had been unable to engage with physical therapy in hospital as he struggled to follow instructions. He physiotherapy team stopped Mr X’s therapy and he was primarily nursed in bed. Mr X could transfer with assistance from staff.
79. While Mr X was nursed in bed in hospital, I have seen nothing to suggest that he should not sit out in a chair as this was unsafe. Supporting a person to try and regain some mobility has many benefits. Mr X’s mobility had reduced in hospital, however that did not mean he could not be supported to try and regain some of it.
80. From the Care Home’s daily records, Mr X often sat out of bed for part of the day. This was sometimes for a meal in the dining room or to watch tv in the lounge. Care staff would later return Mr X to bed to rest. The Care Home notes Mr X was compliant with this most of the time. However, there were days when he declined to transfer and then he would remain in bed.
81. The Care Home felt Mr X was mostly happy to be moved. Mrs X felt he did not have the capacity to make the decision or the ability to communicate his view. The Mental Capacity Act 2005 states that a person who lack capacity to make some decisions may still be able, with support where necessary, to make smaller decisions about their day-to-day life. The Care Home felt Mr X was strong enough to sit out of bed and that it would be in his best interests to do so, as this reduces the risk of isolation. The Care Home respected Mr X wishes when he declined to transfer out of bed.
82. Without medical advice confirming Mr X was unsafe to sit in a chair, this was a matter for the Care Home’s professional judgment. I have not found fault on this point.

Pain and medication management

83. Mrs X complains that Mr X was showing clear signs of pain, such as sweating and flushing red, but the Care Home and the Practice failed to act. Mrs X says Mr X died in unnecessary pain.
84. While admitted to hospital, Mr X is not recorded as being in pain. Mr X was registered with the Practice in mid-December 2023, after he moved to the Care Home. I have reviewed the Practice’s medical records. The Practice was involved with Mr X’s care on multiple occasions in January 2024. It is recorded Mr X could be given paracetamol regularly, as required.
85. The Care Home said it gave paracetamol to Mr X when they felt he was in pain. The carers assessed Mr X’s pain daily and did not note any regular concerns.
86. On 5 February 2024, the day before Mr X died, a GP from the Practice visited him. On arrival, Mr X was sweaty and flushed, with a hot leg. He was diagnosed with cellulitis and prescribed antibiotics and paracetamol.
87. Mrs X complains that the antibiotic capsules prescribed by the GP were too large for Mr X, given his known swallowing difficulties. I have not seen any evidence that the antibiotics were inappropriate. Flucloxacillin capsules can be opened up and the contents sprinkled on soft food to administer. If the Care Home felt Mr X was struggling to swallow the capsules, further advice could have been sought from the Practice.
88. I have not found any evidence of fault in relation to Mr X’s pain management. I acknowledge Mrs X’s strength of feeling on this matter, however I have not seen anything to confirm Mr X had regular uncontrolled pain. The Practice reviewed Mr X several times, including prescribing paracetamol. When Mr X was red faced and sweating on 5 February 2024, the Practice prescribed appropriate medication for pain relief and to treat an infection.

Social worker actions

89. Mrs X complains the Council’s social worker failed to act on her concerns Mr X was deteriorating. Mrs X is unhappy the social worker did not help Mr X to return home or the Nursing Home before he died.
90. The Council’s records show it considered that Mrs X’s wish for Mr X to return to the Nursing Home. However, the Council ultimately decided to accept the Care Home placement instead. I have already addressed above how this decision was not taken properly.
91. The Council’s records also show the social worker was actively exploring ways to support Mr X to return home. This included seeking views from an Occupational Therapist and a District Nurse. The District Nurse advised that Mr X’s pressure care needs could not be met at home and there was no suitable equipment available to assist with this. Following this, the social worker recommended Mr X remain in a care home setting where his need could be met. I appreciate Mrs X was keen for Mr X to return home and disappointed this did not happen, however I have found the social worker took appropriate action to explore Mrs X’s wishes.
92. Mrs X complains the social worker threatened to go to court and overturn Mrs X’s position as attorney if she disagreed with the professionals.
93. The Council’s complaint response says there is no record of this conversation. The Council said it always strives to work with families and attorneys, only considering court if there is evidence the attorney is not acting in a person’s best interests. The Council said there was nothing to suggest Mrs X was not acting in Mr X’s best interests.
94. I have reviewed the Council’s record and there is no reference to the social worker saying this to Mrs X. I am unable to say what happened during this conversation. If an agreement cannot be made between family and professionals, it is sometimes necessary to ask the courts to make the decision. It may be that the social worker was explaining the process to Mrs X. There is nothing in the Council’s records to suggest the social worker was considering this course of action or that she thought Mrs X was not acting in Mr X’s best interests. To the contrary, the social worker was exploring whether Mr X could return home, in line with Mrs X’s wishes. I am unable to resolve this matter any further.

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Actions

Council and Trust

95. Within one month of my final decision statement, the Council and the Trust will
• Write to Mrs X apologising for communication failings around Mr X’s discharge
• Pay Mrs X £100 each for frustration and inconvenience.
96. The Council and the Trust should provide us with evidence they have complied with the above actions.

Council

97. Within one month of my final decision statement, the Council will apologise to Mrs X for the delay sourcing a discharge bed for Mr X, which caused uncertainty for Mrs X.
98. Within three months of my final decision statement, the Council will explain what action it will take to
• ensure it offers a choice of discharge locations to people and their families, in line with the relevant legislation and guidance; and
• ensure discharge decisions properly take into account the wishes of the person and their families; and
• properly record the reasons for any discharge decisions, ensuring this includes the individual circumstances of each case and the reasons if a choice cannot be offered.
99. Within one month of my final decision, the Council will
• Apologise to Mrs X for failings by the Care Home in relation to Mr X’s dietary requirements and pressure care
• Pay Mrs X £200 for frustration and distress as she did not feel listened to
100. Within three months of my final decision statement, the Council will explain what action it will take to
• ensure the Care Home takes appropriate action to clarify a person’s dietary requirements as soon as there are any concerns raised; and
• ensure the Care Home properly considered all relevant information when designing an appropriate pressure care plan
101. The Council should provide us with evidence it has complied with the above actions.

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Decision

102. I have found that fault by the Trust and the Council in relation to Mr X’s discharge. I have also found fault with some aspects of Mr X’s care by the Care Home. As a result, Mr X did not receive the care he was entitled to and was put at risk by his inappropriate diet. Mrs X has been caused uncertainty, frustration and distress.
103. I have not found fault by the Practice.
104. I have now completed my investigation.

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Investigator's decision on behalf of the Ombudsman