Summary: Ms Y complained about failings during her father’s discharge planning, and delays in the repatriation of her mother. We have found fault by the Council for failings in discharge planning. We have also found fault by Bradford Trust and Chesterfield Trust for failings in the repatriation process. These faults led to avoidable expenditure and avoidable stress. We have asked the organisations to apologise, reimburse money the family would not have otherwise paid, make payments to acknowledge the avoidable stress, and take steps to prevent recurrences.

The complaint

1. Mr X was a patient in Bradford Royal Infirmary. Bradford Teaching Hospitals NHS Foundation Trust (Bradford Trust) is responsible for this hospital. The City of Bradford Metropolitan District Council (the Council) is responsible for social services in the area. Mr X’s daughter, Ms Y, complains:
1. There was an unreasonable delay in Bradford Trust and the Council putting a care plan in place to allow Mr X to leave hospital and return home.
2. No one has refunded the domiciliary care fees Mr X paid after he returned home, despite the family having been given an assurance that they would be.
2. For both of these issues, Ms Y also complains there was poor communication, including between the Council and Bradford Trust.
3. Ms Y said that, because of the delays, the family had to make their own arrangements for Mr X’s care in the community. Ms Y said the failure to reimburse Mr X’s care costs left Mr X financially disadvantaged.
4. Mrs X lived with her husband in Bradford. While staying with a relative in another area she broke her leg and was admitted to Chesterfield Royal Hospital. Chesterfield Royal Hospital NHS Foundation Trust (Chesterfield Trust) is responsible for this hospital.
1. Ms Y complains there was an unreasonable delay in repatriating Mrs X to Bradford Royal Infirmary or a care home in Bradford.
5. As with the earlier issues, Ms Y also complains there was poor communication, including between the two hospitals and the Council.
6. Ms Y said Mrs X knew her husband was seriously ill and in hospital during this time, while she was a considerable distance from him and unable to see him. Ms Y said Mrs X was very upset and distressed because of this. Ms Y said that, in the end, the family was forced to accept the only placement offered to them, regardless of whether it was appropriate for Mrs X’s needs.
7. In 2023 the Ombudsmen referred Ms Y’s complaints to Bradford Trust and asked it to investigate and respond to her.
1. Ms Y complains that Bradford Trust failed to effectively or fully investigate her complaint, and failed to provide a comprehensive or factually accurate response to her concerns. Further, Ms Y said there was a considerable delay in receiving Bradford Trust’s response.
8. Ms Y said Bradford Trust’s complaint response caused her stress and frustration, plus time and trouble in having to pursue her concerns further.

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The Ombudsmen’s role and powers

9. 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). The Local Government and Social Care Ombudsman investigates complaints about adult social care providers. (Local Government Act 1974, sections 34B, and 34C, as amended). The Health Service Ombudsman investigates complaints about ‘maladministration’ and ‘service failure’ in the delivery of health services (Health Service Commissioners Act 1993, section 3(1)).
10. We investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, we consider whether it has caused injustice or hardship (Health Service Commissioners Act 1993, section 3(1) and Local Government Act 1974, sections 26(1) and 26A(1), as amended).
11. 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.
12. If there was no fault in how an organisation made its decision, we cannot question the outcome. (Local Government Act 1974, section 34(3), as amended, and Health Service Commissioners Act 1993, sections 3(4)- 3(7))
13. When investigating complaints, if there is a conflict of evidence, we make findings based on the balance of probabilities. This means that during an investigation, we will weigh up the available evidence and base our findings on what we think was more likely to have happened. 
14. 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

15. I considered Ms Y’s written complaint to the Ombudsmen and spoke to her on the telephone. I wrote to the Council, Bradford Trust and Chesterfield Trust to explain what I intended to investigate and to ask questions and for relevant evidence. I also asked Ms Y for copies of notes she made at the time of the events. I considered all the papers I received in response. I read relevant legislation and guidance.
16. I shared a confidential version of this draft decision with Ms Y and the organisations and invited their comments on it. I considered all of the comments I received in response.

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What I found

Relevant legislation and guidance

Hospital discharge during the COVID-19 pandemic

17. In August 2020, in response to the COVID-19 pandemic and the need to keep hospital beds free, the Government introduced the Hospital Discharge Service: Policy and Operating Model.
18. The model set out that patients must be discharged from hospital as soon as it was clinically safe. It consisted of four care pathways:

• Pathway 0 applied to people with simple discharge needs and no requirement for ongoing health and social care support.
• Pathway 1 applied to people who could return home with support from health and/or social care services.
• Pathway 2 applied to patients requiring rehabilitation or short-term care in a 24‑hour bed-based setting.
• Pathway 3 applied to people who required ongoing 24-hour nursing care on a long-term basis, often in a bed-based setting.

19. At the end of March 2022 the Hospital Discharge and Community Support Guidance was updated. This said that local areas should adopt discharge processes that best meet the needs of the local population. It said this could include the ‘discharge to assess, home first’ approach which had been used during the pandemic. The guidance also said that funding to support discharge could be pooled across health and social care.
20. In addition, the March 2022 discharge guidance notes that “…local funding arrangements…should also include clear information for self-funders of adult social care, so they can make informed choices about any onward care needs that do not fall under locally funded eligible costs.”

Social care assessments

21. Section 4 of the Care Act 2014 says that Councils must provide information and advice about support available for adults, including information about choice and finances.
22. Sections 9 and 10 of the Care Act 2014 require councils to carry out an assessment for any adult with an appearance of need for care and support. They must provide an assessment to everyone regardless of their finances or whether the council thinks the person 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.
23. Councils must carry out assessments over a suitable and reasonable timescale considering the urgency of needs and any variation in those needs. Councils should tell people when their assessment will take place and keep them informed throughout the assessment.

Repatriation

24. In 2022 Chesterfield Trust used a Bed Management and Escalation Policy. It told us that this was archived in 2023 and replaced by the Operational Escalation and Flow Policy (Chesterfield’s Escalation Policy). Chesterfield Trust said the content in relation to repatriations was identical in both documents. I had access to Chesterfield’s Escalation Policy during this investigation.
25. Section 11.2 states:

“If a ward has a patient to transfer to another Trust it is their responsibility to contact the Clinical Operations Matron, who will contact the organisation to ascertain their available capacity. If after 48 hours there is no bed allocated then they should escalate to the General Manager, Medicine. If no resolution, then this should be escalated to the Head of Operations for further actions to be taken.”

26. Bradford Trust uses its “Guidance for managing acute referrals to and from inpatient beds via routes other than the Emergency Department: Pre admit and repatriation” (Bradford’s Referrals Policy). This notes that its Clinical Site Team takes responsibility for recording the details of all patients requiring repatriation in and out of Bradford Trust.
27. Bradford’s Referrals Policy states:

“…It is essential that the Clinical Site Team (CST) have visibility of all patients requiring repatriation into and out of [Bradford Trust] as they have responsibility for communicating the requirement for repatriation with respective Trust site management teams in order to ensure a safe and timely transfer. The agreed timescale for repatriation to take place is 48 hours and beyond this timescale the CST will escalate delays.”

28. Bradford’s Referrals Policy says that:

• As soon as a patient is referred and accepted by a Consultant…the details should be provided to the CST,
• The CST will contact the Trusts requiring repatriation to and from [Bradford Trust] daily, and
• The CST will escalate to the Directorate Manager Patient Flow any delays beyond 48 hours and if the delays persist despite escalation between Trusts at this level the help of the Chief Operating Officer (CCO) will be enlisted.

Complaint handling

29. Councils and NHS organisations responsibilities for handling complaints are set out in the Local Authority Social Services and NHS Complaints (England) Regulations 2009 (the Regulations).

• Section 3 states that each organisation must make arrangements to handle complaints in line with the Regulations.
• The Regulations do not specify how long an investigation should take. However, section 13 states that the likely timescales for completing the investigation and providing a response should be determined at the start of the process. This can be done in discussion with the complainant. If the complainant does not want a discussion the body must determine these timescales itself and confirm them to the complainant in writing.
• The Regulations did not set out how complaints should be investigated. Section 14 states that responsible bodies must investigate complaints in a ‘manner appropriate to resolve it speedily and efficiently’.
• Section 14 states that, during the investigation, the body must keep the complainant informed of progress ‘as far as reasonably practicable’. In addition, if the body has not provided a response after six months (or, at the end of any previously agreed longer period), the body must write to the complainant to explain why.
• Section 14 of the Regulations state that, once the investigation is completed, the body must provide a response which:
• Explains how the complaints have been considered;
• Includes the conclusions the body has reached about the complaints – including whether remedial action is needed and, if so, whether this has been arranged or completed;
• Advises the complainant of their right to complain to the relevant Ombudsman.

30. In 2009 the Parliamentary and Health Service Ombudsman (PHSO) issued its Principles of Good Complaint Handling. This set out the expectations that public bodies should respond to complaints in a customer‑focused way. It also noted that organisations should be open and accountable and act fairly and proportionately.

Summary of events relating to Mr X

31. In 2022 Mr and Mrs X lived together at home. Mrs X had significant health needs and Mr X was her main carer. Their family also supported them and privately arranged for a carer to visit Mrs X three times a week to help with personal care.
32. In late May 2022 Mr X had a stroke and was admitted to Bradford Royal Infirmary. As Mr X would not be there to look after her, after contacting the Council, the family privately arranged for Mrs X’s care agency to start visiting her four times a day.
33. Around four days after entering hospital the medical team decided that Mr X was stable enough to leave hospital. The multi-disciplinary team considered that Mr X would need to have support when he returned home. Ms Y said staff told the family that Mr X would be discharged the following week and would receive fully‑funded support at home for six weeks.
34. Mr X remained in hospital and Ms Y said she was told this would be delayed further because of an extended bank holiday. Ms Y said Mr X suffered terrible delirium in the hospital and was confused and distressed as he hated being away from his wife. She said the family asked if it would be acceptable for them to arrange for Mrs X’s provider to support Mr X as well. Ms Y said staff agreed this was a good idea. The family’s understanding was that the fees Mr X would pay to the care provider would be reimbursed later.
35. On 31 May the Council received a referral from the ward. The referral estimated that Mr X would be discharged on 7 June and said he would need support at home.
36. Ms Y spoke to a Bradford Trust therapist the next day. Ms Y confirmed that the family had privately arranged support for Mr X, to start that evening. Staff from the Council spoke to the ward later that day. The ward advised that Mr X’s family had privately arranged support for Mr X. The Council worker closed the social care file.
37. Mr X returned home at the start of June. An assessor from the Council visited and assessed Mr X’s needs in the middle of the month. It determined that Mr X did not need any support from the Council. This assessment and its outcome has previously been investigated by LGSCO and, as such, has not been considered as part of this investigation.

Summary of events relating to Mrs X

38. In mid-August 2022, while visiting family, Mrs X fell and broke her leg. She was admitted to Chesterfield Royal Hospital. It elected to treat her injury conservatively by putting her leg in plaster.
39. In the days after Mrs X entered Chesterfield Royal Hospital its staff contacted Bradford Royal Infirmary to request it take over her care. Bradford Royal Infirmary said it would but that it did not have any available beds. It advised Chesterfield Royal Hospital to call daily.
40. Around the same time Mr X’s health deteriorated significantly. He was admitted to hospital and diagnosed with cancer. Ms Y said that all the time Mrs X was in hospital she knew that her husband was very sick. She said Mrs X was very upset about not being able to see him and it was really hard for her as they were rarely apart.
41. In mid-September, over a month after being admitted, Mrs X’s family accepted a place in a care home in Bradford for her. Soon after her admission Mrs X and the family found it to be unsuitable for her needs. They began planning to move Mrs X to a different placement.
42. Mr X sadly died toward the end of the month.
43. Just over three weeks after returning to Bradford from Chesterfield, Mrs X moved to a different care home.

Analysis

Mr X’s discharge from hospital

44. During this investigation the Council has acknowledged to me that its staff did not have any discussions with Mr X’s family about funding. It also said it “failed to provide comprehensive assessment providing appropriate information to both [Mr X] and his family to afford them to have the opportunity to make an informed decision regarding the onward care needs and options available. Thus, allowing both [Mr X] and family to establish the pathway of choice and the financial consequences based on their decision”.
45. This was fault, which the Council has acknowledged.
46. The Council explained that, under the local Discharge to Assess model, had it continued to work with Mr X it would have referred Mr X to an in‑house enablement service: Bradford Enablement Support Team. It said Mr X met the criteria for this team because he: had experienced a change of function following a stroke; had enablement potential; and, had not received a support package before. The Council said support from this service would have been fully funded until an assessment was completed in the community.
47. We cannot know what decision Mr X and his family would have made had fault not occurred here. It is likely that, with better and fuller communication, Mr X would have needed to remain in hospital for longer to allow relevant assessments to happen, and for any relevant arrangements to be made. However, there is evidence to show that finances were a concern to the family. Therefore, on the balance of probabilities, had Council staff fully explained the options and consequences of different decisions, it appears more likely than not that Mr X’s family would have opted to accept support from the in-house enablement service.
48. Because they were not given this option they paid privately for Mr X’s support. This was a financial injustice to them. I have made a recommendation to address this, below.

Mrs X’s move from Chesterfield to Bradford

49. Both Bradford Trust and Chesterfield Trust have policies in place relating to the repatriation of patients. Both policies note an intent to complete repatriations as quickly as possible, ideally within 48 hours. They both are clear that, if this does not happen, the matter should be escalated.
50. This did not happen in an effective way in Mrs X’s case. She went into hospital in Chesterfield on 17 August and Chesterfield Trust advise that it referred her to Bradford Trust the next day. There are no clear records from Bradford Trust about this. However, on balance, I accept Chesterfield Trust’s account. As such, the aim was to transfer Mrs X closer to home by 19 August. Mrs X did not move from Chesterfield until 19 September 2022. This was fault on the part of both Bradford Trust and Chesterfield Trust. Both should have done more to escalate and resolve this situation, and there should have been clear records of what was done.
51. During this period Mr X returned to hospital and was very unwell. Mrs X was aware of this and was distressed and upset at being away from her husband. This unnecessarily prolonged her time away from her home area, and from Mr X, which was an avoidable injustice to Mrs X. Mrs Y’s family were also caused stress and distress as bystanders to this situation. I have made recommendations to address this below.

Complaint handling by Bradford Trust

52. The Ombudsmen wrote to Bradford Trust at the start of May 2023 and asked it to investigate five issues. Bradford Trust sent a two-and-a-half page response to Ms Y close to seven months later. In terms of the issues being considered under this investigation, Bradford Trust provided very brief chronologies in relation to its involvement in Mr X’s and Mrs X’s care. It did not provide any commentary or analysis in terms of whether there had been any failings on its part.
53. Considering the level of detail included in the response, I can see no justification for Bradford Trust having taken so long to respond to this complaint. This delay was available and was fault.
54. In addition, the response did not reach clear conclusions about Ms Y’s’s concerns. It essentially provided a limited summary of information from its records, but there was no evidence of analysis or consideration of relevant standards or internal policies. This is further evidence of fault.
55. It is evident from correspondence and speaking to Ms Y that she was left frustrated and angry by this response. Further, she felt obliged to spend time responding and escalating her complaint to the Ombudsmen. All of this was avoidable, had Bradford Trust provided a timely and adequate response. As such, this is an injustice.

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Agreed actions

56. Within one month of the final decision the Council should write to Ms Y to acknowledge the failings identified in paragraph 44. It should also apologise for the impact this had on the family’s ability to make an informed decision about Mr X’s post-discharge care.
57. Within two months of the final decision the Council should refund the amount Mr X’s family paid for support from the time Mr X left hospital until the end of the day it completed an assessment in the community (on 17 June 2022). The family paid £1,002.27 during this period.
58. Within three months of the final decision the Council should ensure any of its staff who are involved in hospital discharge arrangements are made aware of the learning from this case. It should provide evidence to the Ombudsmen of this.
59. Within one month of the final decision Bradford Trust and Chesterfield Trust should, separately, write to Ms Y to acknowledge the failings identified in paragraph 50 of this statement. They should also apologise for the impact, as identified in paragraph 51.
60. Within two months of the final decision Bradford Trust and Chesterfield Trust should, separately, pay £250 to Ms Y (as a family representative) to act as a tangible acknowledgement of the avoidable distress the family experienced because of the fault.
61. Within three months of the final decision both Bradford Trust and Chesterfield Trust should ensure the learning from this case (about the need to correctly use the relevant repatriation processes) is shared with relevant personnel and teams. They should provide the Ombudsmen with evidence of this.
62. Within one month of the final decision Bradford Trust should also write to Ms Y to acknowledge the failings in its complaint handling, as identified in paragraphs 51 to 54. It should also apologise for the injustice this caused.
63. Within three months of the final decision Bradford Trust should review any complaint handling policies and procedures it has to ensure they are in line with the NHS Complaint Standards and PHSO’s Principles of Good Complaint Handling. It should also take steps to ensure that relevant staff are aware of their responsibilities under those policies. It should provide the Ombudsmen with evidence of this.

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Decision

64. I have found there was fault by the Council, Bradford Trust and Chesterfield Trust which caused an avoidable injustice. I have made recommendations to put things right.

Investigator’s decision on behalf of the Ombudsmen

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Investigator's decision on behalf of the Ombudsman