Summary: We did not find fault in how a Trust communicated details about a patient’s hospital discharge to a care agency. We found fault by a Council when it failed to complete a scheduled carer visit. This led to a hospital readmission. We also found fault by the Trust with its record keeping. However, we did not find there was a link from the fault to the complainant’s claimed injustice that her mother caught COVID-19 and died during this hospital admission. We have recommended actions to the Trust and the Council to address the service failings. We have also recommended apologies and a financial remedy to recognise the distress the faults caused the complainant.

The complaint

1. Mrs X complains on behalf of herself and her father, Mr Y, about Barking, Havering and Redbridge University Hospitals NHS Trust (the Trust) and Redbridge London Borough (the Council). She complains about the discharge arrangements for her mother, Mrs Y, from King George Hospital on 30 September 2020 and the actions of Immaculate Healthcare Services Ltd (the care agency) on behalf of the Council. In particular they complain that:
• the Trust did not tell Mrs Y’s carers about her discharge in a timely manner;
• the Trust sent Mrs Y home with a catheter in place and failed to tell family or carers; and
• the Council did not complete a carer visit on 30 September 2020 and cannot say when or if a carer tried to visit Mrs Y.
2. Mrs X says the failings led to Mrs Y needing to return to hospital later the same night. While she was there she was diagnosed with a Urinary Tract Infection and needed to stay in hospital. She then contracted COVID-19 and died soon after. Mrs X considers that if the failings by the Trust and the Council had not happened, her mother would not have had to return to hospital and she would not have died.

Back to top

The Ombudsmen’s role and powers

3. 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).
4. 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.
5. Where a council arranges or commissions care services from a provider, we treat the provider’s actions as if they were council actions. Part 3 Local Government Act 1974, section 25(6)
6. Under our information sharing agreement, we will share this decision with the Care Quality Commission.
7. 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)

Back to top

How I considered this complaint

8. I have considered information provided by Mrs X, the Council and the Trust. This includes complaint correspondence and Mrs Y’s health and social care records. I have also considered relevant guidance and regulations.
9. Mr Y, Mrs X and the organisations had an opportunity to comment on a draft of my decision statement and I have considered their comments before making a final decision.

Back to top

What I found

What happened

10. Mrs Y was admitted to hospital on 19 September 2020 because of confusion and decreased mobility. This was her sixth hospital admission since July 2020. She had previously received treatment for a recurrent urinary tract infection, drug induced delirium and decreased mobility.
11. The Trust discharged Mrs Y home on 30 September 2020. She still had a catheter in place. She arrived home around 6:30pm.
12. Mrs Y’s carers did not attend to help Mrs Y into bed. Mr Y therefore tried to help Mrs Y into bed, but during this the catheter fell out. Mr Y did not know what to do and called for an ambulance at 10:50pm. An ambulance attended and took Mrs Y back to hospital shortly after midnight.
13. Mrs Y tested positive for COVID-19 on 8 October 2020. She died on 20 October 2020.

Legal and administrative context

Record keeping

14. The Nursing and Midwifery (NMC) guidance The Code sets out standards of conduct, performance and ethics for nurses and midwives. It says clear and accurate records should be kept of discussions, assessments, treatment and medicines given.

Frustrated visit policy

15. The care agency has a policy for frustrated visits (where a service user is not contactable or not at home). This sets out the requirement for carers to contact the care agency so it can complete relevant checks to establish if further actions are needed.

Hospital discharge

16. Schedule 3 to the Care Act 2014 and the Care and Support (Discharge of Hospital Patients) Regulations 2014 make provisions on the discharge of hospital patients with care and support needs. Local authorities and the NHS have a duty to work together to ensure the safe hospital discharge of people with care and support needs.

Analysis

Communication about hospital discharge

17. The Trust was responsible for contacting the care agency to tell them when it expected Mrs Y to leave hospital and when the care package needed to restart from. The Trust’s complaint response to Mrs X accepts it has no documentation available to show this was done for Mrs Y.
18. In response to my enquiries, the Council provided copies of emails from the hospital social worker to the Council. This shows at 11:02am on 30 September, the social worker advised the Council about Mrs Y’s hospital discharge and that the care package should restart from the last call of the day (i.e. the 8pm call).
19. The Council also provided further emails showing it contacted the care provider about this. The care provider confirmed Mrs Y’s care package would restart from the evening call. It sent this confirmation email at 11:11am. I am therefore satisfied the Trust did inform the care provider in plenty of time for Mrs Y’s care package to restart and there were no issues identified. This is not fault.
20. However, although the Trust made a referral to the care agency, it has no record of this. This was not in line with national guidelines. This is fault. This meant the Trust could not give Mrs X reassurance about it actions in its complaint response. Additionally there is no evidence it contacted the Council’s social care team to check this information before sending its complaint response. This has caused Mrs X and Mr Y worry and distress.

Carer visit

21. The hospital transport records show the ambulance picked Mrs Y up from hospital at 5:25pm and was at her home address by 6:30pm. Mrs Y’s care plan shows her evening carer visit was scheduled for 8pm. This was for two carers for 30 minutes to help with transfers, personal care, provide a snack and prompt medication.
22. In response to my enquiries the Council shared information it received from the care agency. The care agency said this was a “frustrated visit” but it had not recorded this or completed a timesheet to reflect its carers had called. The Council advised the carers claimed they tried to visit Mrs Y at 6:06pm, but she was not yet home.
23. There is no record of the visit or contact with the office to advice there had been a frustrated visit. There is also no evidence the carers or care agency followed this up later that day to check if Mrs Y had returned home. The care agency say Mr Y told the carers they could return the following day. Mrs X has not corroborated this and there is no record of any such conversation in the records.
24. The Council told the Ombudsmen it was unacceptable for the carers to call almost two hours early, even if Mrs Y had been home then, because the time between visits would have been too long. It also told the Ombudsmen it considers it was a failure by the care agency not to follow up with Mr Y or revisit the home at 8pm.
25. The care agency’s policy is that care workers should report a ‘frustrated visit’. I have seen no evidence this was done. This is fault.
26. It is not clear whether the carers attempted a visit at 6pm as the care agency says because of the lack of records. However, even if the carers had visited, it was not at the time the hospital advised the care package would need to restart following Mrs X’s discharge home. I have seen no evidence the carers received any information to suggest Mrs X would not be returning home that day. It was therefore unacceptable to not return or contact Mrs X at the scheduled time. Records show Mrs X was at her home by 6:30pm and would have needed the carer visit to help her with personal care and transfer her to bed. The failure to visit or contact Mrs X at 8pm is not in line with her care plan or the agreed schedule and is therefore fault.
27. At a result of the fault, Mr Y felt he had no choice than to help his wife into bed. He is elderly and the carers’ visits were in place because he could not safely move his wife alone. He should not have been put in this situation. Unfortunately while he was trying to help Mrs X, her catheter was knocked/fell out and Mr Y called for an ambulance. Mrs X was then readmitted to hospital.
28. If the carers had called as scheduled, the Council has confirmed they could have emptied the catheter and followed this up with the social work team and hospital. I therefore consider the fault is directly linked to Mrs X’s hospital readmission. I have addressed the injustice in more detail below.

Catheter

29. The records show Mrs Y had the catheter fitted during her hospital admission because she could not pass urine. The records also show the Trust sent a referral form to the district nurses on 1 October which stated Mrs Y had been sent home “accidentally” with a catheter.
30. The Trust’s complaint response said the wording in the district nurse referral was wrong. It explained Mrs Y needed a trial without catheter (TWOC) before it could be removed, but this was not a reason to keep her in hospital as catheter care could be provided in the community by carers.
31. The Trust had referred Mrs Y to the TWOC clinic as an outpatient, but as she had returned to hospital the following day, this appointment did not go ahead. The Council has confirmed to the Ombudsmen the carers could and would have provided catheter care had they completed their visit on 30 September.
32. The district nurse referral has confused matters by suggesting the catheter was left in place in error. However, turned out not to matter. The catheter could not have been removed until after Mrs Y attended the TWOC clinic. The issues happened because the catheter was not emptied and Mr Y was left to move Mrs Y on his own. Whilst doing this the catheter leaked and Mr Y did not know how to resolve this. He should not have found himself in this position for the reasons explained in the previous issue.
33. The discrepancy with the district nursing referral is not in line with NMC guidance on record keeping and is fault. However, I do not consider this caused an injustice to Mrs Y. I consider the injustice, that Mrs Y needed to be readmitted to hospital, was caused by the fault in the carers not visiting. It is however clear the discrepancies have caused Mrs X distress and uncertainty about what should have happened.

Injustice

34. Mrs X considers if Mrs Y had not needed this readmission she would not have contracted COVID-19. Mrs Y had a positive COVID-19 result on 8 October. Data from the UK government and the World Health Organisation say the incubation period for COVID-19 (the time between exposure to the virus and symptom onset) is on average 5-6 days, but can be up to 14 days.
35. The Trust has accepted it is likely Mrs Y caught COVID-19 in hospital. Given her limited time out of hospital in the 14 days before 8 October, this does seem likely. It is however technically possible she was exposed to the virus during her transport home, at home or when she was taken back to hospital. Additionally, we cannot be sure Mrs Y had not already been exposed to the virus before her readmission on 1 October.
36. The records show Mrs Y had several hospital admissions before the one in October and that her health was deteriorating. When she returned to hospital she had a UTI. She had previous hospital admissions for treatment of a recurrent UTI. I therefore do not consider we can say Mrs Y would not have needed admitting to hospital again soon after even if the catheter problems had not happened.
37. While we cannot say if the readmission directly led to Mrs Y having COVID-19, this does leave Mrs X and Mr Y with uncertainty about the events and the outcome. This has understandably caused them considerable distress.
38. The Council has confirmed to the Ombudsmen that it will take action to address the failings by the care agency.

Back to top

Agreed actions

39. The Council and the Trust have agreed the following actions within one month of the date of the Ombudsmen’s final decision:
• The Trust will apologise to Mrs X and Mr Y for the worry and distress caused by the fault with its nursing record keeping about the discharge arrangements and for the incorrect information in the district nursing referral.
• The Trust will take action to address the identified failings with record keeping and remind staff of their responsibilities for making clear and accurate records of hospital discharge arrangements and communication with external agencies.
• The Council will apologise to Mrs X and Mr Y for the distress caused by the fault with the lack of a carer visit on 30 September and pay them £200 each in recognition of the distress this caused to them.
• The Council will confirm to Mrs X, Mr Y and the Ombudsmen specifically what measures have been taken to address the failings by the care agency and prevent similar failings in future.

Back to top

Final decision

40. I found the Trust communicated details of the hospital discharge appropriately and that the Trust’s decision to send Mrs Y home with a catheter was not done in error. However, there was fault with the record keeping that has led to uncertainty and distress for Mr Y and Mrs X.
41. I found fault by the Council about the lack of a carer visit from the care agency after Mrs Y returned home from hospital. This meant Mrs Y needed to be return to hospital. However it has not been possible to establish whether this directly caused Mrs Y to catch COVID-19.
42. The Council and the Trust have agreed actions to address the fault and injustice to Mrs X and Mr Y. I have therefore completed my investigation.

Back to top

Investigator's decision on behalf of the Ombudsman