The Ombudsman's final decision
Summary: Mr B complained about the care provided to his father at four health and social care locations from October 2018 to April 2019. We found there was fault by a Trust for not doing enough to involve key stakeholders when it assessed Mr B’s father, and for failing to pass on information to a Council about a pending Mental Health Act assessment. This has left the family with uncertainty which is an injustice. We have not found fault by the Trust or Council in the treatment and discharge arrangements for the patient while in various placements between October 2018 and April 2019. The Trust has agreed to apologise, pay a small financial remedy and make service improvements.
The complaint
Mr B complains about the care and treatment of his father, Mr A, at four locations between 12 October 2018 and 1 April 2019. Mr B complains that: From 12 October 2018 to 6 November 2018 Lings Bar Hospital: did not provide appropriate stroke rehabilitation to Mr A, did not consider Mr A’s eyesight impairment, incorrectly told Mr A he would be discharged to a non-hospital environment, and inappropriately transferred Mr A to Leivers Court Residential Care Home.
From 6 November 2018 to 8 December 2018 Leivers Court Residential Care Home: did not provide appropriate stroke rehabilitation to Mr A, and did not consider Mr A’s eyesight impairment.
In December 2018 the Rapid Response Liaison Psychiatry (RRLP) team at Queens Medical Centre: referred Mr A for a Mental Health Act (MHA) assessment without discussing this with Mr B first, failed to make adjustments for Mr B’s disability to allow him to engage in discussions about the assessment, and failed to ask the Council to make reasonable adjustments for the MHA assessment it would conduct, and did not tell the Council Mr B was Mr A’s Nearest Relative when it referred Mr A for a MHA assessment.
From 23 December 2018 to 1 April 2019 Ward B1 of Bassetlaw Hospital: failed to advise Mr B of the correct process for Nearest Relatives to challenge a person’s detention, inappropriately attached conditions to its decision to rescind Mr B’s detention, which effectively kept him detained, did not provide appropriate stroke rehabilitation to Mr A, did not consider Mr A’s eyesight impairment, and did not allow Mr A to see his grandson for three months.
I did not investigate the first two bullet points under point (d). I have explained at the end of this decision statement, from paragraph 68, why I made this decision.
Nottinghamshire Healthcare NHS Foundation Trust (the Trust) is responsible for the services provided by Lings Bar Hospital, the RRLP team at Queens Medical Centre and the ward Mr A was cared for on at Bassetlaw Hospital. Nottinghamshire County Council (the Council) is responsible for the care Mr A received at Leivers Court Residential Care Home. The Council’s staff also had some involvement in the discussions about where Mr A would move to after his Lings Bar Hospital and Leivers Court came to an end.
The Ombudsmen’s role and powers The Ombudsmen have the power to jointly consider complaints about health and social care. Since April 2015, a single team has considered these complaints acting on behalf of both Ombudsmen. (Local Government Act 1974, section 33ZA,as amended, and Health Service Commissioners Act 1993, section 18ZA) 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) 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.
When considering complaints, if there is a conflict of evidence we make findings based on the balance of probabilities. This means we will weigh up the available relevant evidence and base our findings on what we think was more likely to have happened.
The Ombudsmen cannot question whether a decision is right or wrong simply because the complainant disagrees with it. We must consider whether there was fault in the way the organisation reached the decision. (Local Government Act 1974, section 34(3), as amended, and Health Service Commissioners Act 1993, sections 3(4)- 3(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)
How I considered this complaint
I read the correspondence and supporting evidence Mr B sent to the Ombudsmen. A colleague spoke to Mr B on the telephone and I have considered the records of this, in addition to my own telephone contact with Mr B. I wrote to the Council and the Trust to explain what I intended to investigate and to ask for their comments and copies of relevant records. I considered all the comments and records they provided. I also considered relevant legislation and guidance. I also spoke to an LGSCO Investigator and a PHSO Investigator who were, separately, investigating related issues. I shared a draft decision with Mr B, the Trust and the Council and considered the comments I received about it. I also took clinical advice from one of PHSO’s clinical advisers – an experienced mental health nurse. I shared a revised draft with Mr B and the Trust and considered their responses to it.
What I found
Summary of events Mr A has a congenital visual impairment and is registered as blind. In 2018 he lived at home with his wife of around 60 years. Mr A’s wife received some support from carers. Mr B said Mr A was quite physically active.
In May 2018 Mr A had a stroke and went into City Hospital in Nottingham. As a result of the stroke Mr A lost some of his physical capabilities. In early June, while Mr A was still hospital, his wife died while on a different ward. Mr A’s mood became very low and he began saying to staff that he wanted to die.
Staff referred Mr A to the Rapid Response Liaison Psychiatry (RRLP) service. Mr B said that toward the end of June 2018 Mr A was reaching a point of being medically stable enough to leave hospital. Mr B said he foresaw problems with Mr A returning home without his wife there. Mr B asked if Mr A could go to an assessment bed. He said he assumed the Trust would transfer Mr A to an assessment bed in a ward in Queens Medical Centre.
In early July RRLP reviewed Mr A again and suggested an informal admission to a mental health inpatient ward. Mr A agreed to this. On 19 July 2018 Mr A transferred to a mental health assessment unit (at Highbury Hospital) for people over 65 with a diagnosis of dementia or challenging behaviour. Mr B raised concerns about the ward being inappropriate for Mr A. On 30 July 2018 Mr A moved to a mental health assessment ward for people over 65 with illnesses such as depression.
Mr A remained on this ward throughout August and September and into October 2018. In October 2018 staff referred Mr A for a period of rehabilitation. Mr A moved to Lings Bar Hospital on 12 October 2018.
A Social Worker spoke to Mr A at the end of October 2018. They discussed Mr A moving to a non-hospital rehabilitation centre. Mr A agreed to this as he did not feel ready to return home. Mr A moved to Leivers Court on 6 November 2018.
A Social Worker and an Occupational Therapist (OT) completed a home visit toward the end of November 2018. These professionals, plus staff from Leivers Court, noted concerns about Mr A’s ability to cope at home on his own. A Social Care assessment recommended Mr A move to residential care as it would be unsafe for him to return home. Mr A said that he wanted to try going home first and said he understood the risks of this. The professionals respected this wish and began planning for Mr A to go home with support from carers four times a day. These plans were continuing in early December 2018.
On 7 December staff found Mr A on the floor. They called an ambulance the following day as Mr A complained of pain in his leg. The hospital admitted Mr A and referred him to RRLP. RRLP reviewed Mr A and concluded his needs could be managed in the community rather than in a mental health ward. However, RRLP said it would need to review him again before he left hospital.
On 17 December RRLP said it felt it would be appropriate for Mr A to return to Leivers Court for further assessment. RRLP noted this would mitigate the risks it had identified, as opposed to Mr A being at home on his own.
A Social Worker contacted RRLP on 20 December and said there was a plan to discharge Mr A home. RRLP had concerns about this plan and requested a Mental Health Act assessment. An RRLP Nurse called Mr B about the planned assessment, although the precise details of this conversation are somewhat disputed.
Mr A was assessed under the MHA on 21 December 2018. The AMHP recommended Mr A be detained for assessment under section 2 of the MHA. On the following day Mr A transferred to Ward B1 of Bassetlaw Hospital. Mr A remained detained under section 2 until 7 January 2019. Mr A then remained on the ward as an informal patient until 1 April 2019 when he returned home with support from carers four times a day.
Mr B complained to the Trust at the end of January 2019. The Trust responded in July and August 2019 and again in January 2020. Mr B remained dissatisfied and complained to the Ombudsmen.
Analysis Complaint that Lings Bar Hospital did not provide appropriate stroke rehabilitation to Mr A The Chartered Society of Physiotherapy issued a Duty of Care in 2013. This sets out that physiotherapists “must provide a ‘reasonable’ standard of care” to people they treat. The Health and Care Professions Council has standards of proficiency for physiotherapists. This notes (at 4.1) that they must be able to “assess a professional situation, determine the nature and severity of the problem and call upon the required knowledge and experience to deal with the problem”. It also notes (at 4.2) that physiotherapists must be able to “make reasoned decisions to initiate, continue, modify or cease techniques or procedures, and record the decisions and reasoning appropriately”.
Staff at Lings Bar Hospital completed an Admission and Discharge Booklet for Mr A. This noted that Mr A had been transferred to its facility for rehabilitation as he had poor mobility. The document noted Mr A’s previous level of mobility as well as his current ability, along with the goal of being able to mobilise independently.
There is a record to show that Lings Bar therapy staff got information from therapy staff on Mr A’s previous ward. This included information about Mr A’s level of mobility while he was on the ward and the team’s view about whether he had the potential to improve on this.
A Physiotherapist and OT saw Mr A several days after he arrived at Lings Bar Hospital. They noted his recent medical history and assessed Mr A’s previous level of ability across a range of tasks and assessed Mr A’s ranges of movement. Physiotherapy recommended Mr A should practice mobilising with a zimmer frame and do balance and other exercises.
There are records to show that staff regularly did mobility, transfer and balance exercises with Mr A and his progress was reviewed at regular intervals. However, by 23 October 2018 the multi-disciplinary team felt that Mr A had “plateaued in terms of progression.” Therapy staff continued to work with Mr A on various exercises.
In a discharge summary staff noted Mr A had received full rehabilitation including physical and occupational/vocational therapy.
Mr A still needed assistance when moving around the ward when he left. It is recorded in the notes that he had not progressed as he had hoped. However, there is evidence to show that therapy staff were following a prescribed plan which was, in turn, based on an assessment of Mr A’s individual needs. I have not, therefore, found any evidence of fault in relation to this head of complaint.
Complaint that Lings Bar Hospital did not consider Mr A’s eyesight impairment In the Admission and Discharge Booklet staff noted that Mr A was registered blind and needed assistance with activities of daily living because of this. A Risk Assessment and Care Plan Booklet also documented that Mr A was registered as blind. When therapists assessed Mr A on 15 October they documented the same. As such, there is evidence to show that staff were aware of Mr A’s disability and the way in which it impacted on his day-to-day activities. As such, I find no fault here.
Complaint that Lings Bar Hospital incorrectly told Mr A he would be discharged to a non-hospital environment; and Complaint that Lings Bar Hospital inappropriately transferred Mr A to Leivers Court Residential Care Home When Mr A transferred to Lings Bar Hospital Mr B contacted staff to ask why he had been moved there. The previous ward had referred Mr A for residential rehabilitation. Their referral was triaged by a City Hub which determined Lings Bar Hospital would be more suitable for Mr A than a residential placement. It told the referring OT this was because Lings Bar Hospital had nursing staff on duty all the time, it had a part-time mental health nurse and because it was rehabilitation focused.
There is a note to show an OT from the previous ward spoke to Mr B about the rationale for the move to Lings Bar Hospital on 11 October. A Service Head from Lings Bar Hospital also spoke to Mr B about the reasons for Mr A’s admission on 15 October. It is recorded in the notes that, during this call, Mr B asked that Mr A should not be moved to another ward as it could be distressing for him. Staff agreed that Mr A would stay on the same ward for the time being.
On 25 October staff completed a Joint Subjective and Objective Review and Reassessment of Mr A’s needs. This recorded that Mr A was ready to be discharged from Lings Bar Hospital. A weekly analysis of Mr A’s progress from the same day noted that they still needed a decision about where Mr A would go to when he left Lings Bar Hospital. Staff recorded that they had a long conversation with Mr A and said they had concerns that Mr A may fall if he returned home and, as such, felt it would be appropriate for him to move to residential care.
A Social Worker saw Mr A on 30 October and noted that he was worried about how he would cope if he went home. The Social Worker spoke about an assessment bed and noted that Mr A said he would like that as he did not feel he could return home. The Social Worker called Mr B the same day and talked about the reasons for transferring Mr A to an assessment bed. The Social Worker noted that Mr A had agreed to go to an assessment bed. The Social Worker recorded that Mr B said he would support this option. The Social Worker referred Mr A to Leivers Court which, a few days later, confirmed it would be able to meet Mr A’s needs. The objective of transferring Mr A to Leivers Court was to allow for a detailed assessment of his future care needs away from a hospital environment.
On 5 November a Mental Health Nurse saw Mr A. They noted the plan for Mr A to go to Leivers Court and recorded that Mr A “was able to discuss discharge optimistically and has a good understanding of aims”. Another record from the same day noted a member of staff had a long conversation with Mr A about moving to Leivers Court. They noted “He is positive about discharge and is aware of the purpose of moving to Leivers Court”.
Overall, there is evidence to show professionals openly discussed discharge plans with Mr A. There were well documented professional concerns about Mr A’s ability to cope safely on his own at home, and notes to show Mr A shared those concerns. The evidence suggests staff explained the nature of the Leivers Court placement to Mr A and obtained his agreement to the move. As such, I have not found any fault here.
Complaint that Leivers Court did not provide appropriate stroke rehabilitation to Mr A Leivers Court is not a rehabilitation unit. By the time Mr A transferred to it approximately six months had passed since he had suffered a stroke. As noted above, in late October 2018 therapy professionals had reached a view that Mr A’s rehabilitation was unlikely to progress much further.
The purpose of Mr A’s transfer to Leivers Court was not to provide further rehabilitation, but to facilitate an assessment of his needs outside of a hospital environment. In these circumstances, there was no fault on the part of Leivers Court.
Complaint that Leivers Court did not consider Mr A’s eyesight impairment Staff completed an Initial Assessment and Care Plan when Mr A moved into Leivers Court. This noted that he was registered blind. A Manual Handling Plan, Mobility Care Plan and Daily Living Skills – Social Needs Care Plan also noted the same.
As with Mr A’s admission to Lings Bar Hospital, there is evidence to show that staff were aware of Mr A’s visual impairment and considered how it would impact various aspects of his care. I have not, therefore, found evidence of fault here.
Complaint that RRLP referred Mr A for a MHA assessment without discussing this with Mr B first Staff from Queens Medical Centre referred Mr A to RRLP on the day he entered A&E, on 8 December 2018. They were concerned about Mr A’s low mood and statements he made about wanting to die. RRLP assessed Mr A the same day. They concluded Mr A needed further support to manage his depression. They felt this could be managed in the community rather than in a mental health ward. However, RRLP said they would need to review him again before he left hospital.
RRLP reviewed Mr A again on 10 December and 13 December. On 13 December staff noted there was no medical reason for Mr A to remain in hospital. They noted it was unclear about where Mr A should go to from hospital due to concerns about whether he would be able to cope at home. An RRLP multi-disciplinary team discussed Mr A’s case and recommended that Mr A be referred back to an assessment bed.
A Nurse from RRLP reviewed Mr A again on 17 December. They then discussed the case with an RRLP Consultant. RRLP continued to feel Mr A would benefit from a referral back to Leivers Court. RRLP noted they felt that, while they had concerns about Mr A’s risk to himself, these risks could be mitigated if Mr A was in Leivers Court. RRLP determined that they did not need to recommend an admission to a mental health ward on the basis that they understood Mr A would return to Leivers Court. RRLP spoke to a Discharge Coordinator and noted “that at this time, it was not felt appropriate to transfer [Mr A] to a [mental health] ward as risks could be managed in 24 hour setting and ongoing support of mood could be given there”.
On 19 December a Ward Doctor advised RRLP of a possibility of Mr A returning home. RRLP noted “The risks in regard to self harm/attempted suicide are higher if [Mr A] returns home alone therefore I have advised [the Ward Doctor] that if the ward and [Mr A] decide for this option then RRLP should be immediately informed so that a risk assessment in light of this change can be completed”.
A Social Worker called RRLP the next day and said there was a plan to discharge Mr A home. An RRLP Nurse noted they had concerns this would result in much higher risk factors. They said that these increased risks warranted a MHA Assessment. The RRLP multi-disciplinary team discussed the case and agreed on the plan for a MHA Assessment. RRLP then contacted the Approved Mental Health Practitioner (AMHP) office to arrange the assessment. After they had done so an RRLP Nurse called Mr B.
There is a cogent rationale for RRLP’s decision to refer Mr A for a MHA Assessment. This rested on professionals’ interpretation of Mr A’s risk of coming to harm at home opposed to being in a residential facility with staff on hand around the clock. There is evidence of the RRLP multi-disciplinary team discussing Mr A’s case at several points.
However, RRLP could and should have done more to obtain Mr A’s consent to involve his family and key stakeholders in discussions about his care. On balance, it is probable that Mr A would have provided his consent had it been sought. By this time Mr A had been in various NHS facilities and in contact with social care professionals for a considerable period of time. Contact with Mr B and with professionals who had previous experience with Mr A is likely to have been helpful in establishing a more complete picture of his current presentation and what was normal for him. This means that there was a lost opportunity for RRLP to obtain further history and collateral information which would have helped in its assessment. These omissions amount to fault.
I cannot say, on the balance of probabilities, that RRLP would not have referred Mr A for a MHA assessment or that he would not have been detained without this fault. As RRLP had concerns about Mr A’s health and safety it was appropriate for them to act upon them. It is possible RRLP would have continued to have concerns even after speaking to others. Evidence from Mr A’s subsequent admission shows other members of staff shared similar concerns to RRLP. Further, the first time Mr A’s detention was reviewed, around two weeks after he was detained, the consultant determined further assessment under the MHA was required. Nevertheless, RRLP’s failure to do more to involve him (and other professionals) in discussions caused him avoidable frustration. It has left with enduring uncertainty about whether Mr A would have been detained had it not been for the fault. This frustration and uncertainty is an injustice.
Complaint that RRLP failed to make adjustments for Mr B’s disability to allow him to engage in discussions about the assessment, and failed to ask the Council to make reasonable adjustments for the MHA assessment it would conduct; and Complaint that RRLP did not tell the Council Mr B was Mr A’s Nearest Relative when it referred Mr A for a MHA assessment When an RRLP Nurse called Mr B on 20 December 2018 they did so to inform him of the planned assessment the next day. During the complaints process the Trust has acknowledged that the Nurse did not use the terminology ‘Mental Health Act Assessment’ but explained the concept and the assessment process. The Trust said that, in future, it would use the correct term. The Nurse noted that Mr B understood staff concerns.
The Nurse noted that Mr B was “happy to be contacted by the AMHP after MHA assessment” [my emphasis]. The Nurse said they did not know what time the assessment would take place and noted that Mr B would not be available to speak until after 10.30am.
In contrast, Mr B recalls that he told the Nurse he did not think he would be able to support Mr A at the assessment due to the short notice (and his need to arrange a chaperone and transport). Mr B said the Nurse said this would not be a problem and said the person doing the assessment would call him before they did it.
This conversation took place over three years ago. There is no way for me to now establish objectively and fairly what was said at the time. Clearly there was a misunderstanding. However, this alone does not mean there was fault on the part of RRLP service.
By the time of RRLP’s conversation with Mr B the Nurse had already made the referral to the AMHP office for a MHA assessment. They made the referral over the telephone. The form the Council completed was blank at the Nearest Relative section. As with the conversation between the Nurse and Mr B, at this point in time there is no way to objectively determine whether the information was shared but not documented, or if it was not shared.
In Mr B’s conversation with the RRLP Nurse he had noted that Mr A’s admission to a mental health ward in July had been voluntary. He also described the discharge plans that had been taking place at Leivers Court and noted the actions he had taken to remove the risk of Mr A accessing medication at home.
Once RRLP had made its referral it was for the AMHP service to take the matter forward and to determine how it would assess Mr A. They completed an assessment and then called Mr B after making an application to detain Mr A. I have not seen any evidence of further contact from RRLP to the AMHP service after they spoke to Mr B. There is nothing to show that staff passed on Mr B’s request to be called – either before or after the assessment. Having made this undertaking to Mr B staff should have followed up on it. It would also have presented an opportunity to pass on further information, in regard to what Mr B had told the RRLP Nurse about the prior plans for Mr A’s return home. This failure to contact the AMHP service again is a notable omission and amounts to fault.
The way in which the AMHP conducted the MHA assessment has been considered separately, via a distinct LGSCO investigation. I cannot say, even on the balance of probabilities, if the AMHP’s assessment would have led to a different outcome had RRLP passed on more information. While Mr B is clear in his belief that it would have made a significant difference I cannot ignore that, once on Ward B1, Mr A remained detained until 7 January 2019. Nevertheless, Mr B was caused frustration and has been left with uncertainty by this fault and this is an injustice.
Complaint that Ward B1 of Bassetlaw Hospital did not provide appropriate stroke rehabilitation to Mr A Mr A was admitted to Ward B1 of Bassetlaw Hospital on account of concerns about his mental health, and not for rehabilitation or due to concerns about his physical health. Prior to this, while at Leivers Court and during the latter stages of his hospital admission, there were plans for Mr A to return home. The records I have seen suggest a variety of professionals considered Mr A had reached his potential, in regard to his ability to benefit from rehabilitation.
On 24 December 2018, two days after Mr A’s admission, staff referred him to Physiotherapy. A Physiotherapist assessed Mr A on 2 January 2019 and noted his current level of ability. The Physiotherapist asked staff to assist Mr A with walking practice as often as possible to promote his confidence and muscle strengthening.
This was reasonable in the context of the reasons for Mr A’s admission, along with the time that had passed since his stroke and progress since that time. I have not found fault in the ward’s approach.
Complaint that Ward B1 of Bassetlaw Hospital did not consider Mr A’s eyesight impairment Staff recorded that Mr A had a visual impairment in his electronic records. On 23 December a Nurse spoke to Mr B and discussed Mr A’s “extremely limited eyesight and how this effects him (discussed this numerous times during conversation”.
There is evidence to show that staff were aware of Mr A’s visual impairment and considered how it would impact various aspects of his care. I have not, therefore, found evidence of fault here.
Complaint that Ward B1 of Bassetlaw Hospital did not allow Mr A to see his grandson for three months The Trust has a Trust-wide policy on children visiting inpatient and residential areas of its premises. This sets out (at 2.3) that “Children will only be allowed to visit where the visit is assessed to be in the best interests of the child and this assessment should be evidenced within the client’s records”. It also details (at 2.5) that “Visits will be conducted in an environment that is separate from other patients and is appropriate to the needs of the child where relevant”. As such, there was nothing in the Trust’s policies which automatically barred Mr A’s grandson from visiting Mr A.
The Trust advised us that children under 18 cannot enter the ward area of Ward B1. However, it said there is a Family Room outside the ward area which can be booked by family members, to allow children to visit their loved one. The Trust said it does not have any record of any enquiry or request for a visit accompanied by children during Mr A’s admission.
On the basis of the evidence available to me, I have not found evidence to show the Trust unfairly or unreasonably prevented anyone from visiting Mr A during his admission to Ward B1 of Bassetlaw Hospital. As such, I have not found fault here.
Agreed actions
Within one month of the final decision the Trust will write to Mr B and acknowledge the fault I have identified in paragraphs 46 and 54. It will also apologise for the injustice this caused Mr B, as noted in paragraphs 47 and 55.
Within one month of the final decision the Trust will pay Mr B £250 as a tangible acknowledgment of the injustice its fault caused him.
Within one month of the final decision the Trust will share the outcome of this investigation with the RRLP team. It will ask the RRLP team to reflect on its actions and the findings of this investigation, and review any policies and procedures relevant to these circumstances. In particular, the team should consider whether there is sufficient, adequate guidance in place to ensure staff have appropriate levels of communication with key stakeholders to ensure they understand the context of a patient’s presentation. The team should make any necessary amendments or additions with a view to avoiding repetitions in the future.
Decision I have completed this investigation on the basis that there was some fault on the part of the Trust which caused Mr B an injustice, but no fault on the part of the Council.
Parts of the complaint I did not investigate I did not investigate Mr B’s complaints about Bassetlaw’s failure to respect his rights as his father’s Nearest Relative, or about a Consultant attaching conditions to their decision to rescind Mr A’s detention. From the available evidence it is improbable that an investigation would be able to obtain a meaningful outcome.
Investigator’s decision on behalf of the Ombudsmen
Investigator's decision on behalf of the Ombudsman