The Ombudsman's final decision
Summary: We will not investigate Ms R’s complaint about the handling of her mother’s discharge from hospital and related safeguarding concerns. This is because we would be unlikely to find fault with the Trust and Council’s actions. We will not investigate her complaints about communication and complaint handling as there is unlikely to be sufficient remaining injustice to investigate these issues alone and reasonable steps have already been taken to put things right.
The complaint
Ms R complains about Thurrock Council (the Council) and NHS Mid and South Essex NHS Foundation Trust’s (the Trust) handling of her mother, Mrs G’s, discharge from hospital in December 2020. Specifically, she complains that: the decision to escalate safeguarding concerns about Mrs G was unwarranted and disproportionate in the circumstances, Mrs G remained in hospital for six days longer than necessary due to the poor handling of the safeguarding investigation and discharge, communication between the Trust and Council staff was poor and contributed to delayed discharge, communication with Ms R was inadequate; and complaint handling by both the Trust and the Council was poor.
Ms R says the delayed discharge impacted negatively on Mrs G’s health, causing her to decline rapidly after the hospital admission. She also says the situation caused the family a significant amount of unnecessary stress in the run up to her parents’ last Christmas together. She believes the stress contributed to her father’s death in February 2021.
Ms R would like to understand what went wrong, for the Trust and the Council to acknowledge that communication should have been better and for systemic improvements to be put in place.
The Ombudsmen’s role and powers The Ombudsmen have the power to jointly consider complaints about health and social care. Since April 2015, these complaints have been considered by a single team acting on behalf of both Ombudsmen. (Local Government Act 1974, section 33ZA, 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).
We investigate complaints about adult social care providers. We provide a free service, but must use public money carefully. We may decide not to start or continue an investigation if we believe: the action has not caused injustice to the person complaining; or the injustice is not significant enough to justify our involvement; or it is unlikely we could add to any previous investigation by the organisations.
(Local Government Act 1974, sections 34B(8) and (9))
How I considered this complaint
I have considered information provided by Ms R and the Council. I shared a draft decision with Ms R and considered her comments.
What I found
The safeguarding process A council must make enquiries if it has reason to think a person may be at risk of abuse or neglect and has care and support needs which mean the person cannot protect themself. (section 42, Care Act 2014) What happened Mrs G has dementia and lived at home with her husband, Mr G, who was her main carer. A carer from a care agency would also visit three mornings a week to offer additional support.
On 11 December 2020, a carer visited Mrs G and noticed unexplained bruising and a bump on her head which had happened following an accident the previous day. The carer contacted Mrs G’s social worker, who visited Mrs G and requested a GP arrange a health check for her. The next day, a nurse assessed Mrs G and had no concerns.
On 14 and 15 December 2020, a carer raised further safeguarding concerns with the Council about a new injury to Mrs G’s lip, which Mr G said he had caused accidentally.
On 16 December 2020, a carer called an ambulance after finding the bump on Mrs G’s head had deteriorated. The carer reported that Mrs G had a severe headache and her pupils were not reacting properly. The carer shared safeguarding concerns with the ambulance crew that Mrs G’s injuries may have been a result of domestic violence by Mr G.
Mrs G was admitted to hospital with a possible fractured skull and multiple unexplained bruises. The Council received four separate safeguarding referrals from the care agency, the ambulance crew, the hospital and the police. The Council opened a safeguarding enquiry. The police visited Mrs G in hospital but took no further action.
On 18 December 2020, Mrs G had a CT scan which confirmed that her skull was not fractured. Later that day, Mrs G was deemed medically fit for discharge.
On 19 December 2020, a physiotherapist assessed Mrs G’s mobility, however the information obtained was limited by Mrs G’s confusion at the time.
On 22 December 2020, a professionals meeting took place and it was agreed that Mrs G could return home. The safeguarding enquiry was concluded as the concern about the skull fracture was unfounded and it was not possible to determine how the bruises had occurred. The Council arranged an increased care package with single carer visits to support Mrs G and the family expected her to be discharged that afternoon.
However, a physiotherapist completed a further assessment and decided Mrs G required two carer visits. The Council was unable to source double handed care in time, so the discharge could not safely go ahead and Mrs G remained in hospital overnight.
On 23 December 2020, double handed care visits were arranged and Mrs G was discharged home.
Analysis Decision to commence safeguarding enquiry Ms R says that she cannot understand why concerns about Mrs G’s welfare were escalated to a safeguarding enquiry at this point. She says a nurse assessed Mrs G and had no concerns about her physical wellbeing, yet two days later, a safeguarding enquiry was opened although there were no new injuries and nothing had changed. Ms R found the decision drastic, intrusive and unjustified.
As mentioned above, the Council has a statutory duty to make safeguarding enquiries where there is reason to believe a person may be at risk. The Council already knew that Mr G was finding Mrs G’s care challenging, then received four separate safeguarding referrals from multiple organisations over a short period.
I note that the situation had changed since the nurse’s assessment on 12 December 2020. In the following days, Mrs G sustained a new injury to her lip, her head injury deteriorated significantly and a carer raised concerns about Mr G’s behaviour towards Mrs G.
We will not investigate this point as we are unlikely to find fault with the Council’s decision to commence a safeguarding enquiry. While the situation was undoubtedly upsetting for Mrs G’s family, Mrs G’s welfare needed to take priority and the Council had a statutory duty to make enquiries.
Delayed hospital discharge Ms R asserts that Mrs G was medically fit for discharge on 18 December 2020 and should have been discharged at this point. She says Mrs G’s discharge was unreasonably and unnecessarily delayed for a further six days.
A patient being medically fit does not necessarily mean that person is ready for discharge. Mrs G also required her needs re-assessing and her care package to be reviewed, which was ultimately substantially increased. Further, Mrs G was unable to return home until the safeguarding enquiry was concluded.
I will address the possible impact of the physiotherapist’s assessments on discharge below, when considering communication between the Trust and the Council.
The safeguarding enquiry was concluded within eight days of the initial concerns being raised, and four days after it was confirmed that Mrs G did not have a skull fracture. However, the suspected skull fracture was not the only concern raised, and the Council had to reach a view on all issues before the safeguarding process could be concluded.
Ms R says she understands why Mrs G could not return home, however questions why she was kept in hospital once medically fit. She suggests that Mrs G could have instead been discharged to a care home or to Ms R’s own home but says these alternatives were never discussed.
The Council records show that it initially talked with Ms R about the possibility of Mrs G being moved to a temporary respite placement in a care home for two to four weeks, while the safeguarding enquiries were completed. It records that Ms R was unhappy with this suggestion. Ms R felt this would have been unnecessary and the change of environment and separation from her family would have been upsetting for Mrs G.
Mrs G could not be moved to any form of alternative accommodation without various assessments being completed first. These would look at Mrs G’s current mobility and whether the setting was suitable and could meet her current care needs. Discharge to a new location may have taken as long, if not longer, than discharging Mrs G home.
Despite the Council initially believing the safeguarding enquiry could take a few weeks to complete, it appears the Council moved swiftly following the professionals meeting on 22 December 2020. The Council ultimately managed to conclude matters far more promptly than originally anticipated and Mrs G was able to return home before Christmas, which was the preferred option.
Further, when Mrs G’s care requirements were increased to double handed care, the Council records show that it made significant efforts to put the required care in place at short notice to ensure Mrs G’s discharge went ahead the next day, despite considerable trouble sourcing a suitable care package.
I have not seen any evidence suggesting any undue delay by the Council. As such, we are unlikely to find fault with the Council’s actions regarding the time taken to complete the safeguarding investigation and any impact on Mrs G’s discharge.
Poor communication between the Trust and the Council Ms R complains that the communication between the Trust and the Council was inadequate and impacted on the time taken for Mrs G to be discharged.
Having reviewed the information provided in the Trust’s complaint response and the Council’s records, I have not seen sufficient evidence to suggest widespread communication issues causing delay. There is one aspect where it appears that communication between the Trust and the Council could have been better, and that may have had some impact on Mrs G’s discharge.
A physiotherapist assessed Mrs G’s needs on 16 December 2020 and again on 19 December. However, records suggest that this was somewhat limited by the level of Mrs G’s confusion on that day. It is unclear from the information currently available why further assessments were not completed until 22 December 2020. That said, Mrs G was unable to be discharged home before the safeguarding enquiry concluded, also on 22 December. Therefore, it seems unlikely that Mrs G would have been discharged prior to this date, even if the physiotherapist assessments had been repeated earlier.
However, the Council appeared unaware on 22 December 2020 that the physiotherapist’s assessments were not complete and had proceeded to arrange a care package with a single carer and advised the family that Mrs G would be discharged home later that day.
When the physiotherapist completed Mrs G’s assessment on 22 December, it was decided that Mrs G required two carers per visit. As a result, it was unsafe for Mrs G’s discharge to go ahead and she remained in hospital overnight. Ms R told me this was hugely disappointing for her and Mr G. Further, the upset caused was exacerbated by the fact they had been attending a close relative’s funeral, meaning it was already a difficult and emotional day.
Had the physiotherapist’s assessments been repeated on 20 or 21 December 2020, it is possible that the correct double handed care package may have been in place by 22 December and Mrs G’s discharge may have gone ahead that day.
Alternatively, had the Council been aware that physiotherapy assessments were ongoing, it may have avoided the unnecessary upset of the family being advised Mrs G would be discharged when a suitable care package was not in place.
While I acknowledge that the delay would have been frustrating and disappointing for Ms R and her father, I have not seen any evidence to suggest that Mrs G’s discharge was delayed beyond it moving overnight from 22 December to 23 December 2020. I am not persuaded that there is significant outstanding injustice on this point to warrant further investigation.
Poor communication with Ms R Ms R complains that the Trust and the Council failed to adequately involve her, particularly given that she is a Health & Welfare attorney for Mrs G.
I have reviewed the Trust’s complaint response and the Council’s records, which show both the Trust and the Council spoke with Ms R multiple times and that there were also attempts to contact Ms R by phone which were unsuccessful. Ms R says the majority of the communication was initiated by her.
I acknowledge Ms R feels she did not receive adequate updates and found this frustrating. However, there does not appear to be sufficient evidence to suggest that the communication with Ms R was so poor as to amount to fault.
I note that the Trust’s complaint response of 15 October 2021 acknowledges Ms R’s feedback about communication and states it has been shared with staff as a learning point. In my view, this is a reasonable response. I consider an investigation by the Ombudsmen would be unlikely to achieve anything further.
Complaint handling Ms R is unhappy with the way her complaint was handled. She says she has not had answers to all of her questions, the Trust was not clear about their complaint process and the Council’s replies were conflicting.
The Trust has accepted its PALS team could have been clearer about its role and how Ms R’s complaint would be handled. As a result, the Trust has shared her feedback with its staff to ensure communication is clearer in the future. We are unlikely to achieve anything further.
The Council’s first complaint response, dated 30 September 2021, contained some inaccurate information about the number of safeguarding referrals it has received. This confusion was unhelpful. However, the Council apologised for this error and clarified matters in their second response, and also in its letter confirming the outcome of the safeguarding enquiry, both dated 15 October 2021, although I note Ms R remains dissatisfied with the explanation.
In its letter of 15 October 2020, the Council offered to meet Ms R to help resolve her outstanding questions, which Ms R declined. While Ms R told me she did not wish to attend a face-to-face meeting due to the Covid-19 pandemic, the Council’s letter also offered the option of holding the meeting virtually by Teams or Zoom. I consider this to be a reasonable response to her concerns.
I am of the view that, while it seems the handling of Ms R’s complaint could have been better, both the Trust and the Council has accepted this and taken steps to address it. Further investigation is unlikely to achieve more.
Final decision
We will not investigate Ms R’s complaint about the handling of Mrs G’s discharge from hospital and safeguarding concerns as we are unlikely to find fault with the Trust and Council’s actions. There is insufficient injustice to investigate her complaints about communication and complaint handling alone and reasonable steps have been taken to put things right.
Investigator's decision on behalf of the Ombudsman