22. When reaching our decision on a complaint, we look at whether the organisation concerned has got something wrong. We do this by comparing what should have happened with what did happen. If what happened fell far short of what should have happened, we call this a failing. When we see evidence of a failing, we next look at whether that failing had a negative impact on the person in question. If we think it did, we will go on to consider what, if anything, the organisation has done to try to put things right.
Incomplete discharge summary
23. HCPC’s Standards of Conduct, Performance and Ethics state professionals must share relevant information, where appropriate, with colleagues involved in the care and treatment given to a service user and must keep full, clear and accurate records for everyone they care for and treat.
24. Mrs C complains actions agreed during an MDT were not included in her father’s discharge paperwork. She explained that during his stay, the Trust was providing physio (exercises) to her father to stop contracted joints and muscles. She says staff confirmed during the MDT the exercises would continue on his discharge to the home.
25. Mrs C explained the discharge summary did not include details of daily physiotherapy exercises or that her father would need a hoist to get out of bed. She says, as a result, the home did not have the equipment to hoist her father and was not providing her father with the daily exercises he needed.
26. The Trust acknowledged the discharge summary did not include a written care plan for meeting Mr K’s manual handling needs in the home. It explained an OT verbally notified the home by telephone, but the Trust acknowledged his ongoing care needs, such as using a hoist for transfers, using a slide sheet and using a riser and recliner chair, should also have been included in the discharge summary.
27. The Trust first responded to the issue of the discharge summary not including details of Mr K’s manual handling needs in July 2020. It explained the OT gave simple exercises over the phone to the home. It said the OT explained Mr K would need a hoist, a riser and recliner chair and a slide sheet. It explained the home said it was able to provide this for Mr K. The Trust added the care plan for manual handling and exercise programme that were discussed verbally should also have been included in Mr K’s written care plan that it sent to the home.
28. We asked the Trust for a copy of the care plan it says it sent to the home. The Trust told us on 7 May the OT and physiotherapist at the Trust undertook an assessment for seating in a riser recliner chair, deeming Mr K safe to sit in this chair. The assessment was then followed up with a telephone conversation with a staff member at the home to detail the hoisting and seating requirements. The Trust told us it does not have an electronic copy of the care plan - the written plan would have been sent with Mr K to the home.
29. To aid our investigation we sought advice from our physiotherapist adviser. We did this to help us understand whether it was appropriate for the Trust to have completed a handover to a home verbally without recording the details of what was needed for Mr K’s ongoing care in Mr K’s discharge paperwork.
30. HCPC’s Standards of Conduct, Performance and Ethics state professionals must share relevant information, where appropriate, with colleagues involved in the care and treatment given to a patient and must keep full, clear and accurate records for everyone they care for and treat. HCPC’s Standards of Proficiency say occupational therapists must keep accurate, comprehensive and comprehensible records in accordance with applicable legislation, protocols and guidelines.
31. Our physiotherapist adviser explained that while the OT communicated verbally to the home about Mr K’s ongoing needs, this was not written on the discharge summary. This is especially important because Mr K had dementia, which made communication more challenging. Mr K’s medical records contain a discharge arrangements template which had not been completed.
32. We understand how important it is all relevant information is shared with a home following discharge from hospital. We found the Trust’s discharge summary was incomplete, and the discharge planning paperwork in Mr K’s medical records was incomplete. Incomplete paperwork is not in line with the HCPC guidance we have outlined above. This is a failing.
Exercises not on the discharge summary
33. Mrs C complains that during an MDT meeting the Trust confirmed the exercises it had been giving Mr K would continue after his discharge to the nursing home. She explained to us carers at the home were not performing the exercises with Mr K. She explains this was because they were not listed on the discharge summary.
34. We have seen the Trust responded to explain although the exercises were not included in the discharge summary, an OT had given the home simple exercises to do with Mr K. They did this verbally over the phone on 7 May 2020. The Trust said this information would also have been contained within Mr K’s written care plan, which it sent to the home (with Mr K).
35. Based on the evidence contained in Mr K’s medical records, we have not identified any signs that Trust staff were doing exercises with Mr K.
36. We contacted the Trust to clarify whether staff were doing exercises with Mr K. It told us the staff did not do exercises with him.
37. This information contradicted the Trust’s initial complaint response where it explained instructions for exercises had been given over the phone.
38. We also asked the home whether it held notes or records of the Trust passing on any exercises. The home told us it does not have a record of any exercises being passed to it to complete.
39. Therefore, we have different versions of whether the Trusts therapy team were doing exercises with Mr K. In situations like this, we look at what is more likely to have happened. To consider this, we looked at Mr K’s records. For each therapy team’s recorded notes of their encounters with Mr K, there is no mention at any time of exercises being carried out.
40. If Mr K had been having daily exercises, we would have expected to have seen this information recorded in Mr K’s daily intervention records. Similarly, we looked at the notes of the MDT meeting, and again there is no mention of exercises.
41. We also considered Mrs C’s account. She told us she specifically asked at the MDT whether Mr K’s exercises would continue when he got to the home. She told us staff in the MDT told her they would.
42. We consider it is more likely than not the Trust was not providing exercises to Mr K. This is because there are no notes indicating exercises were ever carried out. We are also aware the OT no longer works at the Trust, so we have been unable to ask for their recollection of events.
43. We appreciate Mrs C firmly believes exercises were being given and were not passed on to the home. As we have not been able to substantiate this, we asked our physician adviser whether any potential lack of exercises or details about Mr K’s manual handling would have had any impact on his deterioration. We detail this further in the next section.
Mr K’s manual handling needs were not included in the written care plan
44. The NICE guidance says:
‘Give people information about their diagnoses and treatment and a complete list of their medicines when they transfer between hospital and home (including their care home). If appropriate, also give this to their family and carers.’
45. The Trust told us it has acknowledged Mr K’s manual handling needs were not included in his discharge summary. It told us they should have been in the written care plan it sent to the home.
46. We asked the Trust to send us a copy of the written care plan it says it sent to the home. The Trust told us the written copy was sent with Mr K to the home, and there is no copy of the care plan on its electronic records.
47. This means the Trust has not been able to show it sent a care plan, and it has not shown his manual handling needs were included in the care plan.
48. We have seen the Trust gave a verbal handover. We asked our physician adviser whether the Trust’s verbal handover was appropriate.
49. Our physician adviser told us it is not unusual to give a verbal handover to a home, but a written handover should also be given. This is important if a home needs to give specific care towards a patient. It is especially important if the person has dementia and is unable to engage or remember what has been happening to them before discharge.
50. Therefore, we consider there was a failing in the Trust’s communication with the home. It did not act in line with the NICE guidance outlined above because it has not been able to evidence it gave the home information on Mr K’s future treatment in written form.
Impact
51. Mrs C says the Trust’s failure to fully complete the discharge summary and send the home details of his ongoing manual handling needs led to his death.
52. We asked our physician adviser whether this would have had any impact on Mr K’s deterioration while he was in the home.
53. Our physician adviser explained the Trust’s lack of written communication would have had very little impact on Mr K’s condition. Mr K had two severe and progressive illnesses (Parkinson’s disease and dementia), which limited his ability to understand, move and interact. Sadly, Mr K died as a result of a DVT and pneumonia. We do not consider the failing we have identified (poor communication) can be linked to the injustice Mrs C has claimed.
54. Mrs C also says the events caused distress during a difficult time for her and her family. We understand learning incomplete information was given to the home would be worrying for the family. We consider the Trust’s poor record keeping likely has caused Mrs C distress and frustration. We can link this injustice to the failing we have found.
55. We asked the Trust what learning it has taken and what, if anything, it has done to address not sending Mr K’s manual handling needs to the home as part of his written care plan and what it did to address this information not being on his discharge paperwork.
56. The Trust told us its ‘Transfer of Care Hub’ now make a post discharge telephone call 24 hours after discharge. It explained this call highlights, in a timely manner, any concerns a home may have, which its staff are then able to action. The Trust told us the introduction of this telephone call means it can prevent a similar recurrence to that identified with Mr K’s care plan.
57. While we are pleased to see the Trust makes a call to a home following discharge, the evidence we have seen shows the Trust was already making follow-up calls before the complaint. Additionally, while we consider this a welcome step in the discharge process, we do not consider it addresses the failings we have identified in its poor record keeping and communication.