Physiotherapy Referral
14. Mr H complains on behalf of his father, about the care and treatment provided to him by the Trust. He specifically complains the Trust did not refer his father for further physiotherapy following discharge to a nursing home, until three/four months later.
15. Mr H considers the Trust should have continued to provide physiotherapy following his father’s discharge to a nursing home.
16. Within the Trust’s complaint response dated 21 August 2023, it said its Physiotherapist (PT) Team assessed Mr A and regularly reviewed and evaluated him. It explained that due to his stroke and past medical history he was unable to fully engage with physiotherapy. The PT assessments showed it would not be in his best interest to continue with further intensive physiotherapy.
17. Following Mr A’s assessment and experience, the Trust said its PT team said it sadly decided there was minimal chance of recovery following his stroke. Therefore, he was not referred to the community PT.
18. It said the occupational therapy (OT) team discussed there were no specific goals for him and a referral for further PT would not be made. It said they explained Mr A would still be referred for OT within the community for seating and upper limb position.
19. The Trust explained it referred Mr A to its OT team and Speech and Language Therapy (SALT) Team who referred him to the community PT. It assessed him after his discharge.
20. The relevant guidance is the HCPC: The standards of conduct, performance and ethics for physiotherapists. This document explains how physiotherapists in the UK must work safely and effectively.
21. Our adviser said based on the initial PT assessment, within the medical documentation, the Trust should have referred Mr A for further physiotherapy. This is because the last entry by the physiotherapy team (16 February 2023) was to:
‘..Continue PT [physiotherapy] as able..’.
22. However, the Trust has provided us with supplementary evidence in the form of a statement from its PT Team Leader who explains why the PT team did not refer Mr A for ongoing physiotherapy following his discharge.
23. The supplementary evidence shows the PT team followed HCPC standards. This is because the evidence adequately ensures the PT team followed standards of their HCPC proficiency (sections 4.1 to 4.6). They detailed their reasoning for ceasing physiotherapy treatment, justified their decision, demonstrated logical and systematic approach.
24. The medical records show that during Mr A’s inpatient physiotherapy sessions he did not appear to make any progress in his physical abilities which were attributed to, poor engagement, lack of ability to follow instructions, fatigue - both related to his recent stroke and his previous mixed dementia and Alzheimer’s in his past medical history. For example, the PT team recorded:
• 23 January 2023: ‘difficulty to follow instructions at times.’
• 24 January ‘pt[patient] sleepy’ • 26 January, ‘difficulty to follow instructions.’
• 27 January, ‘pt not engaging…minimal rehab potential. Difficult to engage in sessions.’
• 1 February, ‘in and out of sleep during sessions.’ (‘MDT [multidisciplinary team] outcome, sleepy, not waking up for therapy, not much progress.’) • 16 February, ‘pt dozed off during exs[exercises], difficulty completing exs due to this.’
25. Our adviser said this was the reason the PT team did not consider it was appropriate for further referral to physiotherapy services. Considering the Trust’s Lead PT statement and medical records, the evidence shows the Trust’s decision not to refer Mr A was in line with HCPC guidance.
26. Our adviser said it is commonly accepted that co-existent conditions such as dementia, sensory impairments, or other comorbidities can complicate delivery of rehabilitation.
27. The relevant guidance is NICE [NG 97]: Dementia: assessment, management and support for people living with dementia and their carers (Section 1.9.2). This relates to additional harm patients with dementia of hospital stays include disorientation and the effects of being in an impersonal or institutional environment, which is likely to have affected Mr A while an inpatient.
28. It is also commonly accepted that discharge from physiotherapy from stroke patients should never be an irrevocable decision but should include the opportunity for review and access back into services.
29. NICE [NG236]: Stroke rehabilitation in Adults: Section 1.2.11 says:
‘..Review people's goals at regular intervals during their stroke rehabilitation..’
and 1.17.5 says:
‘…Review the health and social care needs of people after stroke, and the needs of their carers, at 6 months and then annually..’.
30. In line with NG236 guidelines, our adviser said the Trust discharged Mr A under the early supported discharge team (ESD) SALT and OT, who had access to physiotherapy. ESD team subsequently arranged a review on 22 May when it was clear via communication with Mr H and the OT team that Mr A’s abilities and needs had changed after a period of time in the nursing home – improved communication and active movement in right hand.
31. We consider the Trust provided opportunity to Mr A to review his condition and access him back into physiotherapy service.
32. We understand Mr H’s concerns about the Trust not continuing physiotherapy following his father’s discharge from hospital, causing a delay to physiotherapy treatment. We have carefully considered his and the Trust’s account, the medical records and clinical advice. Having done so, we do not consider the Trust should have referred Mr A for further physiotherapy following his discharge to the nursing home, in line with HCPC and NICE guidelines. There is no indication of a failing.
33. Had there been an indication of a failing, it is unlikely we could link this to Mr A’s clinical impact. This is because our adviser said there are no clinical guidelines or standards to support or suggest that not having physiotherapy on discharge (as in Mr A’s situation) would have had a detrimental effect on his mobility.
Communication
34. Mr H complains the Trust did not communicate its decision not to provide physiotherapy for his father until he complained to the Trust in May 2023.
35. Within the Trust’s complaint response, it said the OT discussed there were no specific goals for Mr A and a referral for further physiotherapy would not be made. Although a referral to the PT team would not be made, Mr A would still be referred for OT within the community for seating and upper limb position. Despite this it said it is clear it did not effectively communicate with Mr H as a family to keep him informed of its decision making and rationales in Mr A’s care. It apologised this was not communicated in more depth.
36. The medical records show the Trust did not communicate to Mr H its decision not to provide physiotherapy following his father’s discharge.
37. Our adviser said the PT team did not meet the HCPC standards of proficiency in which they are required to communicate appropriately and effectively (paragraph 2.3), work in partnership with Mr A’s carers involving them in decisions about care, treatment and service (1.2) or communicate effectively with carers. (7.1).
38. We consider the Trust did not communicate to Mr A’s family its decision not to continue physiotherapy following his discharge to a nursing home, in line with HCPC guidance. This is an indication of a failing.
39. Having seen indications of failings, we next looked at whether this had a negative impact on Mr A and his son, and, if so, whether the Trust has put things right. We do not normally progress a complaint to detailed investigation where we find appropriate action has been taken to put things right or if we cannot link the impact to the failing.
40. Mr H says he had to employ a private physiotherapist to help his father’s progress until he received therapy from the Trust. He believes the delay in physiotherapy had a detrimental effect on improving his father’s mobility following his stroke.
41. Mr H said because he felt he needed to employ a private physiotherapist, he had to pay out about £1,000 for this therapy until the NHS provided one.
42. As we do not consider the Trust should have referred Mr A for further physiotherapy following his discharge to the nursing home, we cannot link the lack of communication, concerning this, to the clinical impact. Furthermore, the Trust did provide physiotherapy in the nursing home from May 2023 for several months. The private physiotherapy invoices Mr H has provided, indicate private physiotherapy was carried out in September/October 2023, not during the gap in therapy following his father’s discharge.
43. Although we do not consider the lack of communication caused Mr H to pay for physiotherapy, we recognise it was upsetting not being told whether the Trust was to continue physiotherapy.
44. Based on our Principles, where there have been failings leading to an injustice (in this case, upset), the public organisation should try to offer a remedy that returns the complainant to the position they would have been in, if the failings had not happened.
45. An appropriate range of remedies will include:
• an apology, explanation and acknowledgement of responsibility • remedial action, for example service improvements to minimise the risk of this happening again • financial remedy.
46. The Trust has acknowledged and apologised for the lack of communication.
Its complaint file shows it has carried out service improvements to minimise the risk of this happening again.
47. The Trust has spoken to its PT team and provided feedback regarding how it communicates decisions about withdrawing therapy input and not referring to community services. This is to improve its communication and to avoid the poor experience Mr H’s family had.
48. It highlighted to the PT team the importance of contemporaneous documentation in patients’ healthcare records. This includes documenting whether a follow up referral would be made by the hospital and discussions held about a patient’s progress with them and their family.
49. If a referral has not been made, it provided feedback that staff should document the rationale for this in the healthcare records, along with whether the PT team has discharged the patient and if the patient has a new functional baseline (the patient’s new ability to support their care such as walking, transferring, following a stroke), including the reason why.
50. We are sorry to learn of Mr H’s complaint. As we have identified indications of failings, we have carefully considered whether the Trust has acted in line with our Principles. The Trust has acknowledged and apologised for the failing and put service improvements in place to minimise the risk of this happening again. We are of the view the action taken is in line with our Principles.
51. We are sorry to learn of Mr H’s and Mr A’s complaint about the Trust and the impact this has had. Our primary investigation decision is not made without recognition of the impact this has had. We hope we have explained the thorough consideration we have given to our decision and clearly outlined the reasons for them.