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Gateshead Health NHS Foundation Trust

P-002963 · Statement · Decision date: 26 September 2024 · View Gateshead Health NHS Trust scorecard
Transfer, discharge and aftercare Care and discharge planning
Complaint (AI summary)
Mrs R complained the Trust inappropriately discharged her mother twice, failed to consider her support needs, kept poor records, and did not explain care home eligibility, causing distress and mental health deterioration.
Outcome (AI summary)
The ombudsman closed the complaint, finding no indication that anything went seriously wrong with the Trust's actions or care provided to Mrs R's mother.

Full decision details

The Complaint

3. Mrs R complains following her mother’s admission, the Trust: • decided to discharge her mother in January 2023, despite her family’s concerns and the likelihood of her being unable to manage at home • kept no records about the decision to delay telling her mother it was going to discharge her on 27 January • did not sufficiently consider how best to support her mother before discharging her • readmitted her then noted her mother needed soft food but did not reflect this when it discharged her to a care home • did not explain why her mother was not eligible for a funded care home placement when it discharged her.

4. Mrs R says her mother’s mental health deteriorated leading up to, and after, the Trust first discharged her. She is concerned the Trust has not accepted this. She feels her mother’s final months were unnecessarily filled with anxiety and stress, and this has added to her bereavement. Mrs R says delays in the Trust’s complaint handling and poor responses added to her experience.

5. Mrs R would like the Trust to acknowledge its failings and the impact they had on her family. She would also like it to explain what went wrong and make changes to address this.

Background

6. Mrs V fell at home and was found on the floor, leading to her being admitted to the Trust on 11 December 2022.

7. The Trust discussed possible discharge plans on 20 December. It documented Mrs R was concerned her mother would not cope. The Trust considered Mrs V ‘medically optimised’ on 28 December. It noted she was interested in getting help at home following her discharge.

8. An occupational therapist visited Mrs V’s home on 8 January. The Trust discharged Mrs V on 27 January. She was readmitted one day later, after she had a fall at home.

Findings

12. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone wrong.

Decision to discharge

13. We considered Annex D of the DHSC discharge guidance. This reflected that when any person is reviewed on a ward round, doctors should actively consider discharging them to a less acute setting. This should happen unless there is a clinical need or exception. This helps to ensure there is capacity to care for patients who need to be in hospital.

14. We looked at whether the Trust acted in line with that guidance. Mrs V’s records reflect the medical input she received. Our adviser explained Mrs V was stable but had ongoing symptoms she felt were an issue, like her shortness of breath. Although she had COVID-19 chest infection, this was not severe enough to require oxygen therapy.

15. The Trust considered Mrs V medically fit for discharge from 28 December but she did not want to go home. Our adviser explained being in hospital puts people at risk of infection so patients would be discharged at the earliest opportunity, in line with the DHSC guidance, unless there is a good reason not to do so.

16. Mrs V’s records show she was still mobilising independently with a Zimmer frame on 27 January, the day she was discharged, and had not had any falls during her admission. There are limited observations available in the records, but doctors have noted no concerns that required her to remain in hospital.

17. As Mrs V fulfilled all the criteria for discharge, as set out in the guidance, we have not identified any indication of a failing.

Communication about discharge

18. Social care is practical help for people with illness or disability, funded by local councils and users. People can arrange care and support privately themselves. If they want the council to arrange or pay towards their care, they have to ask it for a needs assessment. The assessment tells them what type of care will help them and how it will be delivered.

19. In Mrs V’s case, the Trust’s records refer to her awaiting a social package. Often staff will have limited notice on when the package of care a patient needs will be ready. We appreciate Mrs R may therefore have felt her mother was not as well-informed as she would have liked. This must have added to what was already a difficult time.

20. Mrs V’s records show psychiatrists did discuss the plans for discharge with her. Due to the potential distress it would have caused her, our adviser said they would not have had a daily discussion about where the plans were up to. Staff would not necessarily have had information to share and there is no indication the Trust withheld any information from Mrs V.

21. We recognise Mrs R feels the Trust did not communicate with her mother as it should have. We hope we have helped her understand why there is no indication of a failing here.

Soft diet

22. GMC ‘Good medical practice’ covers information sharing with colleagues. Point 44a says ‘You must contribute to the safe transfer of patients between healthcare providers and between health and social care providers. This means you must: a share all relevant information with colleagues involved in your patients’ care within and outside the team’.

23. During Mrs V’s first admission, the speech and language therapy team (SALT) did not make a strict recommendation that needed to be adhered to. This meant Mrs V was able to eat what she wanted. The team noted her dental situation meant a level 6 diet, of bite-sized food, would be easier for her to manage.

24. Mrs V appeared to be having a relatively unmodified diet during this admission. She had a fish dinner on 19 January, and pureed chicken stew on 21 January. She had carrots and chicken casserole on 23 January and cottage pie with vegetables on 25 January. She had a normal meal on the day the Trust discharged her, too.

25. There is no evidence of a SALT assessment when Mrs V was readmitted. She was noted to be ‘tolerating normal diet (soft option)’. Our adviser said it might have helped for the care home to have information about her bite-sized diet but there is no indication there was a clinical need, as such.

26. Based on the available information, we have not identified any indication of a failing in this part of the complaint either.

27. Overall, we have seen no reason to investigate the concerns Mrs R brought to us further. We would like to thank her for bringing the complaint to us and we hope we have reassured her about the care her mother received.

Our Decision

1. We have carefully considered Mrs R’s complaint about the Trust. We understand she was concerned about the care her mother, Mrs V, received and the Trust’s communication. We were very sorry to hear Mrs V later passed away.

2. We do not dispute how anxious Mrs R and her mother were and how stressful the situation must have been for them. As we will go on to explain, we have seen no indication that anything went seriously wrong. We hope the information in this statement will give Mrs R a better understanding of what happened and why.

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