Discharge
16. DOH guidance says every person on every general ward should be reviewed to determine if they meet specific criteria to remain in hospital. If they do not, then active consideration for discharge to a less acute setting must be made.
17. RCOT guidance says occupational therapists should seek to act in the best interests of patients to ensure their optimum health, wellbeing and safety. They must use observations to gather information about the functional abilities of service users and analyse and critically evaluate the information they collect.
18. It says OTs should enable people to take the risks they choose and to achieve their chosen goals as safely as possible. With the individual’s agreement OTs should actively involve their carers and/or family, keeping them informed and included in decision making.
19. Looking at the DOH guidance we can see Mrs P met criteria to be considered for discharge. She had not had surgery and did not require IV treatment. Her functional impairment could be met in the community. She was not in the last hours of life and her National Early Warning Score (NEWS) was 0 when the Trust discharged her.
20. NEWS is a system where scores are given based on a patient’s breathing rate, oxygen saturation levels, blood pressure, pulse rate, level of consciousness and temperature. The score helps to identify the deteriorating patient.
21. Our physician adviser says from a medical perspective, there was nothing to indicate any concern in Mrs P being discharged from hospital. There is nothing to suggest Mrs P had acute functional impairment which could not be met in the community.
22. Considering this point further, we can see an occupational therapist (OT) first saw Mrs P on 5 December. At that time, they noted she would be discharged with a catheter in place and that she needed the use of a hoist to transfer into and out of bed.
23. They considered she would need a hospital bed and hoist at home. Mrs P was keen to go home as soon as possible and the OT planned to arrange the necessary equipment and package of care for her.
24. They identified she needed carers to visit her at home four times per day to assist her with activities of daily living. This is the maximum package of care available in a person’s own home. It includes:
• morning visit (to assist with getting out of bed / toileting / personal care, breakfast / medication) • lunch time visit (to provide lunch / toileting /change of position which may include transfer to bed / chair / medication) • tea time visit (to provide meal / toileting/ change of position which may include transfer to bed / chair / medication) • bedtime / evening visit (to provide drink / snack / toileting/ change of position which may include transfer to bed / chair/ medication)
25. Our OT adviser explained that to meet the guidance at paragraph 17, as well as consider Mrs P’s daytime needs, staff should have completed a ‘nighttime assessment’. This involves considering if Mrs P required any nursing intervention (such as to use the commode), after she had settled in bed for the evening.
26. We have seen no evidence in the records that staff completed such an assessment or considered Mrs P’s ability to manage at home overnight. This is not in line with the RCOT guidance, set out at paragraph 17.
27. On 7 December, a physiotherapist assessed Mrs P and identified that she did not require a hoist for transfers. They said she could instead use a rotunda (a device that allows carers to transfer people from sitting to standing and back to sitting, without manual handling).
28. The physiotherapist noted that nursing staff had reported Mrs P had not managed to sit out of bed for more than an hour. The physiotherapist raised a concern about Mrs P’s ability to manage at home between visits.
29. The following day staff continued to arrange equipment and carers for Mrs P’s discharge. There is nothing to suggest anyone considered the physiotherapist’s concerns about Mrs P’s ability to manage between visits. This was not in line with the RCOT guidance.
30. Mrs D says she also raised concerns with the OT about her mother’s ability to manage at home, particularly overnight, but they dismissed these.
31. We can see there were several conversations with Mrs P’s family about her discharge. This is in line with the guidance at paragraph 19.
32. We asked our OT adviser what should happen if a relative raised a concern about the safety of a patient on discharge. They said that this should be discussed with the family but staff would need to consider any comments alongside the patient’s wishes, if they have capacity.
33. Mrs D discussed her concerns with the OT on 7 December. The record says the OT notified Mrs D of the plan for delivery of equipment. It says Mrs D said she would arrange for the old bed to be moved. The OT agreed that due to Mrs P’s increased needs, the package of care would increase to carers coming in four times per day. (They had previously been coming in three times.)
34. The record of this conversation does not document Mrs D raising any concerns about her mother’s discharge home. Instead, the note appears to contradict Mrs D’s account as it suggests she agreed with the plan.
35. On the balance of probabilities, we prefer Mrs D’s account. She provided a clear account of what happened and we have no reason to doubt her recollection. Added to this is the fact we have already identified other concerns in the Trust’s assessment process which suggests it was not as robust as it should have been.
36. We have found there were gaps in the assessment process when considering Mrs P’s care needs and her ability to manage at home. The assessment was not in line with the RCOT guidance. This is a failing in the discharge process.
Impact of this failing
37. Mrs D told us that the morning after her mother’s discharge from hospital, the family visited her at home. They found she was ‘hanging out of bed’, was cold and lying in her own faeces. This must have been upsetting for them to see.
38. Our OT adviser explained that the nighttime assessment would be based on whether, during her admission, she had required interventions by staff overnight.
39. If an assessment had concluded she needed overnight intervention, then other options would have been considered. Our OT adviser explained four visits per day, with the last being the patient’s bedtime, is the maximum amount of care which can be offered at home (unless a patient has very severe needs and is then eligible for alternative funding). The alternative would be discharge to a care home.
40. The records show that during her admission, Mrs P generally did not need any overnight intervention. However, there were two occasions when she did, on 7 and 11 December. Therefore, it is not clear whether an assessment would have shown Mrs P was able to manage alone overnight.
41. If, following assessment, staff considered a care home was more suitable for Mrs P’s needs, it would need her consent.
42. Mrs D told us that before her mother’s admission, she had been considering moving to a care home as she felt she was struggling. We do not doubt this was a possible future option for Mrs P at that time. However, the records show during her admission Mrs P was very clear she wanted to go home as soon as possible.
43. This means we do not know, based on the evidence available to us, whether Mrs P would have agreed to go to a care home. It is possible she may have accepted the potential risks of going home.
44. Because the assessment was incomplete the potential risks to Mrs P had not been identified. She did not know whether those risks could be fully mitigated by the maximum care package. This means Mrs P did not have an opportunity to make a fully informed decision about her discharge.
45. Knowing that her mother’s safety and care needs were not fully considered has caused upset to Mrs D.
46. We have set out the recommendations to put this right at the end of our report.
Capacity
47. NICE quality standards say the starting assumption must always be that the person has capacity. Capacity must not be determined based on age, appearance, condition or an aspect of the person’s behaviour. It is decision specific. Someone may have capacity to make one decision but not another. Everything practicable should be done to support the person to have capacity to decide.
48. We can see that when Mrs P declined to have surgery to fix her fracture, this decision was against medical advice. Due to the serious risks of not having surgery, doctors completed an assessment of Mrs P’s mental capacity.
49. Our physician adviser says if someone is acting against medical advice, a mental capacity assessment is sensible, even if the person does not appear confused.
50. The assessment found Mrs P had capacity to make decisions. At the same time, Mrs P indicated she wanted to go home. She made this clear to staff several times during her admission. Although she was keen to go home, Mrs P agreed to work with physiotherapy and would go home once doctors considered it safe.
51. Although we have found a failing in the discharge assessment (as set out earlier in our report), doctors considered Mrs P was medically fit for discharge and the proposal from OT staff was that Mrs P could be discharged home with transfer aids and a package of care. This means her decision to go home was in line with the advice of hospital staff.
52. Prior to Mrs P’s admission to hospital in November 2022, her mother had been assessed by the Memory Assessment and Support Service from another NHS Trust. Following this and brain scans, they diagnosed her with dementia.
53. Mrs D says she told Trust staff about this diagnosis, although this is not documented in the medical records. We know staff did not have access to the assessment report, as it was not completed until January 2023.
54. In any event a diagnosis of dementia would not on its own be reason to doubt a person’s capacity, as set out at paragraph 47. Mrs D highlights that the assessment notes her mother’s dementia ability score indicated a severe decline in functioning.
55. In looking at the dementia diagnosis, we can see that it sets out there has been a severe decline in cognitive function over the previous year. The assessment indicated Mrs P needed support to manage her finances and with activities of daily living, but it does not suggest her cognitive function was so severe she could not participate and contribute to the assessment.
56. We have seen evidence in the records from several Trust staff that Mrs P was alert and orientated during her admission, and with assistance, she was able to communicate with them. She was able to clearly articulate that she wanted to go home and that she wanted to be with her family. Staff were taking steps to facilitate her return home (although we have found failings in relation to this above).
57. We have seen no indication it was necessary to complete a further assessment of Mrs P’s capacity in relation to her discharge from hospital. We have therefore not found a failing here.