12. Ms H complains the Trust did not promptly arrange the appropriate care her mother would need upon discharge and did not communicate properly with Ms H to ensure appropriate plans were put in place. Ms H believes this meant her mother deteriorated and died in hospital, rather being discharged to an appropriate setting.
13. Based on what is documented in Ms E’s clinical records, there is evidence the Trust started planning her discharge from the day after she was admitted. A discharge coordinator was allocated in line with the NICE guideline NG27, which says:
‘1.5 Discharge from hospital
Discharge coordinator
1.5.1 Make a single health or social care practitioner responsible for coordinating the person’s discharge from hospital…’
14. We have also seen from Ms E’s clinical records that there were a lot of discussions with Ms H in relation to discharge plans.
15. On 8 June there was a discussion with Ms H who explained her mother lived with her and had a private carer. Ms H said there was no need for any further support upon her mother’s discharge. There was a further discussion later that day when Ms H raised concerns and wanted her mother to be reviewed by the occupational therapy and physiotherapy teams. There was a discussion about the need for social care input and a query as to whether Ms E needed a short-term placement upon discharge.
16. On 9 June Ms E was reviewed by the occupational therapy and physiotherapy teams. It was noted Ms E was independent with transfers but unsteady on her feet, was at high risk of falls and had poor safety awareness.
17. On 10 June Ms E was reviewed, and it was considered she was medically optimised for discharge. This means there were no current urgent medical issues that required hospital treatment.
18. There was a further discussion with Ms H on 11 June. Ms H explained she was currently staying with her mother but lives on the mainland and was considering selling her house and moving. Ms H mentioned the possibility of her mother going into a care home as an interim plan. She suggested she would speak with her mother’s existing carers to see if they could provide any more support.
19. On 13 June there was a discussion between the Integrated Discharge Team (IDT) and Ms H. Ms H said she was able to continue to support her mother and was happy for her to be discharged with the current carer in place while waiting for a respite or short-term placement to be arranged. Ms H again said she would contact her mother’s carers to find out if they were able to provide more support.
20. Later that day Ms E deteriorated, with her blood glucose reaching high levels. Based on the advice from our geriatrician and nurse advisers, at this stage it was necessary to keep Ms E in hospital for treatment.
21. By 17 June Ms E was unwell, with acute kidney injury and aspiration pneumonia. Ms H was informed her mother was very poorly and may not survive. We recognise this must have been upsetting news for Ms H.
22. It is documented by the IDT on 23 June that there was some confusion around the discharge plan for Ms E. This led the IDT assessor to call Ms H and discuss the plan. However, Ms E was no longer medically optimised for discharge, so any discussions that were had at the time would have had no impact, as she could not have been discharged at that point.
23. We consider there is sufficient evidence in Ms E’s clinical records to show Ms H was appropriately involved in the discharge planning process. We acknowledge Ms H feels she was not offered appropriate help with arranging an increase to the care already in place.
24. It is evident there was some confusion around the plans for discharge. Ms H initially reported her mother did not need any further support on discharge. This conversation was appropriately revisited during the admission when it was noted Ms E’s mobility had deteriorated and the support that was already in place may not be sufficient. There was some confusion around the Trust’s referral for the short-term placement and why this was cancelled. The Trust has acknowledged the discharge options could have been better explained and apologised for this.
25. Ms H says some of the conversations have not been documented accurately. It is not possible for us to be certain what was discussed, and we have considered why Ms H feels the conversations have not been accurately recorded. However, the entries in the records are specific and detailed and have been reviewed by our advisers, who have not raised any concerns about evidence of inaccurate recording. The records will also have been completed at the time of the events, whereas recollections can change over time. For this reason, we have relied on what is documented in the records as the Trust’s understanding of what was discussed at that time.
26. Overall, we consider the evidence available to us shows communication was in line with the NICE guideline NG27, which says:
‘1.5.29 The hospital- and community-based multidisciplinary teams should recognise the value of carers and families as an important source of knowledge about the person's life and needs.
1.5.30 With the person's agreement, include the family's and carer’s views and wishes in discharge planning.
1.5.31 If the discharge plan involves support from family or carers, the hospital-based multidisciplinary team should take account of their: • willingness and ability to provide support • circumstances, needs and aspirations • relationship with the person • need for respite.’
27. Based on the advice from our geriatrician adviser, the discharge planning process was appropriate from a medical perspective. Our geriatrician adviser explained Ms E was frail, had had repeated falls at home, had been on several courses of antibiotics, and was considered at high risk of falls. Her existing care package together with Ms H’s support was no longer sufficient to meet her needs. From what is documented in the clinical records, the Trust believed Ms H was unsure about the best option to support her mother going forward. For these reasons, it was right to keep Ms E in hospital and continue discussions with Ms H until the appropriate support package could be agreed and put in place. The evidence in the clinical records supports that staff were being proactive with this.
28. We recognise the Trust has acknowledged there was some confusion around the referral and apologised for this. We note this confusion occurred in the context of a changing picture of Ms E’s clinical needs and ongoing discussions with Ms H about availability of carers. Our view is that this is not an indication that the Trust failed to act in line with its responsibilities as set out in the NICE guidance.
29. In addition, our geriatrician adviser explained it was appropriate for Ms E to be kept in hospital as she had delirium, and the Trust’s decision not to discharge her at that time meant she was kept in a place of safety. This was in line with the NICE clinical guideline 103 which says, ‘1.4.1 Ensure that people at risk of delirium are cared for by a team of healthcare professionals who are familiar to the person at risk. Avoid moving people within and between wards or rooms unless absolutely necessary.’ While this guidance relates to moves between wards or rooms, our geriatrician adviser confirmed the same principle applies to moving people to different care settings, as this can lead to a worsening of delirium.
30. Unfortunately, while discharge planning discussions were ongoing, Ms E deteriorated. There was a period during 10 to 13 June when Ms E was considered medically optimised for discharge. This does not mean a patient is ready to be discharged as it is necessary to ensure there is an appropriate discharge package in place, so the patient has the support they need. There is no guidance on how long this process should take as this is individual to the patient’s needs and is done in discussion with family. We appreciate Ms H feels this process took too long and her experience during this time was very stressful to her. We have seen sufficient evidence to support that appropriate discussions were taking place during this time. This included a plan for Ms H to contact her Mum’s carers to find out if they were able to provide more support.
31. With the above in mind, we have not seen anything to indicate the Trust failed to act in line with applicable guidelines in the planning and communication around Ms E’s discharge. This means that, based on all the evidence available, we do not uphold this complaint.