East Lancashire Hospitals NHS Trust

3. Mrs T complains about the care East Lancashire Hospitals NHS Trust (the Trust) provided her mother, Mrs R. She specifically complains the Trust failed to discuss who could have provided her mother’s rehabilitation on 20 December 2023.

4. Mrs T says this led to her mother being transferred to a rehabilitation hospital, where she developed pneumonia. She says this led to her death. She says if the options were discussed, she would have cared for her mother at home. The impact on Mrs T was grief and anxiety.

5. She is seeking service improvements regarding communication and discharge options.

6. This very brief background is only intended to place the key events in context, not provide a full account of everything that happened.

7. Mrs R (aged 92) was admitted to the Trust in November 2023 after a fall. She had a fractured hip and had surgery. Over the following two weeks she had physiotherapy and improved. On 20 December she was deemed medically fit for discharge.

8. She was seen by an occupational therapist (OT) who decided she would benefit from support in place at home. This was arranged with local social services.

9. There was a change in plan, and Mrs R was instead sent to the local rehab hospital. At this hospital, Mrs R became unwell with pneumonia and sadly died a month later.

13. Mrs T told us the Trust called her explaining it was discharging her mother with social services support. Staff then told her the plan had changed, and she was going to the rehabilitation hospital.

14. The Trust said in its complaint response the reason for the change was due to a delay in social services being able to carry out an assessment.

15. Mrs T feels if the Trust had spoken to her, she would have taken her mother home and cared for her herself.

16. Mrs R’s records show the OT saw her on 20 December, and they discussed the plan to go home with social services support with her and Mrs T. The change in plan was not documented, so it is unclear who made this decision and why.

17. We considered whether it would have been appropriate to send Mrs R home with her daughter without social services support. Our OT adviser explained further detailed assessments would have been required. As these did not take place, it is not possible for us to determine if it would have been safe for Mrs R to go home without a care package.

18. RCOT guidance says that with patient’s consent, carers and relatives should be actively involved with patient care and kept informed and included in decision making. It also says communication should be documented.

19. It is not clear who made the decision, but our adviser explained this responsibility applies to the wider team managing discharges from hospital.

20. Taking into account the above, we consider there was poor communication and documentation from the Trust regarding the change in plan for Mrs R. We cannot say that it would have been appropriate to discharge her without a care package. We can say this led to uncertainty for Mrs T about whether the outcome would have been different if a conversation had taken place.

21. As an outcome for her complaint, Mrs T is seeking service improvements, regarding communication and discharge options.

22. Our service model guidance sets out how we consider cases. It says, at 3.59: ‘Resolution means delivering an answer or outcome for a complainant that resolves the complaint they have brought to us.’

23. We asked the Trust to consider providing service improvements. It has agreed to arrange a meeting between Mrs T and the key leads for the service, who are implementing service improvements. It said it would like to discuss her desired outcomes to resolve the complaint.

24. It confirmed it would arrange this directly with Mrs T and will record the meeting. Following this, it will write to her with the agreed outcomes.

25. We discussed this with Mrs T, and she agreed this would be a satisfactory resolution to her complaint.

26. We thank Mrs T for bringing her complaint to us. She told us how difficult this process has been, and we appreciate her patience while we carried out our assessment. We hope the agreed resolution allows her the opportunity to feel heard and involved in service improvements.

1. We have carefully considered Mrs T’s complaint about East Lancashire Hospitals NHS Trust (the Trust). We were sorry to hear of her experiences and extend our sincere condolences on the loss of her mother.

2. We have sought clinical advice, and undertaken conversations with the Trust. The Trust has agreed to take steps to put right the impact on Mrs T. We consider the Trust’s actions will resolve Mrs T’s complaint.