A complaint over how an elderly woman was discharged from a Yorkshire hospital to a care home against her wishes has partly being upheld by the ombudsman.
The Ombudsman for Local Government and Social Care has published a report following an investigation into a complaint made by a woman referred to as Mrs D over the discharge of her mother – Mrs X – from hospital. Mrs D told the ombudsman that the way Calderdale and Huddersfield NHS Foundation Trust and Calderdale Council had managed Mrs X’s discharge had caused the family “significant distress.”
The ombudsman upheld Ms D’s complaints related to the Trust involving assessments of Mrs X’s capacity for decision-making and consent, as well as the failure of both organisations to communicate adequately about community nursing necessities.
In response to the upheld grievances, the Trust and council acknowledged the recommendations from the Ombudsman. While no personal resolution can be granted due to Mrs X’s death, the Ombudsman noted that Ms D too endured anguish and uncertainty resulting from these oversights.
To compensate for Ms D’s troubles, the Trust and the council were tasked by the Ombudsman to issue formal apologies for the recognized mistakes and their consequences for her. However, they clarified that the other parts of the complaint, which addressed the treatment and care Mrs X received while in hospital, were not substantiated.
The Ombudsman stated that an investigation would likely not uncover sufficient solid evidence of fault by the Trust or conclude that any fault by the Trust resulted in significant injustice to Mrs X. Regarding the substandard care in the care home to which she was discharged, they believed an investigation would unlikely contribute to the results of the council’s safeguarding enquiry and complaint investigation, particularly as the care home has since ceased operations.
Halifax Town Hall
Ms D lodged a complaint that her late mother, Mrs X’s, hospital discharge process was flawed, resulting in her being sent to a care home despite her preference to return to her own home, where she could be cared for by her family and care workers. The Ombudsman reported that Mrs X had a very negative experience in residential care and missed out on community nursing and physiotherapy after leaving the hospital.
While residing in the now-closed residential home, Mrs X received subpar care. A safeguarding investigation by Calderdale Council found that the care provider failed to meet Mrs X’s health, food, drink, and safety needs.
Mrs X returned to her own home and passed away a month later.
The Ombudsman ruled that the Trust’s failure to explicitly consider either assessing her ability to decide on her discharge destination or the possibility of delaying that decision until she no longer had delirium which she had at the time, and this was a key factor and was no longer on an impaired cognition plan of care was fault. The Trust should also then have clearly noted its decision and reasoning for it.
If the Trust decided not to assess Mrs X’s ability to decide on her discharge destination, it should have explained how it reached that decision despite Mrs X’s delirium and impaired cognition. If it decided to continue with an assessment, it should have carried one out in line with the Nursing and Midwifery Council’s Standards Code.
Failure to do any of the above was also fault.
There were also faults in the way the Trust failed to follow its own discharge policy, found the Ombudsman.
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