Failings found with Lancashire Council, East Lancashire NHS Trust and Victoria Care Home around a mishandled hospital discharge, ignoring the family in care planning, overlooking the need for an appropriate interpreter for assessments and then inadequate continence care, poor record keeping and poor communication by the Care Home

Decision Date:   02 December 2022

What happened
Following a fall in December 2019, prior to COVID-19, Mrs Z was admitted to hospital and diagnosed with an acute stroke and fractured arm. The hospital’s Integrated Discharge Team recommended a short-term residential care placement, so Mrs Z’s long-term care needs could be assessed. Mr X, Mrs Z’s son, initially wanted Mrs Z discharged home; however he agreed to a temporary placement to enable her long term needs to be assessed.

Mrs Z’s initial care needs assessment was completed in hospital by the Social Worker on 27th January 2020 with referrals being sent to Occupational Therapy, Physiotherapy, Speech and Language Therapy, the Community Stroke Team and Dieticians for their involvement – [an example of a more integrated assessment overall, one would hope].

Discharge to the Care Home took place on 7th February 2020, but Mrs Z’s wheelchair was not transferred with her.

A physiotherapy assessment was planned for 14th February 2020 at the Care Home and attended by the Community Stroke Team, Mrs Z’s Social Worker and an Urdu speaking Social Worker, to act as an interpreter. However Mrs Z only spoke Punjabi and was reluctant to engage with the exercises, therefore the full assessment could not be completed.

Two weeks later, on 28th February 2020, another physiotherapy assessment was arranged with the Community Stroke Team and Occupational Therapist (OT), it was noted that the OT spoke “some Urdu” and again therefore no interpreter was present. The assessment was completed using non-verbal cues.

The Care Home raised concerns in respect of Mrs Z’s preference for sleeping in her chair as she often refused to go to her room and sleep in her bed, becoming distressed. Mrs Z’s ability to transfer would fluctuate and she often required two carers to assist her. Mrs Z also had swelling in her legs and was advised to sleep with her legs raised.

Following a multidisciplinary meeting on 10th March 2020, it was agreed Mrs Z could be discharged with a package of care to Mr X’s home scheduled for 13th April 2020.

Mrs Z had a fall in the Care Home 3 days later. She was found on the floor in the lounge and had suffered a head injury. The home checked her for injuries and contacted a medical advice service. Staff were advised by a GP to monitor Mrs Z for concussion and give pain relief. Mr X was not contacted.

Mr X visited the next day, noticed the bruises on Mrs Z’s face and raised his concerns with the manager as to why he was not contacted; he said he felt she needed to go to hospital for an x-ray. The Care Home called the medical advice service again and were advised to monitor and provide pain relief. Mr X then contacted his local GP practice as he was unhappy with the Care Home’s response. A Senior Nurse from the GP practice visited Mrs Z and advised there was no clinical need for Mrs Z to go to hospital. Mr X then raised a safeguarding concern with the Council.

The Council concluded its safeguarding enquiry on 1st April 2020 and found the Care Home had not adhered to its falls procedure, but this did not significantly impact Mrs Z, as the home sought appropriate medical advice and acted accordingly. However, the home had not contacted Mrs Z’s family about the incident so the Council reminded the Care Home to follow local policies and procedures and “emphasised the importance of good communication.”

Mrs Z was discharged on 13th April to Mr X’s home with a care package in place. Mr X then complained to the Ombudsman for a multitude of failings in respect of:

Discharge: Mr X complained that he was not involved in choosing the discharge location for Mrs Z first time round; that the wheelchair was not transferred with her upon discharge to the home; that her assessments were delayed, and that there was a lack of support for getting Mrs Z home.

The Care Home: Mr X complained that the Home had failed to provide adequate personal care to Mrs Z, with meeting her continence needs, failed to supervise Mrs Z properly, leading to falls, failed effectively communicate to with family members, failed to notify the family of falls (the Care Home had falsely claimed they had contacted family members), failed to manage and make adjustments to Mrs Z’s food, fluid and medication correctly, failed to seek appropriate medical advice following falls, and failed to manage Mrs Z’s swollen legs appropriately.

Physiotherapy Assessments & Safeguarding: Mr X also complained there was a delay with physiotherapy sessions starting; Mrs Z did not have an appropriate interpreter present for the physiotherapy assessments which contributed to the delay; and he was unhappy with how the council handled the safeguarding concerns raised.

What was found

In respect of East Lancashire Hospitals NHS Trust not transferring the wheelchair with Mrs Z upon discharge, the Trust were found at fault. The Trust had already apologised for the delay which was caused by a communication error and corrected the oversight.

In respect of Mr X not being involved in the discharge process, the Ombudsman could not find any evidence that Mr X had been consulted in respect of the placement until after the decision had been made. This represented fault for both the Council and the Trust as “this was not in keeping with the principles of the Discharge to Assess model.”

In respect of the Council’s delaying Mrs Z’s care needs assessment, the Ombudsman’s report states that there was evidence the Council was actively working on the care assessment throughout Mrs Z’s stay in the Care Home. These assessments were not shared with Mr X. No fault was found for causing undue delay in respect of the care needs assessments but the lack of involvement and communication with Mr X did constitute fault.

The Care Home
The Care Home were unable to provide the Ombudsman with Mrs Z’s full daily records. The home advised that it was possible the missing records were part of records that were destroyed when the home experienced a flood. The Ombudsman noted that whilst unpredictable events do happen, as the Home was unable to confirm what had happened to the records, this was fault.

In respect of the Home not appropriately supervising Mrs Z which Mr X believed led to her having at least two falls, the Ombudsman checked the records provided and noted Mrs Z was regularly checked. The Care Home reviewed Mrs Z’s risk of falls three times, identified her as high risk and put appropriate measures in place. The Ombudsman therefore found no fault on that count.

In respect of the Care Home not taking appropriate steps to find alternative sleeping arrangements for Mrs Z, the Physiotherapist advised against a recliner with the alternative solution being to use a footstool. The Ombudsman did not find fault with this decision as records noted staff would actively try to encourage Mrs Z to sit in her room and found a balance between supporting Mrs Z and not causing her excessive distress.

In respect of the Care Home not managing Mrs Z’s oedema correctly, a Senior Nurse visited and advised that Mrs Z’s legs should be raised; she was later prescribed a course of water tablets. Following the Nurse’s visit, care notes referenced Mrs Z’s legs being raised and her oedema improving. The Ombudsman found no fault.

In respect of the Care Home not managing Mrs Z’s nutritional and fluid intake needs, the Care Home had a detailed plan, including input from the Speech and Language Therapist. The Ombudsman therefore found no fault there.

In respect of the Care Home mis-managing Mrs Z’s medication, the Ombudsman could not find any evidence from the Care Home or the speech and language assessment that indicated Mrs Z’s medication needed to be crushed and so could not find the Care Home at fault with this.

In respect of how the Care Home handled Mrs Z’s fractured arm, the Care Home was clearly aware of Mrs Z’s fractured arm. References to the fracture were mentioned in the hospital discharge documents, care plan and mobility plan. There were also detailed notes from management. The Ombudsman concluded there was no fault: staff were aware of the fracture and mindful of this when carrying out their duties.

In respect of the Care Home providing poor pressure management care to Mrs Z, the Care Home did not always move Mrs Z from her wheelchair soon enough and did not provide her with a pressure cushion as acknowledged in their complaint response. The Ombudsman found the home at fault for this.

In respect of the Care Home providing inadequate continence care, Mrs Z was discharged to the home with a catheter in situ, and once the catheter was removed, appropriate steps should have been put in place to manage Mrs Z’s incontinence. There were four recorded visits by the Community Stroke Team, three of which found Mrs Z wet. The Stroke Team notes stated that they were concerned, had raised concerns with the Care Home, and the Care Home would be conducting a continence assessment and liaising with the District Nurses. The Ombudsman could not find any evidence that the Care Home discussed Mrs Z’s continence needs with the Nurses and so they were found at fault. This is not in keeping with the Care Quality Commission Guidance Regulations: Dignity and respect – paragraph 10.1 or Paragraph 13.4(c)

In respect of the Care Home providing poor medical attention following Mrs Z’s fall on the 13th March 2020, it was noted the Care Home contacted the 24hr GP service twice, but the safeguarding raised by Mr X to the Council found the home failed to follow its own falls policy and procedures as the Care Home did not contact family members and certain documentation had not been completed. The Ombudsman agreed with the Council’s findings and agreed this was fault on the part of the Care Home.

In respect of poor communication, the Ombudsman reviewed the records available and noted that there was limited evidence to suggest the home proactively communicated with Mr X, which was fault.

In respect of the delay to the physiotherapy sessions starting, the Community Stroke Team received a referral for Mrs Z and undertook their assessment four days later which was in keeping with its five working day timescale. However, it was noted that Mrs Z only spoke Punjabi, yet an Urdu speaking Social Worker was in attendance and therefore unable to fully complete the assessment. The second assessment, scheduled 14 days later, was completed using non-verbal cues with the OT, who “spoke some Urdu”. The Ombudsman noted that Mrs Z suffered with cognitive difficulties which impacted on her communication, and therefore it was vital she had clear communication, especially during an assessment. The failure to provide a Punjabi speaking interpreter for both assessments was fault: the Trust did not provide care and support process in line with NHS or Care and Support Statutory Guidance.

In respect of the safeguarding enquiry, the Ombudsman did not find fault with the way the Council completed its enquiry: the staff considered the concerns and put forward their recommendations in a proportionate way.

Concluding the Ombudsman’s enquiry, it was found that the Trust and Council failed adequately to involve Mr X in the discharge process, failed to provide an appropriate interpreter for the Occupational Therapist and Physiotherapy Assessments. The Care Home failed in respect of Mrs Z’s continence care, record keeping and in communication with Mr X.

The Trust and Council apologised to Mr X and Mrs Z, paid Mr X £250 for causing distress and uncertainty and paid Mrs Z £200 for failings in her continence care.

The Council and Trust also had to review their policies and procedures in respect of providing people with interpreters, integrated discharge and the importance of involving carers and relatives.

The Council also needed to review the Care Home to ensure its archiving methods minimised the risk of missing records, review the continence care policy, and ensure that the Care Home had clear guidance for staff communication with families.

Points to note for councils, professionals, people using services and their carers, advocacy groups, members of the public

Paragraph 3.30 states that some groups in need of information and advice about care and support may have particular requirements. Local authorities must ensure that their information and advice service has due regard to the needs of these people. These include, but are not limited to, “people who do not have English as their first language.”

Principle 4(9) states that professionals and primary care staff may use their language and communication skills to assist patients in making appointment or identifying communication requirements, (language brokering) but should not, other than where immediate and necessary treatment is required, take on the role of an interpreter unless this is part of their defined job role and they are qualified to do so.      There is a reference in the guidance to “immediate and necessary treatment” justifying non-use of a registered interpreter, but this would not have been the situation here for a planned assessment date. 

Principle 2(2) states that although not being able to speak English is not a “protected characteristic” defined in the Equality Act 2010, section 13G of the National Health Service Act 2006 states that NHS England “in the exercise of its functions, must have regard to the need to reduce inequalities between patients with respect to: their ability to access health service; and the outcome achieved for them by the provision of health services.” 

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The full Local Government Ombudsman report on the actions of Lancashire County Council can be found here:

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