Date of decision: 30 June 2025
Summary
The complaint highlighted that Wiltshire Council and NHS services between them provided inadequate communication on hospital discharge for an older adult. Absence of clear information denied the family the ability to make informed choices, resulting in avoidable distress and financial loss.
What happened
In March 2024, the Council, Wiltshire Health and Care, and the NHS Integrated Care Board co-ordinated hospital discharge for an older man with dementia and delirium. His son, who held a lasting power of attorney [albeit unspecified as to type by the report], was told that care would be funded for 4-6 weeks post-discharge, with a social care assessment promised within two weeks. The man went home with a package of personal assistance.
Care funding ended abruptly after two weeks, without notice. The health funding ended and Mr Y funded his own care after this because his savings were above the threshold.
The Council completed an assessment of Mr Y’s needs in July 2024.
Mr Y moved to a care home shortly after.
It appeared that the relevant Council and ICB had a discharge to assess policy which treated patients who are fit enough to return home as entitled to a package of support at home or intermediate care, and that in the case of people with delirium, the ICB was prepared to cover the cost for up to two weeks.
- Patients are entitled to return home on a Home First pathway. This provides patients with support at home or intermediate care (short-term support to help recovery and increase independence). Wherever possible, patients should be supported to return to their home for assessment. WHC coordinate the hospital discharge along with input from the hospital staff and the Council.
- For patients with a delirium (a change in mental abilities resulting in confusion and a lack of awareness of surroundings), extra care is needed. Based on national outcomes, within two weeks the patient should show health improvements once they are home and in familiar surroundings. In these cases, the ICB will fund up to two weeks care to allow the delirium to settle. However, if the patient does not improve, the discharge Multidisciplinary Team (MDT) will agree a social care assessment and Adult Social Care should then liaise with the family about meeting future care needs.
It must have been that nobody told the family about this approach.
What was found
The Ombudsman found fault by the Council and Wiltshire Health and Care [we think that this was probably a Local Authority Trading Company for delivering reablement or other hospital discharge services] over serious communication failures about discharge planning, funding duration, and care choices, breaching Care Act duties.
The records showed that Mr X was told the care would be free for up to 28 days and continuation of care would be subject to financial assessment.
The records showed the news that the health funding was ending was phoned through to Mr X, along with the expectation that Mr Y would pay for his own care given his savings were above the threshold. Mr X questioned the funding because he had understood it would last longer.
The ICB was also clear in its communication to the Council that it should assess Mr Y’s needs and consider his options for future care. The Council did not seem to have been aware that that was the case.
The MDT meeting notes also said that “family are happy to take over funding and self-fund” when the health funding ended. But Mr X was not part of these discussions or email exchanges. The Council did not appear to have ever clarified the funding arrangements or that these differed from their previous conversation.
The family was excluded from MDT discussions, contrary to guidance and best practice. Faults caused unnecessary distress, loss of opportunity to make timely care decisions, and unjust financial expense.
The Ombudsman directed the Council and Wiltshire Health and Care to send apologies, pay £500 for uncertainty and distress, and implement process improvements to clarify responsibilities in discharge arrangements.
Points to note for councils, professionals, people using services and their carers, advocacy groups and members of the public
This is another report that shows the chaos that can arise under Discharge to Assess Directions to health and social care.
The Council told the Ombudsman it considered the ICB was responsible for explaining the discharge plan, including the funding arrangements, to Mr X. The ICB told the Ombudsman it would be the hospital discharge team (WHC). WHC explained that as the social worker already knew Mr Y, in this case the Council took this role on. But there was nothing to show that the Council knew that this was being assumed.
The Council apparently agreed that it would have been helpful to provide written information about the relevant discharge pathway!
The Care Act 2014 places a clear duty on councils to assess any adult who appears to need care or support, regardless of their financial means or eligibility, and to involve them and their representatives from the outset. The law requires prompt, transparent communication about assessment processes, care options, and financial responsibilities, especially where decisions are being made during a period of transition such as hospital discharge, because it is possible that some sorts of short term needs will be met by the NHS, and also that some longer term needs can be regarded as covered by Continuing NHS Health Care.
Social care assessments must be carried out over reasonable timescales and keep the individual and their carers informed throughout, with the authority providing written and accessible information and advice under section 4 of the Act.
In the circumstances described, omission and delay in assessing needs and providing information amounted to a real risk of breach of statutory duty, contrary to the mandatory principles set out in section 9 and section 4 of the Care Act. This would have been because of Discharge to Assess Guidance having been implemented locally in the area without anyone mapping how it aligns with the Care Act, we suspect.
Where councils fail to provide adequate information or carry out timely assessments, individuals and families may experience significant harm – including financial loss and avoidable distress – which can amount to unlawful conduct under established community care law.
The social worker recorded that he or she had discussed with Mr X that funding was for two weeks but the LGSCO said that the records did not support that stance, and previous records of conversations between Mr X and the Council had said funding was for 28 days.
Professionals should ensure families are included in all decisions and MDT meetings concerning care arrangements. Effective protocols are essential to clarify responsibilities for providing information and completing assessments when roles cross and overlap as between health and social care bodies. As Mr X was not involved in discussions and the outcome was not shared with him, this may have contributed to ongoing confusion about the funding. The Council confirmed that since Mr X made his complaint, along with health organisations, a process is now in place to ensure families are involved in such discussions.
Of course this should have happened much, much sooner, since Discharge to Assess has been national policy for several years now! As a footnote the report mentions that WHC no longer provides hospital discharge services so that may connote yet another integration experiment that has been seen to have failed. However, the ICB had agreed to support the Council and local health services with making improvements about discharge planning, specifically putting a process in place to clarify who has responsibility for sharing information relevant to a patient’s hospital discharge and funding arrangements, and record where there is a variance to standard practice.
Please use the following link if you want to read the original Local Government and Social Care Ombudsman’s Wiltshire Council (24 005 840) report.
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