Date of decision: 01 July 2025
Summary
A poorly planned discharge of a vulnerable adult from hospital into an unsuitable care home, involving poor communication and co-ordination by the Council and NHS Trust with a focus on poor updating of the plan as things moved on.
What happened
In February 2023, an adult patient was admitted to hospital after a fall and head injury. Hospital staff determined he could not safely return home, and a referral for a care home placement was made in March 2023. His discharge was delayed due to a positive Covid-19 test, with another referral completed after his isolation ended in April 2023. A ‘Discharge to Assess’ bed was unavailable immediately, resulting in a continued hospital stay until early May, when the person moved to a residential care home.
The hospital continued with clinical observations during the period when discharge was delayed. The Care Home completed a pre-admission assessment a few days before the man moved. This included discussion with clinical staff and up-to-date information about the man’s health and needs. The hospital prescribed anticipatory end-of-life medication, but he did not need this medication at the point he left hospital. His condition was stable, and he was aiming to improve his ability with rehabilitation. He had some pressure sores, but these were being managed with a pressure relieving mattress and regular turning. There was no medical sign at this point that he needed medical care.
However, the hospital records from the day the man left hospital noted that a pressure sore to his sacrum had worsened. In response to the Ombudsman’s enquiries, the Trust said it had reviewed the man’s records and noted he had a ‘significant pressure sore’ on the day of discharge. It accepted this could potentially mean a nursing care placement would have been suitable. The Care Home assessment had noted the man’s pressure sores were ‘superficial’ (skin not broken) and was happy it could manage his pressure sores.
When he moved to a D2A bed within the Care Home, his health declined rapidly, and he died within days. The family alleged the Council and NHS Trust failed to update discharge information after delays and changes in needs, resulting in an inappropriate care home placement.
The Council responded to the complaint with delay and failed to co-ordinate with the NHS Trust, referring the family instead of handling the complaint jointly.
When the daughter complained to the Ombudsman, she said that the residential care home was inappropriate and could not meet his needs. She considered that he should have been moved to a Nursing Home.
What was found
The Trust failed to update and clarify the patient’s discharge criteria on the day of transfer, breaching its statutory duties under discharge policies.
This failure could have affected the suitability of the placement, potentially requiring nursing care, but records showed no clear evidence that a different outcome would have resulted. The records did not show that there were any issues with pressure care or that the Care Home did not adequately manage the man’s pressure sores. The Ombudsman could not therefore say the outcome would have been different, but accepted that this did leave some uncertainty. Clinical staff anticipated that the man’s health would deteriorate at some point, but did not necessarily expect it would have been so soon after he left hospital. This did not mean that the Care Home was unsuitable or could not meet the man’s needs, and was also not linked to the potential reason nursing care could have been considered on the day the man left hospital. The Trust told the Ombudsman that it had introduced a new procedure, whereby patients who have waited longer than seven days for a discharge destination are reviewed regularly by multiple members of the discharge specialist nurse team. This should help identify any changes and ensure the discharge destination is still appropriate where there have been changes to a patient’s health or needs.
The Council delayed and failed to comply with statutory complaints handling requirements, omitting collaboration with the Trust and proper signposting to the Ombudsman. The daughter said that the failure to deal with her complaint effectively added to her overall distress and frustration. The Council acknowledged that best practice would have been to collaborate with the Trust rather than telling the daughter to make a separate complaint. The complaint was only received by LGSCO following a referral from the PHSO. (The Trust had provided appropriate signposting to the Ombudsman for the health part of the complaint.) This meant the complaint potentially took longer to be considered. Both organisations agreed to apologise and take remedial action to prevent recurrence. No financial compensation was specified; apologies and procedural improvements were required.
Points to note for councils, professionals, people using services and their carers, advocacy groups and members of the public
The Ombudsman found fault in the Council’s failure to follow the regulations or its own policy in not considering the complaint jointly with the Trust, and in failing to signpost the daughter to the Ombudsman.
The Trust accepted there was fault by not clarifying the situation with the man’s pressure areas on the day he left hospital. This could have changed the discharge destination if his pressure areas were so bad that nursing care was indicated. However, the Care Home’s assessment had noted that the pressure sores were ‘superficial’ and they were happy they could manage his pressure sores. We note the use of the term ‘superficial’ appears to differ significantly from the hospital’s description of the pressure sore as ‘significant’. It is not clear whether the home’s pre-admission assessment was several days before the actual admission or whether its confidence was renewed on the actual date of admission – it seems the former.
The report refers to the Trust’s internal policies, but does not refer to the Government’s Hospital Discharge and Community Support Guidance. This sets out that where a patient is likely to need an interim package of care on leaving hospital, the relevant care transfer team should ensure that a multi-disciplinary team assess the appropriate discharge pathway. The assessment should be dynamic and subject to revision. Post-discharge needs should be discussed with patients and their families. The requirement to involve patients and their carers is set out in s74 of the Care Act. It appears from the report that the guidance may not have been followed in this case.
The Ombudsman’s report did not directly refer to the central duties under section 9 (assessment of needs), section 13 (eligibility criteria), and section 1 (wellbeing principle) of the Care Act, or elaborate on what the investigator meant when saying that hospital staff determined that the man could not go home: that is not a decision for hospital staff; it’s a care planning thought process under the Care Act, and one of professional judgment.
A decision that a person is medically optimised is obviously one for clinical staff; a decision that a person needs interim funding by the NHS is a perfectly possible feasible outcome of this scenario, but it would make the ICB / Hospital Trust responsible for the first placement.
A joint funded integration discharge approach might determine that someone should be in a residential care home for reablement or stabilisation – but that would still mean that one organisation or the other – or both – was responsible for that decision and the parallel decision that it should be free for some time. CHC checklisting used to make it clear which organisation should pay, but that is evaporating, in terms of practice, now.
But even though this man was terminally ill and was given anticipatory drugs for end of life care, there is no reference to a Checklist, no consideration of Fast Tracking him for CHC, or any further interim solelyNHS responsibility; and no discussion of who funded the placement at all – in this report, which we think only obscures and compounds the wrongdoing, even though it was not about charging, for the period of poor care, at all.
IF what is being planned is a chargeable Care Act placement (say a temporary or a short term albeit non reablement driven stay – or a permanent long-term care package), it is imperative that councils maintain live, continuously updated assessments for individuals where needs are changing during inpatient stays, particularly following events such as a lengthy delay in hospital or a deterioration in physical health.
Care Act guidance also requires joint working between councils and NHS bodies to provide seamless transition and avoid gaps in care or responsibility—for example, failure to collaborate over complaints handling as noted here. Councils must have robust protocols and practical systems to ensure information is shared, particularly after periods of clinical deterioration. Where local authorities refer families between agencies instead of acting jointly, missed opportunities can arise for timely remedy and accountability.
The broader implication is the need for ongoing training in Care Act duties, scrutiny of discharge practices, and continual review of complaint-handling processes to prevent recurrence of similar failings, in an era where the AIMS of integration and co-operation are still falling down because of lack of joint training and legal literacy as between health and social services organisations.
Please use the following link if you want to read the original Local Government and Social Care Ombudsman’s Leicestershire County Council (24 001 324) report.
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