A report of investigations into unsafe discharge from hospital

Issue four: Patients being discharged with no home-care plan in place or being kept in hospital due to poor co-ordination across services

Our casework shows that poor service co-ordination and provision can not only affect people's health but also undermine their dignity and human rights. If people do not have a home-care plan in place, they can be left unable to eat or go to the toilet. Equally if suitable care home placements are not readily available, people can be stuck in hospital wards for weeks and even months at a time.

This experience is extremely distressing for anyone but especially for those with conditions such as dementia. People with such conditions may lack capacity and can be subject to restrictive care arrangements if they exhibit challenging behaviour while in hospital. Such arrangements can amount to a person being deprived of their liberty, which is why it is essential that they are authorised according to relevant legislation and guidance, specifically designed to provide legal protections for vulnerable people.

In our casework we found that division between different aspects of health care, such as acute and community health services can result in people being discharged without the support they need to cope at home. Equally lack of co-ordination and collaboration between health and social care services can result in lengthy delays in finding suitable care packages for older people with complex needs. This means they can be stuck in hospital wards at the expense of their dignity and independence.

Elderly man with dementia was locked on a psychiatric ward for over nine months

What happened

Mr A had vascular dementia and a personality disorder. After a series of incidents at his care home, he was admitted to a psychiatric ward where he remained as an inpatient for two years. Once Mr A was considered fit to be discharged from the psychiatric ward, discussions about discharge arrangements began between the hospital and the council.

The council decided that Mr A was 'beyond social care' and refused to fund a dementia care nursing home for him. Despite a series of discharge planning meetings between hospital and local authority staff, it was nine months before a suitable nursing home was found for Mr A.

During this time Mr A was stuck in the locked psychiatric ward without the hospital going through the necessary procedure to see whether this was a deprivation of liberty or not. One of his advocates said this made Mr A feel imprisoned.

What we found

A local authority cannot distance itself from its responsibilities because it considers a person's needs or behaviour to be too challenging or complex. Yet by refusing to find a care home for Mr A on the basis that he was beyond the help of social services, this is effectively what the local authority was trying to do.

Attempts by the hospital to try and engage senior managers at the local authority were unsuccessful. Without active input from the local authority it took the hospital longer to find an appropriate placement for Mr A and its job was made much harder as a result.

The delay in finding a care home for Mr A meant the hospital kept him locked on its psychiatric ward without carrying out necessary checks to see if this action meant he was being deprived of his liberty. If the hospital had gone through this process, it would have found that he was indeed being deprived of his liberty and the correct procedure for authorising such restrictive care arrangements would have taken place. That procedure includes a system for reviewing care plans and introducing less restrictive options, including supported access to the community.

Without this review, Mr A was left feeling 'like a prisoner' for over nine months, adding to the distress and anxiety he was experiencing.

93-year-old woman soiled her bed and then refused to eat or drink after being discharged without mobility support

What happened

Mrs E was a frail 93-year-old woman, with limited mobility and multiple medical problems. She lived at home but was dependent on the support of her family and a privately funded carer, who assisted with routine personal and household tasks.

District nurses referred Mrs E to the Trust's A&E because she had cellulitis (an infection of the skin and the tissues just below the skin surface) of the left leg and had become less mobile. The Trust discharged Mrs E six days later, arriving home at 9.30pm. The live-in carer and the ambulance crew helped her to bed. According to Mrs E's family she remained in bed, unable to get up until her daughter arrived back at the house at 11.30am the following morning. By this time she had soiled herself and was extremely distressed. She refused to eat or drink because she was unable to get to the toilet.

Mrs E complained about the Trust's management of her discharge. She said that the circumstances of her discharge and the immediate aftermath were extremely distressing for her and the traumatic experience contributed to an accelerated deterioration in her health.

According to Mrs E's family she remained in bed, unable to get up until her daughter arrived back at the house at 11.30am the following morning.'

What we found

There was an incomplete assessment of Mrs E's needs on discharge, including a failure to obtain relevant information from Mrs E's family and carer, as required by relevant guidance. There was also a lack of co-ordinated discharge both in terms of communication between staff within the hospital, district nurses and the intermediate care team, which provides clinical support to help people stay at home rather than be admitted to hospital.

This resulted in a lack of appropriate equipment being in place when Mrs E returned home. The Trust made the problems worse when it discharged Mrs E late in the evening.

The failings in the management of Mrs E's discharge caused her needless distress, anxiety and loss of dignity. However, it was not possible to prove that Mrs E's deterioration in health and admission to a nursing home were caused by failings in the discharge process.