Trust failed to give a joint response to a complaint that involved health and social care

What happened

In autumn 2011 Mr D went to A&E after a fall at home. Staff noted Mr D had difficulty swallowing when they tried to give him food and drink. They referred him to the speech and language therapy service.

Mr D was malnourished so staff started to give him intravenous fluids because he either refused drinks or had difficulty swallowing. Mr D was often non‑communicative and did not co‑operate with staff, which was part of his condition. Although the Trust recommended high‑calorie liquid feeds and high‑energy supplements, Mr D only ate intermittently throughout his stay in hospital.

The next month, the Trust decided that Mr D was medically fit for discharge. Trust staff, social workers, Mr D's representatives, and the manager of the home where Mr D had lived, held a case conference to discuss discharge arrangements. The Trust agreed that Mr D would return to his supported accommodation and that social services would carry out a care package assessment. A discharge liaison nurse would carry out an urgent assessment for nursing home placement if Mr D's condition did not improve after discharge.

Because of disagreements about Mr D's discharge destination, he stayed in hospital for some weeks. The Trust then decided he was medically fit for discharge but his condition was slowly deteriorating because he refused intravenous fluids and would not drink. Staff thought that Mr D's failing condition was made worse by the unfamiliar hospital environment.

Mr D's blood sugar levels fell. He also had pneumonia and was dehydrated, and eventually his blood oxygen levels fell to a dangerously low level. His blood pressure also dropped. Mr D's condition continued to deteriorate and he died soon after.

What we found

The appropriate staff were involved in Mr D's care and were aware of the difficulties he had eating and drinking. Mr D had severe Huntington's disease and was very malnourished on admission. Although they gave appropriate care, staff were unable to make sure that Mr D had enough food and fluids, and they could not stop his condition declining.

There were disagreements about the most appropriate place of discharge for Mr D but there were no faults or omissions in the discharge planning process.

There was fault in the Trust's complaint handling. Mr R was concerned about the involvement of social services as well as the Trust. The Trust told Mr R several times that he needed to fill in a form for it to work with social services. When the Trust eventually sent out what it thought was the appropriate form, members of the team dealing with Mr R's concerns had moved on. The way the Trust dealt with Mr R's complaint meant that he did not receive a co‑ordinated response from the Trust and the local authority. The Trust had earlier assured him that the organisations could give a joint response.

We partly upheld the complaint.

Putting it right

Although we found no fault in the care and treatment the Trust gave Mr D, its complaint handling was flawed. Mr R became frustrated with the complaints procedure and did not get the joint response he expected when he first raised his concerns.

The Trust apologised to Mr R for the way it had handled his complaint and explained what lessons it had learnt. It also paid him £250 compensation.