Hospital failed to identify or act on woman's dementia needs while in hospital; social services failed to assess her mental capacity

Summary 890 |

Ms J complained that her grandmother who was in her nineties had poor care after she went into hospital with breathing difficulties. She also complained social services failed to give her grandmother the support she needed.


What happened

Mrs G, who was in her nineties, had lung disease and dementia. She lived with her son, and her other children gave her care and support. Mrs G had a package of care from the Council to help with her personal care.

Mrs G went into hospital with breathing difficulties. Clinicians found she had heart failure, problems relating to her lung disease, and had had a mild heart attack. The Trust discharged Mrs G into the care of her family, with a package of care arranged by the Council, after she had been in hospital for over a week.

Before Mrs G's discharge, her Family talked to the hospital and social services about whether they felt able to look after her at home. Social services said Mrs G needed a therapy assessment and possibly a placement in intermediate care (short–term care provided free of charge for people who need help to recover after being in hospital). But the next day Mrs G's daughter told hospital and social work staff the Family felt able to look after Mrs G at home.

Mrs G had to be readmitted to hospital a few weeks later because of a bloody swelling on her hand, where she had pulled a tube out in hospital.

Mrs G continued to receive a package of care from the Council, and went into respite care for three days a few months after she was discharged from hospital.

What we found

We investigated this complaint jointly with the Local Government Ombudsman because it concerned the actions of a local authority as well as an NHS provider.

The Trust failed to identify and take into account Mrs G's additional needs as a person with dementia, after she was admitted to hospital. This meant many aspects of her hospital care were not appropriately changed to meet the needs of a dementia patient. This resulted in distress to Mrs G and her family.

The Council failed to formally assess Mrs G's capacity to make decisions about her care. But it is unlikely that decisions about Mrs G's care arrangements would have been different if this had happened. The Council did not share a copy of its care review document until Mrs G's Family asked for it. But the Council properly assessed Mrs G's needs and provided a suitable care package to meet those needs.

Putting it right

The Trust wrote to Ms J to apologise for the faults we identified. It also produced an action plan confirming the action taken to address the faults in clinical care we found.

We asked the Council to apologise and to make sure that if there were concerns about a person's capacity, an assessment is made and recorded as part of the discharge planning process. We also asked the Council to make sure that scheduled reviews and care plans for those with dementia were promptly shared with a suitable representative.

Health or Parliamentary
Health
Organisations we investigated

Stockport NHS Foundation Trust

Location

Greater Manchester

Complainants' concerns ?

Not applicable

Result

Apology

Recommendation to learn lessons or draw up an action plan