The people featured in this report all experienced care that falls well below established good practice and in some cases statutory requirements. We found that while some people suffered because of avoidable clinical errors, the majority suffered because they did not have the support they needed despite being deemed medically ready to go home.
Our casework on hospital discharge illustrates how failures in communication, assessment and service co-ordination are compromising patient safety and dignity, undermining patients' human rights and causing avoidable distress and anguish for their families and carers.
To summarise we highlight three key areas that warrant particular attention:
- Failures to check people's mental capacity and offer legal protections for those who lack capacity
Guidance on discharge planning is clear that people's consent to discharge arrangements must be obtained in line with the relevant legislation and guidance. Their mental capacity should (when in doubt) be assessed and recorded, and care arrangements that deprive people of their liberty should be identified and authorised according to the deprivation of liberty safeguards. These safeguards were designed to protect people's dignity and human rights; healthcare professionals should be expected to familiarise themselves with these safeguards as part of their professional duty. Therefore, it is deeply worrying that hospitals are not recognising when they are depriving people of their liberty.
- Carers and relatives not being treated as partners in discharge planning
Failures by hospitals to notify family members that relatives are being discharged are common features of these cases. Families and carers often play an important role in their loved one's recovery process. It is therefore, vital that hospitals treat them as partners throughout the discharge planning process and don't treat their involvement as an afterthought.
- Poor co-ordination within and between services
Poor co-ordination of the discharge process has led to delayed transfers of care, poor or absent care and emergency re-admissions. Our casework exhibits a lack of joint working at various points across the discharge process: within hospital teams, between acute and non-acute NHS services and between health and social care services. Integration has, of course, been a longstanding policy objective of all governments for many decades but this has proved difficult to put into practice. The new care models programme, at the centre of the NHS Five Year Forward View, offers a significant opportunity to break down historic barriers to the way care is provided in England. It is therefore, important that the government uses learning from the new care model pilots, and other recent integration initiatives, to improve people's transfer of care from hospital.
As the final tier in complaints process we on only see a fraction of the total number of complaints about NHS organisations. However, we know that complaints about discharge arrangements have increased recently, and that the cases we have identified are illustrative of problems highlighted by a number of recent reports by national health bodies and organisations representing vulnerable people.
In response to a clear consensus on the need for system wide leadership on this issue, the Department of Health has recently established a national programme to develop a vision for improving discharge.
This rightly brings together organisations across the NHS and local government, and provides an opportunity to develop a holistic approach to improving patient outcomes and experience of hospital discharge. In developing the vision, the Department of Health and its partners should assess the scale of the problems we have highlighted, identify why they are happening and take appropriate action so that all people experience acceptable standards of care on leaving hospital.