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Health services failing to prevent unsafe discharge of elderly patients – PHSO

Hospitals are discharging elderly patients to their homes without ensuring they are fit or have proper support, the Parliamentary and Health Service Ombudsman (PHSO) has said in a new report.

The PHSO investigated 221 complaints relating to hospital discharge in 2014-15, an increase of over a third from the previous year, and upheld over half compared to 37% in the year before.

The NHS received 6,286 discharge complaints, a 6.3% increase from the previous year.

Julie Mellor, Parliamentary and Health Service Ombudsman, said: “Our investigations have found that some of the most vulnerable patients, including frail and older people, are enduring harrowing ordeals when they leave hospital.

“Poor planning, co-ordination and communication between hospital staff and between health and social care services are failing patients, compromising their safety and dignity.

“Health and social care leaders must work harder to uncover why 10 years of guidance to prevent unsafe discharge is not being followed, causing misery and distress for patients, families and carers.”

The PHSO’s report contains shocking true-life cases, including a woman in her nineties who did not receive a medical examination and was sent home despite complaining of severe abdominal pain. When she was discharged, she collapsed and died in her granddaughter’s arms.

In another case, an 80-year-old woman with Parkinson’s, dementia and a history of depression and suicide attempts was admitted to hospital three times after a fall and each time returned home despite saying she was unable to cope, begging to be placed in a care home and saying she would end her life if she wasn’t. The woman’s daughter said she now had nightmares because of her mother’s experiences.

Janet Morrison, chief executive of charity Independent Age, said: “The individual cases highlighted by this report are tragic in their own right, but they are also a sign of a health service under severe strain. Higher bed occupancy rates means there is a greater pressure to get people out of the system quicker. And ever growing demand is increasing the pressure on already stretched hospitals.

“It can’t be right that elderly and frail patients are being discharged without the correct care and support in place. We need to make sure our health and social care services are properly funded and integrated in the first place. Our duty of care to older people cannot begin and end at the hospital doors.”

The PHSO found that patients were being discharged before they were clinically ready to leave hospital, without being assessed or consulted, without a home care plan or without informing their family or carers.

For example, an 85-year-old woman who suffered from dementia was admitted to hospital after suffering from vaginal bleeding. After treatment, she was discharged in a dishevelled state with a cannula still in her arm and without informing her children.

Her daughter visited the next day and found her mother had been left with no food, drink or bedding and unable to visit the toilet.

However, in other cases patients were left in inappropriate care because it wasn’t possible to return them to their homes. One elderly men with vascular dementia and a personality disorder was locked on a psychiatric ward for over nine months without the hospital checking to see if this was a justified deprivation of liberty because the council decided he was ‘beyond social care’ and refused to fund a care home place for him.

The PHSO said improvements must be made to discharge best practice, including starting discharge and transfer planning before or on admission to hospital, involving patients, families and carers in the decision-making process, better co-ordination between health and social care services and ensuring community services maintain contact with the patient after they are discharged.

Anna Crossley, professional lead for acute, emergency and critical care at the Royal College of Nursing (RCN), warned that such changes might not be possible because of current shortages of nurses, saying: “Discharge planning is only possible with the right workforce in the right place and with the ability to deliver services across the whole health and social care system."

Important public conversation needed

Phil McCarvill, deputy director of policy at the NHS Confederation, said: “There is no greater priority in the NHS than patients’ safety and wellbeing. The experiences of the people in this report were unacceptable and we know that everyone in the NHS will take the findings seriously. This should trigger an important public conversation about when it’s most appropriate to discharge patients so that the process is as safe and dignified as it can be.

“Most discharges from the NHS are successful and the report of our Commission on Improving Urgent Care for Older People set out the range of good work currently underway in the service to ensure care is as good as possible. This includes planning support for discharge from the moment someone is admitted to hospital. It means ensuring that the people who use services are active partners in shaping their care, not simply passive recipients. 

“Health and social care is in an incredibly difficult place, with demand increasingly outstripping resources, and this is reflected in growing delays in discharging patients. It’s vital that all of us – including government and national bodies – align around the common goal of transforming services to better meet people’s needs. Underfunded social care services continue to put immense pressure on NHS services and hamper efforts to improve care. This must be addressed by the government.”

Delayed care transfers, where medically fit patients have to remain in a hospital bed, have increased by 6% in the past year.

Chris Hopson, chief executive of NHS Providers, said: “In the past few years we’ve seen the outcome of a disjointed approach to workforce planning in the NHS – this has particularly been the case in respect of clinical staff. Our approach is unsustainable given we spend two-thirds of the NHS budget on staff, including doctors, nurses and other clinicians.”

He said a much more strategic and joined-up approach between the government and arm’s length bodies was needed, and that the junior doctors’ strikes show the importance of ensuring the NHS workforce feel engaged, supported and valued.

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