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Elderly parents
Original poster

Shambolic discharge from hospital

37 replies

Jothesquirrel · 15/03/2025 08:29

My 85 year old mother has just been discharged from hospital after a 7 week stay following a fall. Before her fall she could just about get around with a walker and now seems to have lost all mobility. During her stay in hospital she contracted cellulitis, pneumonia, a UTI and norovirus, and has emerged weaker and much thinner.

The original discharge plan was for her to go to a cottage hospital for rehab, but then it was decided that she would make more progress in a home setting. She has carers that come in four times a day to give her medication, attend to her personal care etc. She is completely bedbound at the moment.

We were told by the hospital's Occupational Therapy team that the plan would be for her to have physiotherapy at home, provided by the community team, that as she has 'goals', a renablement team would be coming in to assess her progress, and that they would recommend a package of care and advise us of care agencies. We were told that the carers would be funded for 3 weeks (or possibly 6) and then we would need to self fund after that. I was told just before her discharge that there was no need to look for private carers yet.

The reality has been very different. The carers are fine but there has been no visit from the community physio team and when I chased this with the Urgent Response Team, not only did I discover that she hadn't even been referred to the community team, but that the carers are only coming for 10 days, not 3 weeks (let alone 6). They were very dismissive of my concerns and just said 'the hospitals often get it wrong'.

Is this typical? I'm really shocked that the carers are only provided for 10 days. We have been given absolutely no help at all with the next steps. My dad lives with my mum but is cognitively impaired and is not able to organise any of this. When she fell he left her on the floor for 24 hours, and didn't think to call anyone, not even my brother who lives 10 mins away, so he is completely unable to look after her.

I have arranged for two care agencies to come round next week to do an assessment but I don't want to rush into care that might not be right, especially when I thought we had more time. I'm also trying to find a private physio to get a realistic assessment of what progress she might be able to make.

I'm really angry and upset that we were told her best prospect of progress was a home setting when no effort has seemingly been made to enable this, and now we feel that we've just been cut adrift.

OP posts:
Original poster
Jothesquirrel · 15/03/2025 09:10

TwinklyRoseTurtle · 15/03/2025 09:07

West Sussex have a UCR team which is a 2 hour response for hospital avoidance, teams usually comprise of nurses/physios for urgent community physio ( it is a 2 hour response and will be triaged) if any nursing need the physios will refer mum to them too, I will add the contact number but referrals for this type of service usually require professional referral only so you can wait until Monday to see your usual GP or ring 111 and ask to be referred- if you explain mum is off her feet and bed bound they will triage accordingly- I will add the number here I found for the service but as I said it’s usually professional referral only : 0300 3737 111

good luck OP hope mum gets sorted x

Show quote history

Thank you. It was the UCR that I spoke to and to be honest they were not helpful at all. I will follow up with the GP though.

OP posts:
TwinklyRoseTurtle · 15/03/2025 09:08

Also to add- if the comm physio don’t think mums safe at home or needs more intensive physio there are usually community physio beds available in units which the physio can organise x

TwinklyRoseTurtle · 15/03/2025 09:07

Jothesquirrel · 15/03/2025 09:03

They are in West Sussex, and the hospital is East Surrey. I have written to her GP and will follow up on Monday.

I know I sound calm, but I am fuming and so upset on her behalf.

Show quote history

West Sussex have a UCR team which is a 2 hour response for hospital avoidance, teams usually comprise of nurses/physios for urgent community physio ( it is a 2 hour response and will be triaged) if any nursing need the physios will refer mum to them too, I will add the contact number but referrals for this type of service usually require professional referral only so you can wait until Monday to see your usual GP or ring 111 and ask to be referred- if you explain mum is off her feet and bed bound they will triage accordingly- I will add the number here I found for the service but as I said it’s usually professional referral only : 0300 3737 111

good luck OP hope mum gets sorted x

Original poster
Jothesquirrel · 15/03/2025 09:04

HelenWheels · 15/03/2025 09:03

i am sorry that sounds dreadful
can you sort out a rehab place for her yourself?

Yes, thanks, I am looking into that option.

OP posts:
Original poster
Jothesquirrel · 15/03/2025 09:03

TwinklyRoseTurtle · 15/03/2025 08:52

It happens more often than you think, if you don’t mind OP what city are you in? Maybe able to signpost, if the care ends and you cannot get another one, you do have the option to send mum back to hospital and refuse her discharge until they can put her in reablement setting- your GP can also sort this depending on area but you don’t have to wait until the care ends if you feel it was an u safe discharge can send mum back in - you will need an ambulance and before anyone jumps in- it won’t be an emergency ambulance but she will need one as she will need a stretcher - hope some of this makes sense x

They are in West Sussex, and the hospital is East Surrey. I have written to her GP and will follow up on Monday.

I know I sound calm, but I am fuming and so upset on her behalf.

OP posts:
HelenWheels · 15/03/2025 09:03

i am sorry that sounds dreadful
can you sort out a rehab place for her yourself?

Original poster
Jothesquirrel · 15/03/2025 09:01

@WilmaFlintstone1 I was told that after the 10 days we would need to sort out our own care, not be handed over to another service. We were prepared to self-fund (eventually) but it's the complete lack of guidance that is so concerning.

OP posts:
TwinklyRoseTurtle · 15/03/2025 08:52

It happens more often than you think, if you don’t mind OP what city are you in? Maybe able to signpost, if the care ends and you cannot get another one, you do have the option to send mum back to hospital and refuse her discharge until they can put her in reablement setting- your GP can also sort this depending on area but you don’t have to wait until the care ends if you feel it was an u safe discharge can send mum back in - you will need an ambulance and before anyone jumps in- it won’t be an emergency ambulance but she will need one as she will need a stretcher - hope some of this makes sense x

WilmaFlintstone1 · 15/03/2025 08:48

Jothesquirrel · 15/03/2025 08:29

My 85 year old mother has just been discharged from hospital after a 7 week stay following a fall. Before her fall she could just about get around with a walker and now seems to have lost all mobility. During her stay in hospital she contracted cellulitis, pneumonia, a UTI and norovirus, and has emerged weaker and much thinner.

The original discharge plan was for her to go to a cottage hospital for rehab, but then it was decided that she would make more progress in a home setting. She has carers that come in four times a day to give her medication, attend to her personal care etc. She is completely bedbound at the moment.

We were told by the hospital's Occupational Therapy team that the plan would be for her to have physiotherapy at home, provided by the community team, that as she has 'goals', a renablement team would be coming in to assess her progress, and that they would recommend a package of care and advise us of care agencies. We were told that the carers would be funded for 3 weeks (or possibly 6) and then we would need to self fund after that. I was told just before her discharge that there was no need to look for private carers yet.

The reality has been very different. The carers are fine but there has been no visit from the community physio team and when I chased this with the Urgent Response Team, not only did I discover that she hadn't even been referred to the community team, but that the carers are only coming for 10 days, not 3 weeks (let alone 6). They were very dismissive of my concerns and just said 'the hospitals often get it wrong'.

Is this typical? I'm really shocked that the carers are only provided for 10 days. We have been given absolutely no help at all with the next steps. My dad lives with my mum but is cognitively impaired and is not able to organise any of this. When she fell he left her on the floor for 24 hours, and didn't think to call anyone, not even my brother who lives 10 mins away, so he is completely unable to look after her.

I have arranged for two care agencies to come round next week to do an assessment but I don't want to rush into care that might not be right, especially when I thought we had more time. I'm also trying to find a private physio to get a realistic assessment of what progress she might be able to make.

I'm really angry and upset that we were told her best prospect of progress was a home setting when no effort has seemingly been made to enable this, and now we feel that we've just been cut adrift.

This is awful, your poor parents. It sounds like the current carers are a bridging team who will hand over to another service after their 10 days. This is common in my area and I sometimes deal with them as part of my job.

What should happen is an assessment before they finish and allocation to permanent carers after this. It gives social services a few days to find a care agency to take over. If your Mum needs carers four times a day that can’t just end after 10 days, a permanent arrangement should be made.

Speak to the GP surgery and ask if there’s a care coordinator who can refer to the community physio. I do lots of these referrals and find they go in fairly quickly (usually within 10 days). That’s my area though so not sure how quick it is elsewhere.

Ritasueandbobtoo9 · 15/03/2025 08:39

Ring your local Community Therapy Team and ask them to send some out.

OneFineDay13 · 15/03/2025 08:38

That's really shocking! I would be angry too

cheezncrackers · 15/03/2025 08:33

That's appalling OP. I would be making a formal complaint to PALS about this. Your DM should never have been discharged home when she's in such a frail state and to a home with a DH who is completely unable to care for her in her bedbound state. She should've gone to rehab for an appropriate amount of time to get her up and about again, not dumped at home with barely any care.

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