Shambolic discharge from hospital

[Jothesquirrel]

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.

I really want to assure you that your experience is not the norm, sadly I can’t, had very similar issues after my mum had a fall age 86, hospital genuinely did more harm than good, the initial rehab placement in an NHS rehab bed achieved almost nothing, it’s a sad reflection of the state of the NHS that the best care she received was from a care home as part of the ongoing rehab package and that wasn’t brilliant. Carers one back home varied from good to dreadful, mobility was quite poor and she seemed to lose all her abilities to do pretty much anything, prior to the fall she was 100% self caring. Carers would make her a sandwich for her dinner but leave it in the kitchen so she just didn’t get it, had a second fall which just compounded the problem, in the end my sister effectively sacked the carers and moved in to look after her for her last two weeks, hope your experience does turn out better.

@Sadcafe Thank you, and so sorry to hear about your mum's experience

I’d say to the hospital it was an unsafe discharge and that you will be making a formal complaint.

In the long term, it sounds as if your dad needs to be in a care home if he can’t even deal appropriately with his wife falling.

I’m not surprised you’re so angry and upset. It sounds like a really difficult time for you.

If you're self funding there will not be any guidance, you are left to it. But the care companies you choose will visit and do their own assessment of your mother's needs.

The same applies if you decide on a temporary (or permanent) placement in a care home. You will have to do all the work yourself, and the manager of the care home will assess to check they can meet her needs.

It does feel like being thrown in a the deep end but the good news is that it gives you choice. I have been through this with my mother and I was glad that I was able to choose the right type of care for her because she was paying for it, rather than being stuck with what the authorities offered.

In terms of physio, it is possible to rehab a frail elderly person, my mother was successfully rehabbed after a broken hip when she was in her 80s with moderate dementia. So it would be worth pursuing that avenue.

Well they don't know that for sure

anyway, if it helps, I am literally at mum's now, looking at the very real possibility of her dismissing carers because she no longer needs them. (Not good for me but that's a whole other story). She doesn't even need a stick at home now. I hope your mum recovers well.

They've basically over promised and under delivered; it was the same with my DHs aunt. So sorry but not altogether surprised this has happened to you; these people will obfuscate to your very face.

I would be now looking at care homes for your mother as home in the longer term does not sound sustainable.

Previously worked as a community nurse. They had rapid response team for a short time then during this time patient was assessed then passed over to care company which you pay for. Is this the same where you are

Op you are rightly angry. Very poor discharge coordination by the sounds of it. I work in community health, I think you are well withing your rights to complain about this as there is definitely a learning need and a need to review how they are providing information and cross over services.

This leaves a very vulnerable frail lady at risk of malnutrition, pressure damage, further falls or incidents if she tried to get up, continence needs etc the list goes on.

I have no answer for your particular area but just to say that it would be very reasonable to complain.

I haven't trawled through all the responses but if you haven't been advised so far, then I would encourage you to place an online safeguarding referral to your local authority ASAP too.

In my experience the GP was next to useless. And as you have two parents to be concerned about you have reached what is termed "crisis" point. Both parents need social care involved as much as the hospital discharge team (in fact they should have been working together on this).

On top of that PALS complaint, and your GP. You need to make as much noise about this as possible. It is appalling, but sadly happens.

In hospital , the way it works is that if the therapy team feel that patients have potential for rehab then they are referred to community hospitals or inpatient therapy beds.
If they are too frail or unable to engage well with therapy , they go straight home or to a nursing home but essentially very little is done at home.

I suspect you have been lied to. Your mother would not ‘do better’ from a mobility point of view by going straight home. I do think you need to get PALS and your GP involved - it is completely unrealistic to expect you to organise care with a week’s notice. Use the word safeguarding as it is unsafe for her husband with cognitive impairment to be left as the carer.

You were lied to @Jothesquirrel so they could get the bed
Wonder what Wes Streeting is going to do about unsafe discharges

Sadly, poor care seems to be par for the course these days.

My elderly relative (88) was in the last stage of heart failure. On 27 December he was admitted to hospital as he was struggling to breathe and had very low levels of iron and needed an urgent transfusion. While there, he contracted flu, needed oxygen therapy, and could barely walk, even with a zimmer frame.

On 31 January he was discharged and sent home in an ambulance, despite the fact he lived alone in a house with four flights of stairs, meaning the bathroom and kitchen were inaccessible to him. The hospital was aware of this fact, but a physio said she'd managed to get him to walk along the corridor with a frame for eight metres and he would cope "just fine". He was discharged with a care package - three visits a day for a week to make sure he was taking his medication properly.🙄

On 1 March a nurse found him in the floor at home; he'd fallen and broken the top of a femur bone and had been there all afternoon. (None of the family lived nearby and the speed with which he was discharged caught us by surprise before we could make plans to visit him.). He was taken back to the same hospital where they operated on his leg on 3 March.

He never recovered. Having operated, the surgeon had "the talk" with us, and my relative was placed on end of life care with a syringe driver in place. He died on 10 March.

While there's little doubt he would have died within months rather than years, I do feel what was certainly an unsafe discharge contributed to, and accelerated, his death, which was far from peaceful.

The problem is money, but on this occasion an unsafe discharge cost the NHS approximately £14k (based on 2023 figures) when the costs of an emergency ambulance, surgery, and subsequent palliative care are taken into account.

The cost of human suffering is incalculable.