Elderly Parent - unsafe discharge, any advice?

[havanesehope]

My Dad has been in hospital again, this time for two months. They have found a large heart aneurism this time. He has been in bed virtually the whole time and asleep. The hospital social worker has failed to communicate with us at every step of the way. My Mum is too ill to care for him, she has stage 4 cancer and just manages her own needs with a bit of help with me. I was informed yesterday that they are discharging him home tomorrow! He can barely walk, can’t go to the toilet himself, can’t wash, barely eats. There is no suitable bed downstairs. I talked previously about a respite/ residential place, the discharge team have totally ignored this! Any advice from anyone who has found themselves in a similar situation?

Go back to the discharge team and ask how he will get to the toilet at home. Ask how he will get fed. How he will get washed.

Thank you

Are they sending him home with a package of care?
How is his cognition? Does he have capacity about his discharge choices / destination?
Do you have LPA if not?
I would absolutely expect the in-parting team to discus discharge plans with appropriate family members / next of kin. Has any info been communicated to you at all?

When I was in this situation with my Mum I simply told them that we wouldn’t be prepared to collect her and we wouldn’t open the door if she was delivered home. It felt awful, but it meant that they did find her interim convalescent care until
she was properly able to come home.

You to need to tell the nurse in charge today that there is nobody at home who can care for him, and no bed or bathroom that he can access. Make it clear that this would be an unsafe discharge with a very high risk of readmission

It might be possible to have him home with appropriate equipment delivered (hospital bed, commode etc) and a full care package, but that should only be planned after full discussion with him (if he has got mental capacity) and whoever he lives with. If he doesn’t have capacity then does anyone have LPOA for health and welfare? They should be involved if so, and if not decisions should be made in conjunction with family in his best interests.

Unfortunately LPOA is just for finances at the moment. The care package they have put in is woeful. It doesn’t address lack of mobility, not being able to clean himself, toileting etc. Good tip re not accepting him home. They have failed to communicate anything. He has diminished capacity not total lack of capacity. He is very confused though and disorientated.

Make it very very clear that even if he said that "someone" (you /DM) will be providing care that this not going to happen.

Part of the problem may be if he has capacity and is telling the SW that everything will be great and your family can manage once he is home while ignoring the work needed to care for him.

Are the nurses supportive and able to explain to you what is needed from their side to put a care package in place?

And ask for a physio assessment. You need written proof of his mobility (or lack of) and his inability to walk distance or go up/down stairs.

How is he being managed at the moment? His he been deemed a fall risk? is there someone with him when he is moving to the loo or is he being bedpaned?

Get all of the problems charted by the nursing and care staff.
What he cant do and what care is provided etc
If he has limited capacity they can discharge him so you need to make sure the documentation fully records his care needs so that at a minimum the has to be a proper plan and proper equipment provided in any homecare package.

He is being bed panned. He has a long history of falling, it goes back years. Unfortunately he is giving the impression that things can be managed at home. There has been no physio assessment.

If he tells them he can manage and they deem he has capacity then there is nothing you can do. I speak from bitter experience. It’s like banging your head against a brick wall.

OP what is the package of care? It absolutely will involve washing / dressing / toileting.

Are you absolutely sure he hasn’t had a physio and / or OT assessment? I would be really unusual for an elderly person to have an admission for that long and not have a therapy assessment.
You say he is delirious. Has he got ongoing delirium that is new? Or is he living with dementia?
Sorry so many questions but I’m trying to get a good picture of what’s actually happening to see if I can advise.

Can you go back to them and tell them exactly what you and your mum together could do for him? What I had with my dad is that he was asked if there were people at home and said their were. He wasn't asked what care these people could provide and he didn't think to mention it!

Across the two trusts I work across there is no proper hospital social work team in either any more and hasn't been since before covid. Many hospital trusts now operate a 'Discharge to Assess' model (D2A).

This means that nearly all discharges are managed by the discharge coordinators employed by the hospital which are usually a mixture of nurses/OTs and Physios.

The local authority only get involved after discharge or if there is a particularly complex situation that needs involvement while the person is still in hospital.

I've lost count of the amount of annoyed phonecalls we receive from relatives that the 'hospital social workers' aren't getting back to them - when no such thing exists anymore. Or relatives ringing the local authority demanding care act assessments before discharge when that hasn't been the process for ages and getting shirty when it's explained they need to speak to the discharge coordinator on the ward.

None of that should mean that a discharge takes place unsafely though.

Ask for the Discharge Coordinator for the ward and not the hospital social worker and see how you get on.

You contact pals, the ward manager, senior social worker, safeguarding lead and take no responsibility for his discharge. You write an email with your concerns, copy in his consultant, GP and community safeguarding team.

The Safeguarding team would have zero interest in this.

It's absolutely nothing to do with them at this stage and wouldn't meet the s.42 criteria.

Not all local authorities have senior social workers and many hospital trusts don't involve the local authority in discharge planning any more if they use the D2A model. No point complaining to people/teams that have no more influence over someone's discharge than the OP.

The OP needs to ask for her dad's discharge coordinator. No matter what model is being used there will be a Discharge Coordinator of some sort.

As another pp has said. Contact the discharge co ordinator urgently. It's quite possible that he has been deemed 'medically fit' for discharge by the consultant/ward which means it's now in the hands of the discharge co ordinator. If the package of care isn't sufficient then they will have to increase it. Unfortunately if he has capacity then you often end up with a crisis or readmission. As your mum can't cope, you'd be looking at either discharge to 6 weeks re enablement unit or 6 weeks care package up to 4 visits a day. Discharge coordinators will often talk in the vein of 'trying out' a care package to see if it works
If you feel that the discharge plan is unsafe (not enough care visits, assumptions have been made about who is doing what etc) then you need to put 'unsafe discharge' in writing to the discharge team immediately. Without this and contacting the discharge team immediately then the discharge will go ahead

As others have said you need to refuse his discharge on the grounds it is not safe , they may want his bed but there are places in respite for exactly this purpose. We had similar with my dad who was nearing end of life with Parkinson’s and was suffering from hallucinations and becoming violent due to repeated infections- I made it quite clear that it was not safe for my Mum to be alone with him and as such we would refuse access if they did discharge

The UHB I work for has its own social work team and discharge liaison team. There’s also community reablement team.

It’s unusual to just discharge someone with nothing in place………..unless OPs dad has fibbed and told them he’s got support at home

Yep echo the above - kick up an absolute stinker and if you can, take your mother to your home so there is no one at his home to let him in or be deemed able to care for him. Take his house keys with you.

Get a list of which teams has done assessments and what has been document to date.

NB if he is a documented fall risk he needs a home care team of 2 (or more) and a hoist and a (hospital) bed on the ground floor.

Most teams will not lift or not even want to roll on a low bed due to the risk of harm to their backs. So basic care for bedpans and dressing and washing and putting on clean sheets would be a problem.

The carers will have to provide food and water.

They would also have to provide his meds and prompt if he has reduced capacity most providers will draw a line on this as it is medical activity. What is the plan for that?

Also check if he is sleeping through the night as DM is at high risk of coming to harm if she feels guilt and goes to help him.

And get your DMs needs documented her own illness, if she is on any pain meds /sleep aids etc so that its very clearly included on his file that his wife can not be his carer.

This isn’t correct. Unless someone is assessed as needing a hoist to transfer, they would not be provided with one. Many older people who fall / are at night risk of falls live at home. They certainly do not all have hoists. Same with a double handed care package. That is only provided if he needs assistance of two for his transfers and / or self care. If it has been assessed that there is a risk he will fall out of bed, then a low bed and crash mats should be provided and advice given to carers on how to support if he rolls off.
If the OPs dad is a very high falls risk, then a risk assessment should be completed on how this will be managed at home, which includes things like the low bed described above.

Oh and I also meant to say that low beds can be raised to the height of a standard hospital bed for care / transfers. They are only lowed when the person is in bed and unsupervised.

I have managed to speak to the charge nurse and his discharge is now not taking place at the moment. He is quite delirious but no dementia. I have insisted that he needs a residential setting and at the very least a respite setting with someone overlooking 24hrs. I’m not sure if I’m going to get anywhere but I am using all the advice on this thread. Thank you all. See what tomorrow brings.

Yes my Dad is a massive falls risk. Has been for years. Some memory issues as well, he has had some contact with the Parkinson’s team in the hospital but have had no feedback as yet.

They can't discharge him if he's delirious, they need to investigate the cause first.