The Local Government and Social Care Ombudsman said the treatment of the man, known as Mr F, “engaged” article 3 of the Human Rights Act because it “could be perceived as degrading”. However noted it was for courts to say whether the act had been breached.
The ombudsman has ordered the trust to review its discharge policy and the council to ensure staff and homes are reminded of their duties under the Mental Capacity Act 2005.
Mr F was taken into Boston’s Pilgrim Hospital in February 2019 because of a suspected stroke.
He had previously been in a respite home, called Home X, while his son and carer was in hospital.
He was discharged to the Gardens Residential Home, in Boston, on March 7.
The Ombudsman’s report said Mr F’s hospital social worker was contacted by the home the same day to “express concerns”.
She was told Mr F “was only in hospital gowns, was going blue with the cold and he was shivering”.
He was also discharged with a walking stick that “was not his and he did not need”.
The Ombudsman’s report said a pre-discharge checklist was “blank” and that the trust had “no record” of what Mr F had with him on admission.
However, they said he “would have been dressed in hospital pyjamas if he did not have his own clothes”, “should have had enough blankets on discharge to keep him warm and preserve his dignity” and “did not need any equipment on discharge”.
“The trust’s fault caused Mr F distress, discomfort and loss of dignity,” said the ombudsman.
Lincolnshire County Council was also found at fault after Mr F was sent to the home.
Despite a needs assessment and care plan being prepared, the home raised concerns the discharge was “inappropriate because of Mr F’s complex health problems and need for palliative care”.
Mr F was allowed to stay for one night but was moved back to the respite home the next day.
The ombudsman report said home staff had realised that his “mobility was extremely poor and that his vision and hearing was worse than had been identified on the pre admission assessment”.
They said the full range of Mr F’s medical conditions and the need for palliative care had not been identified.
However, the council and home were both unable to provide copies of a pre-admission assessment or evidence a manager had input into his admission.
“The home had all the information it needed to enable it to carry out an accurate pre-admission assessment,” said the ombudsman, who found faults under the Equality Act 2010.
“Because of the faults, Mr F suffered the inconvenience and distress of moving twice in 24 hours, while he was still in poor health and very vulnerable.”
Sadly, Mr F died in 2020. Both the trust and the council have apologised to his son.