"Breakdown in communication between health and social care"

My elderly neighbour recently fractured her hip in 3 places. She has been in Wishaw General Hospital since then. After a traumatic and major operation, physiotherapy deemed  her safe to go home. She has no siblings and no family at all so needed a care package put in place. Before her accident she was totally self-sufficient, which is commendable. She was advised that home support would be provided for an initial period of 2 weeks then reassessed to see how she is coping.

On the said discharge morning, she was advised to shower early, for this she needs assistance and was dressed and anticipating discharge all day until 15.00 when she was told that in fact the Home Assessment Team had no carers and she would not get home. No one had actually as yet been to her home to assess her environment to decide if/what aids she may require to rehabilitate at home.

This elderly lady lives totally alone and cannot at this moment in time cope alone. She has now been advised by hospital staff, who I must say have been nothing but kind and supportive, that she must sit each day for an unknown period until HAT can provide home support for her.

I find it totally astounding the lack of empathy for this lady’s mental and physical needs. She is cognitively very capable, however the accident has left her body unable to carry out basic daily activities. It is beyond frustrating that a hospital bed is being occupied by someone who would mentally and physically thrive by being home in their familiar comfortable environment with  the required support.

In the meantime it is interesting to learn that there is a hospital discharge team available to support such vulnerable adults but that no referral has been made to them. What is the current social work criteria for returning such vulnerable adults in NLC home? Is there a process in place for a home assessment prior to discharge, if so, why has this not been carried out? It appears, there is a breakdown in communication between health and social care to offer a duty of care to my elderly neighbour.