"Poor discharge planning, but the carers have been fantastic"

My father was admitted to Dr Grays Ward 8 in November after a fall at home. He had a failing heart, chest and kidney infection and was hypothermic. He was then moved to Ward 7 where he stayed for 12 weeks. The overwhelming thing about his stay was just how fantastic the staff are. The medical care was brilliant and I have been astonished that 12 weeks on, he is still alive. The nurses are just wonderful human beings. They are stretched to the limit- and relied very heavily on bank nurses - but their care, kindness and amazing good humour in the face of their daily tasks was inspirational. My mother and I were in almost every day and never met a nurse who was anything less than cheery, caring and supportive. You are truly wonderful people.

However - it ended badly - and I place the blame squarely on the social work department. A few weeks ago a social worker requested a meeting on a Friday afternoon to discuss Dads next step. Medically he was much better but had lost nearly 13kgs (his BMI was 16) and hadn't been out of bed in 10 weeks.

As soon as we arrived in the ward the social worker appeared and said that they have a bed available at a cottage hospital where he can get some rehabilitation. We readily agreed and they went away to arrange, and returned to confirm that he would be transferred the following day - Saturday. We questioned this with nursing staff and they agreed that it would be probably be Monday. Dad was excited and looking forward to a big step forward. Sunday night we received a phone call from the ward to say there had been a mix up and no bed was available. He would stay where he was. Not a problem but we knew that really he was a 'bed-blocker' as he was no longer in need of intensive medical care. Senior nurses assured us that he was on the list for a cottage hospital place. Fast forward to last Monday. Mum received a phone call from Dad mid morning to say that he had been told he was being sent home on Tuesday. He was taken to physio to practice steps with his zimmer and when he returned to the ward his bed was stripped and belongings stuffed into two plastic bags. Discharge brought forward to Monday afternoon - despite no communication from the hospital/social work dept to either Mum or myself. I eventually managed to speak to the social worker, but found their attitude appallingly dismissive. Never at any time had anyone suggested that he would be sent straight home without rehabilitation or without warning. He arrived home at 4. 45pm in a taxi in his pyjamas (it had been -6 that night). One bag contained medication and a letter that we later realised was for his GP but wasn't addressed or in an envelope. But no instructions for the medication. I phoned the hospital to ask if care was in place and was relieved to discover it was as he was still catheterised - but wasn't advised when it would start. A lovely carer arrived shortly after Dad and reassured us all.

I had assured my Mum that he would never be sent home without warning that we would have an opportunity to discuss our concerns. (She was very concerned about her ability to care for him as she has her own health issues,so it was shocking to have him sent home with no time to prepare -even to have enough food in (their home is rural and she doesn't drive). She has been shell shocked and is struggling to cope, but the carers have been fantastic.