Review and discharge meetings
21. Mr A said staff did not communicate with or invite him to any review meetings from 24 December 2018 to 9 January 2019, including the discharge meeting on 9 January. The Trust said it does not need the consent of close family members when discharging patients. It encourages patients to invite and include their involved close family members to be part of the discussion, by attending the ward care review. It could see Mr A’s mother attended the review on 9 January and was supportive of the Hospital discharging Mrs A, with ongoing support from the Home First team and care co-ordinator.
22. The CPA (Care Programme Approach) supports patients recently sectioned under the MHA. This includes ongoing review and planning of a patient’s care. Patients should agree discharge plans and involve the family and carer if this is what the patient wants. This is in line with section 26.16 of the MHCOP which says, ‘People must consent to the involvement of their families or advocates if they have capacity to give or refuse such consent.’
23. We can see at the review and discharge meetings on 19 and 28 December, 2 and 9 January, Mrs A was under a CPA with capacity to consent when she was an informal patient. The Trust completed several reviews and care planning for Mrs A before it discharged her on 9 January.
24. Our psychiatrist adviser referred to the Trust’s CLPG30 Guidance, paragraphs 7.5 and 7.6 which says:
The review process includes inviting all those involved in a patient’s care plan. Where appropriate, carers should be involved in the review. The care co-ordinator/lead professional must ensure they obtain the views of those involved in the care plan who are unable to attend the review. The review should determine the views of the patient, carer, and professionals. All parties must agree any changes and record disagreements.
25. Our mental health nurse adviser referred to the Trust’s CLPG30 Guidance, paragraph 7.2 which says:
‘…It may not be practical to have all those individuals involved in the care plan attend the review meeting, and it is essential that the patient’s feelings and views are taken into account….In some cases, the review may consist of just the patient and the co-ordinator. However, the care co-ordinator should ensure the views of others are represented.’
26. They also referred to the Trust’s CG24 Guidance, paragraph 6.8 which says:
‘Unless the patient is discharged under the Zero Tolerance policy the patient and their carers/ relatives/advocates must be fully informed and give agreement to the discharge prior to the discharge taking place. This must be documented in the patient's record...’
27. We can see Mrs A attended the ward meetings alone with medical professionals on 19 and 28 December and 2 January. She attended the discharge meeting with her mother in law on 9 January. To understand what happened at each meeting, we looked at the section called ‘Patient/ relative views’ for each meeting.
28. At the ward review meeting on 19 December, Mrs A’s care planning was ongoing, and it recorded, ‘Mr A wants records before discharge.’
29. At the ward review meeting on 28 December, the records said, ‘Mrs A would like overnight leave for the weekend but partner Mr A wants an update from staff before this happens…we said we can sort this out and staff can talk to Mr A to reassure him.’
30. The notes from the meeting on 2 January said Mrs A reported Mr A would be more than happy for the Trust to discharge her. She consented for the Trust to chat to Mr A about her progress. The ward review management plan recorded, ‘Staff to discuss progress with Mr A.’
31. Finally, at the meeting on 9 January the records said Mrs A’s leave went well and she spent a lot of time with her mother in law. It said the psychologist tried to arrange family therapy, but Mrs A said when Mr A received an email about this, he ‘shrugged it off.’ The Trust said the aim for that day was to discharge Mrs A with ongoing support.
32. We can see it was the responsibility of the patient, Mrs A, to decide who she wanted to tell and invite to the meetings. This is in line with the MHCOP guidance. She did this on 9 January as she decided to invite her mother in law to the discharge meeting. There is no reason she could not have invited other carers, including Mr A, to the review and discharge meetings. Therefore, we have seen no failing in this.
33. As stated in the Trust’s CLPG30 Guidance, paragraphs 7.2, 7.5 and 7.6, it may not be possible for all those involved in the patient’s care plan to attend the meetings. However, in line with this guidance, it is important for the Trust to obtain the views of those involved in the care plan who were unable to attend. Mr A was part of Mrs A’s care plan and the Trust involved him by recording his views, as seen in previously mentioned paragraphs. We have seen no failing in this.
34. In the Trust’s CG24 Guidance, paragraph 6.8, the Trust should tell the patient, their carer, relative or advocate of and give agreement to the discharge. We can see a close family member, Mr A’s mother, attended the discharge meeting on 9 January with Mrs A. His mother was aware of and did not express any concerns of the Trust discharging Mrs A that day. Therefore, we have seen no failing in this.
35. However, we can see Mr A wanted an update about Mrs A’s progress before it discharged her, Mrs A consented for this, and the Trust were aware and agreed to this. Our Principles of Good Administration says,
‘Public bodies should do what they say they are going to do. If they make a commitment to do something, they should keep to it, or explain why they cannot.’
36. As we can see no evidence the Trust followed its plan through by contacting Mr A to discuss his wife’s progress, we can this is a failing as it did not follow our Principles of Good Administration.
37. When we find failings, we next look to see the impact. Mr and Mrs A said because the Trust did not communicate or invite Mr A to any review meetings from 24 December to 9 January, he and his young children were not prepared for Mrs A’s return home, which was distressing. Mr A said he only found out the Trust discharged his wife when he returned from work that day. They say Mrs A took an overdose, an acute hospital and PICU admitted her. They say the events affected their son’s mental health as he stopped talking to people.
38. The records show that Mrs A already spent a lot of time at home in the weeks before the Trust discharged her. However, as Mr A was expecting an update on his wife’s progress and this did not happen, he and his children would have been unprepared and not reassured about her return home. We acknowledge it must have been distressing for them to find out the Trust discharged her at that point. We have made recommendations to put things right.
39. Both our advisers agreed they could not say the Trust caused Mrs A to take an overdose, an acute hospital and PICU admit her, and it affected their son’s mental health. We recognise that this was an incredibly difficult time for the whole family, and we do not wish to diminish the impact that this had. We consider that at the time of the discharge, Mrs A’s mental health was stable and there could have been other contributory factors for the deterioration.
Discharge on 9 January 2019
40. Mr A said the Trust should not have discharged his wife on 9 January as it was too soon. He said social services told him the Trust should not discharge his wife from Hospital without telling him, and without his consent to ensure adequate support was in place, as he has two young children.
41. The Trust said when Mrs A returned to the Hospital on 2 January, she said her leave went well and was keen for it to discharge her. After another period of leave Mrs A attended the discharge meeting on 9 January with her care co-ordinator, a member of staff from the Home First team and Mr A’s mother. The Trust said this period of leave also went well and there were no concerns about Mrs A going home and being with her children.
42. Our psychiatrist adviser referred to the Trust’s CG24 Guidance, paragraph 6.1:
‘Discharge planning is a continuous process which should begin at the point of admission, ensuring that patients and their carers/ relatives understand and are able to participate in care planning decisions. The process should continue until the patient is formally discharged from services.’
43. Our psychiatrist adviser also referred to the Trust’s CG24 Guidance, paragraph 6.6:
‘The patient will be identified as medically and mentally (where applicable) well/ fit for discharge by the medical team with recognised authority to do this. This decision must be clearly documented by the medical staff within the patient’s records. In some cases, patients may discharge themselves against medical advice and therefore the usual general instructions may not be possible.’
44. The records show that at the time of the Hospital discharge Mrs A was a voluntary patient on the ward. Our psychiatrist adviser explained her mental state was stable, she was an adult and had mental capacity to consent to her discharge. She also participated in the review and discharge meetings and clearly expressed her wishes for the Trust to discharge her.
45. She spent a lot of time with a close family member who attended the discharge meeting with her. Mrs A’s medical records also showed she was medically and mentally well and fit for the Trust’s medical team with recognised authority to discharge her. The Trust gave Mrs A an extended period of leave for two to three weeks from when she became an informal patient on the ward. This was to ensure the sustained stability in her mental state before discharging her.
46. We recognise it was an upsetting and worrying time for Mr A as the Trust did not update him on the progress of his wife before it discharged her. Our psychiatrist adviser said even if he disagreed with the Trust discharging his wife, it did not need consent from him and had no legal authority to continue with Mrs A’s hospital admission. Therefore, it was appropriate for the Trust to safely and timely discharge Mrs A on 9 January, in line with the Trust’s CG24 Guidance, paragraph 6.6.
47. We can see since the Trust discharged Mrs A from Section 3 MHA, it was continually reviewing and planning her care and full discharge from the Hospital. The evidence shows Mr A was aware the Trust would eventually fully discharge her at some point soon. This is because he kept saying he wanted an update on his wife’s progress before this happened. Therefore, we can see the Trust acted in line with its CG24 Guidance, paragraph 6.1.
48. We can see further evidence to support that Mrs A’s mental state improved before the Trust discharged her on 9 January. Mrs A was on lithium which is for treatment of mood disorders. Even though Mrs A’s lithium level was at the lower end of the normal range, the Trust were happy to leave this medication dose as it was since her mental state was stable. All the evidence shows her mental state was stable and there were no concerns with her mental or physical health on 9 January. Therefore, as the Trust acted in line with its CG24 Guidance, paragraphs 6.1 and 6.6, we can see no failing in this issue.
Unclothed and anti-ligature clothing
49. Mr A said when Mrs A returned to the Hospital on 17 January staff stripped her naked and did not give her a blanket until one hour afterwards. Mr A said staff left her naked for 24 hours and only gave her clothes back 10 minutes before they transferred her to PICU on 18 January. Mr A said PICU told him the Hospital should not have stripped her naked. He also said the Hospital did not give her anti-ligature clothing when she was in seclusion even though she was a ligature risk.
50. The Trust said it uses seclusion as a last resort to maintain safety for patients. It removed Mrs A’s clothing for her own safety when it nursed her in seclusion. Its policy is for patients to remain clothed and unclothing Mrs A was a last resort after clinical discussion. She was using every piece of her clothing to dangerously self-harm, even with staff intervention. It had no option but to remove her clothing to keep her safe. It was conscious about maintaining as much privacy and dignity and could only achieve this by giving her a hospital blanket.
51. The Trust said its policy did not cover the provision of rip proof clothing whilst in an acute ward. It escalated this issue to senior management, and the executive team agreed to provide this on acute wards at the Hospital. This involved amendments to its policy.
52. The records show the Trust admitted Mrs A in seclusion on Ardleigh Ward on 17 January at 6.55pm. This is an acute ward where it gives care to patients with intensive medical and nursing support for periods of acute psychiatric distress. The reason for her seclusion was because she refused to co-operate with staff, stuffed tissue down her throat and used pieces of fabric and clothing to self-strangulate.
53. A doctor agreed to the seclusion and said Mrs A’s behaviour escalated and she was a high risk to herself. Mrs A’s care plan for seclusion shows how the Trust were managing her risks and recorded, ‘…currently nursed in seclusion to prevent access to self-harm items…’ It said it recovered all items of Mrs A’s clothing to prevent use.
54. Although we can see the Trust removed Mrs A’s clothes in seclusion, the records do not show when staff gave her a blanket in the first place. Only that she had a blanket which covered her during her seclusion. The Trust said when it removed Mrs A’s clothing it gave her a blanket. However, the Trust had to remove the blanket as she also tried to use this as a ligature. About an hour later, Mrs A requested medication after initially declining this. The Trust gave this, and she asked for her jumper. The Trust were not confident that Mrs A would refrain from using clothing to self-harm, but it returned the blanket to her. Therefore, on the balance of probabilities, as the Trust and Mrs A agree she was without a blanket for about an hour, we can see it was more likely than not that this was the case.
55. Our mental health nurse adviser referred to section 26.161 of the MHCOP which says:
‘Individuals should never be deprived of appropriate clothing with the intention of restricting their freedom of movement…’
56. The Trust’s RMPG05 Guidance, paragraph 3.11 says that depriving someone of access to usual clothing is a restrictive practice. Paragraph 5.6 of this guidance says:
‘If a restriction is deemed appropriate…the principles of dignity and respect must be observed at all times and especially at times when restrictive interventions are being implemented.’
57. Our mental health nurse adviser said the Trust recognised that Mrs A presented as a serious risk to herself by having access to her own clothing whilst in seclusion (fashioning ligatures from her own clothing). A ligature is an item used for tying or binding something tightly. As a last resort, for a patient’s safety, the Trust can remove a patient’s clothing whilst in seclusion. In line with MHCOP the Trust appropriately did this after it completed a risk assessment which showed that Mrs A’s access to her own clothes was a significant risk to herself.
58. Section 26.163 of the MHCOP says that the Trust should not use tear-proof (anti-ligature) clothing as a first line response to such risks and it should never use it as a substitute for enhanced levels of support and observation. It also said the requirement to wear tear-proof clothing should not be a blanket rule within a service.
59. We can see the Trust was observing Mrs A on level three observation whilst in seclusion. This involves a staff member observing the patient within continuous eyesight or at arm’s length. Our mental health adviser said the staff member would be observing a patient through a Perspex screen for the patient’s safety. The Trust also gave her a blanket to cover herself. However, it should have done more to protect Mrs A’s dignity whilst she was in a vulnerable state, naked, in seclusion, as stated in section 26.162 of the MHCOP. This says:
‘It may be appropriate…for individuals to be asked to wear special tear-proof clothing, such a decision should be authorised by the patient’s responsible clinician. An MDT (multidisciplinary team) should undertake an individualised risk assessment before this decision is taken…. This is particularly likely to be the case where the risk of shredded clothing being used to self-harm or attempt suicide has been assessed and is considered to be very high.’
60. As stated in section 26.162 MHCOP, the Trust should have at least considered whether anti-ligature clothing was appropriate for Mrs A when it decided access to her own clothing was a risk. As the Trust assessed her to be at serious risk of self-harm using pieces of fabric and clothing, it seems more likely than not that it would have assessed her as suitable to wear tear-proof clothing. Therefore, we can see the Trust did not act in line with section 26.162 of the MHCOP and is a failing.
61. Section 26.165 of the MHCOP says:
‘Any requirement that an individual should wear tear-proof clothing should be proportionate to the assessed risk and documented evidence should show that it is used only as long as absolutely necessary. As soon as the risk is assessed to have diminished, consideration should be given by nursing staff or the MDT team to a return to usual clothing. This will require ongoing dynamic risk assessment.’
62. The records show on 18 January at 1.30am that a doctor reviewed Mrs A asleep, breathing and lying on the mattress covered in a blanket. The Trust then discontinued her seclusion at this time and said she should still be on level three observation. The seclusion discontinuation form on this date and time said the reason for discontinuing seclusion was because Mrs A was not currently agitated and had been asleep under the blanket which she used appropriately.
63. The records do not show the exact time the Trust returned Mrs A’s clothing to her on 18 January. We can only see that staff observed Mrs A dressed on 18 January at 3.30pm, and paramedics transferred her to PICU over an hour later at 4.40pm.
64. In line with section 26.165 of the MHCOP, the Trust should have assessed whether it was still a risk to return Mrs A’s usual clothing. We consider it could have done this after it assessed the risk in Mrs A’s behaviour reduced and it discontinued her seclusion. We see no evidence the Trust assessed her for this at any point during and after it discontinued her seclusion. Therefore, we can see the Trust did not act in line with section 26.165 of the MHCOP and is a failing.
65. Our mental health nurse adviser referred to section 26.166 of the MHCOP which says:
‘Positive behaviour support plans (or equivalents) should detail primary preventative strategies that will aim to avoid the ongoing need for such restrictions. The patients should be told what they need to do so that they can wear their usual and preferred clothing.’
66. We found a failing in the Trust not following section 26.166 of the MHCOP. This is because we can see no evidence the Trust told Mrs A what she would need to do for it to return her clothes.
67. We then looked at the impact of these failings on Mrs A and Mr A. Our mental health nurse adviser said the impact of the Trust not following the MHCOP meant that it did not protect Mrs A’s dignity. We can also see the Trust did not follow its RMPG05 Guidance, paragraph 5.6, to protect Mrs A’s dignity and respect when deciding to unclothe her for her safety.
68. We understand that this was a difficult and extremely distressing experience for Mrs A. She would have felt degraded and disrespected. We recognise that this incident was made even more difficult because of abuse she has experienced in the past. It is understandable that an incident like this would have brought back difficult memories at that specific time. We can link what the Trust did wrong to Mrs A feeling extremely upset and distressed. We can also see how this would have caused distress and frustration to Mr A when he found out. We have made recommendations to put things right.
Observation
69. Mr A said only one member of staff observed his wife in seclusion from 17 to 18 January, and for part of the time this was a male member. He said there should have been a minimum of two members of staff and not a single male staff member observing her.
70. The Trust said patients in seclusion do not need two members of staff to nurse them. After reviewing the staff rotas for the whole unit and speaking to staff who were on the unit at the time, it also confirmed it did not allocate or involve any male members of staff to care for Mrs A.
71. The discharge meeting of 9 January shows that Mrs A asked for a female support worker. The seclusion care plan said only female staff nursed Mrs A due to dignity and minimal clothing.
72. The records do not show how many staff members observed Mrs A at any one time whilst she was in seclusion. We assume there was only one as the Trust said patients in seclusion do not need two members of staff to nurse them. The records show only female staff nursed Mrs A when she was in seclusion from 17 to 18 January.
73. As we have previously explained, the records show that Mrs A was on level three observation during her time in seclusion. We consider the Trust acted in line with the CLPG8 Guidance in only allocating one staff member to observe Mrs A in seclusion. We also found that only female staff observed her at this time. Therefore, we have found no failings in these issues.
Complaint handling – nominated investigator
74. Mr A said when he raised his complaint to the matron on Ardleigh Ward they said an impartial person would investigate his complaint. However, the Trust nominated the matron, who in turn investigated his complaint. He said the matron was running the ward his wife was based at between 2 to 18 January so they would not have been impartial to deal with the complaint.
75. The Trust’s complaint department wrote to Mr A on 22 January 2019 saying the Ardleigh ward manager contacted it due to his concerns about his wife’s care and treatment. It said it would forward Mr A’s complaint to the director of mental health services and appoint an investigator. We can see the Ardleigh ward manager is the same person Mr A referred to as the matron. The Trust said it appointed the ward manager to investigate Mr A’s concerns.
76. The records from 19 December to 9 January said Mrs A was based on Ardleigh ward and the authorisation details at the end of the ward review meetings shows a doctor’s name and the ward manager’s name. Although Mrs A was based in the seclusion room, the records from 17 to 18 January do not show the ward manager’s name. We could not see any evidence in support of Mr A’s statement that the ward manager told him an impartial person would investigate his complaint.
77. The Trust’s Complaint Policy said it offers a speedy and efficient system, that is open, fair, and flexible to the needs of people wanting to make a complaint. It said directors are responsible for appointing a suitable person (not involved in the events leading up to the complaint) as the investigating officer.
78. Investigating offers will conduct a thorough investigation in a timely manner into the concerns through examination of relevant documentation. It will base their decision on the available facts and evidence, acting fairly and objectively. It said when the Trust deal with complaints fully and effectively within the service this often results in the most satisfactory outcome to complaints.
79. Our Principles of Good Complaint Handling says public bodies must ensure it investigates complaints thoroughly and fairly to establish the facts of the case. Ensuring the decisions are proportionate, appropriate, and fair, and ensuring someone not involved in the events leading to the complaint reviews it.
80. We can see that, although the ward manager signed off the ward review and discharge decisions, she was not present, directly, and actively involved in the discussions at the meetings between 19 December and 9 January. Although she would have had an overseeing role to the nurses on the Ardleigh ward, she was not directly involved in the care and treatment of Mrs A during her time in the Hospital between 19 December and 18 January. There is nothing in the Trust’s Complaints Policy and procedure that says a manager of the service complained about should not investigate a complaint.
81. From the evidence we have seen, we are satisfied the Trust acted in line with its complaint policy and our Principles of Good Complaint handling by appointing the ward manager to investigate the complaint. This is because they were not directly involved in the discussions and care and treatment leading up to the events Mr and Mrs A complained about. The ward manager was a suitable person familiar to the area of care Mrs A received. Therefore, we have not found any failing in the Trust appointing the ward manager to investigate the complaint.
Complaint handling – closed case
82. Mr A said the Trust told him it would not be taking any further action on his case on 20 February 2019. He said the Trust told him it was closing his complaint because Mrs A left the ward. He asked the Trust to put this in writing to him. It responded by saying it extended the deadline to complete the investigation.
83. The Trust apologised to Mr A for the confusion. It said it raised a safeguarding alert when Mr A raised his concerns about what happened when his wife returned to the Hospital during 17 and 18 January. The Trust then closed the safeguarding alert and investigated the issues under its complaints policy. This is because she was no longer a patient on Ardleigh ward at the time, so it removed the alleged risk.
84. We can see the Trust raised a safeguarding alert and started a complaints investigation on 21 January for the issues that happened on 17 and 18 January. The Trust contacted Mr A on 19 February and the outcome of it was to continue with the complaint investigation. The records show it attempted to call Mr A on 20 and 21 February and the call went to voice message.
85. On 11 March the ward manager emailed Mr A apologising and giving their reason for the delay in completing the investigation. They said it was due to information relating to the complaint which it decided to investigate. They then asked Mr A for an extension to complete and submit the investigation by 22 March. As Mr A was confused by this email, he responded to them on 12 March and said they told him on 20 February it closed his complaint and would not take further action.
86. From review of the information, we can see the Trust had a conversation with Mr A around 19 and 20 February about an update on his complaint. We could not see any evidence in the records that the Trust told him it closed his complaint and would not take any further action on 20 February. We do not doubt Mr A’s recollection of this conversation and it clearly caused Mr A concern. The emails in March suggests there was confusion in communication about his complaint between Mr A and the Trust. We recognise this is a shortcoming of the Trust, but we do not think this fell so far short of what should have happened to be a failing.
87. As the investigation was clearly ongoing at this point, this supports the position there was confusion in communication between Mr A and the Trust. It seems the Trust told him it closed the safeguarding concern and Mr A interpreted this as though it closed his investigation complaint.
88. As the Trust updated Mr A on the progress of the complaint, we can see the Trust acted in line with our Principles of Good Complaint Handling. This says, ‘Public bodies should keep the complainant regularly informed about progress and the reasons for any delays…’ It also says that public bodies should respond flexibly to the circumstances of the case. The Trust did by incorporating all his concerns in the complaint investigation.
89. In addition, we can see the Trust acted in line with our Principles of Good Administration by doing what it said it would do. This is because the Trust continued with the complaint investigation as it said it would. We see no concerns and no failing in this issue.