Discharge
11. Firstly, we looked at whether the Trust considered Mr E’s needs.
12. Care Programme Approach (CPA) is a framework for managing secondary mental healthcare. The Trust’s CPA policy says all service users should have a formal review from their care team, including the psychiatrist, at least once a year. It also says the decision to discharge will be agreed within a CPA review and the psychiatrist should be directly involved in the decision-making.
13. Mr U says Mr E needed 24-hour care and monitoring and he sometimes experienced negative, suicidal thoughts. Mr U feels Mr E’s notes show the severity of his needs and how he needed more than the therapy the Trust were offering. He feels the Trust should have continued to provide care for as long as Mr E needed it, and it was flawed to discharge him until he was ready for face-to-face support.
14. We considered Mr E’s care records. The Trust did a CPA review virtually via Attend Anywhere on 12 January 2021. It noted his low mood and worry about getting COVID-19. The Trust did a risk assessment and found Mr E to be at low risk to himself and others. It planned to see him when he had his first COVID-19 vaccination.
15. The next CPA review was on 17 May 2021 and done via Attend Anywhere. The records say Mr E appeared ‘settled and calm in mood’, that he said his mental state had been up and down, and that he had been struggling to get through the day and had not accessed the community for 18 months because of COVID-19. The notes say he had suicidal thoughts but had no plans to act on these. The noted plan included completing graded exposure work (therapy to help overcome anxiety and phobias) once they could start face-to-face appointments. After this, the Trust planned to discuss a referral to cognitive behavioural therapy (CBT) with Mr E.
16. It appears the Trust met the requirements of the CPA policy and did a CPA review more regularly than once a year. The Trust’s notes show it was aware of Mr E’s mood and state and that he had suicidal thoughts. It assessed these risks and made a care plan accordingly.
17. We have not seen anything in the care notes to suggest a significant change in Mr E’s mental health from May 2021. From what we have seen, the Trust were fully aware of Mr E’s needs.
18. We listened to what Mr U says and how we feels Mr E’s needs were severe, and he needed more than the Trust were offering. Based on what we have seen, there are no signs that Mr E was asking for more help or that his needs meant the care plan was not enough. For this reason, we do not consider the Trust failed to understand the seriousness of Mr E’s needs. There is also evidence of the psychiatrist being involved in the decision to discharge and this is in line with the CPA policy. It did not discharge Mr E because it considered he had no needs, or because it did not understand his needs. The Trust had clearly set out his needs in his care plan. It discharged Mr E because he was unable to start the treatment it had offered. By doing this, it left open the possibility of Mr E being readmitted to services once he was ready. Until then, the Trust made sure other services were available to give contact and support. We will also discuss this further below.
19. Secondly, we looked at whether the Trust considered Mr E’s vulnerability to COVID-19. In May 2021 the government confirmed health services remained open including mental health services. Restrictions on indoor and outdoor gatherings were lifted. People who had their second COVID-19 vaccine would be due a booster six months later. On 27 September 2021 the government reduced the recommendation for social distancing from two metres to one metre. It recommended that face masks continued to be worn in clinical areas.
20. Mr U says Mr E had the second vaccine in May 2021 and agreed to see the community psychiatric nurse (CPN) in the garden from this time. He says in October when they knew they were due to have the third vaccine, he asked to go back to Attend Anywhere until they were fully vaccinated. He says at the time Mr E struggled to go out of the house and his GP records show this. Mr U explains Mr E was having his booster on 6 November which would have allowed him to interact more in the community.
21. Based on the government guidance at the time, it was important for the Trust to continue to offer mental health support. As Mr E had his second vaccine in May, he was due the booster in November. By this time the government had reduced the socially distancing measures but encouraged face masks for safety.
22. We consider the Trust did consider Mr E’s vulnerability to COVID-19. We can see from Mr E’s CPA review in January 2021 the Trust were aware he was worried about getting COVID 19, that he wanted to have the vaccine before going out of the house and, at that time, he had not been in the garden. It agreed to hold sessions with him virtually until he had his second vaccine. Our view is this shows the Trust were considerate of Mr E’s concerns.
23. After Mr E had the second vaccine, it was reasonable for the Trust to explore face-to-face support, as this was not against government guidelines as long as safety measures were taken. Mr E had regular virtual sessions with his CPN since the care plan was made in May 2021. There is evidence of the Trust having ongoing discussions with Mr E about moving to face-to-face consultations and accessing services within the community. It was not until 18 August and 6 September that Mr E and Mr U agreed to a home visit in the garden. The notes show the CPN offered to show a negative lateral flow test each time and sat socially distanced.
24. We understand that once Mr U knew they were due to have a booster, he wanted them to be fully vaccinated before continuing with face-to-face support. The government guidance did not change to say that until someone was fully vaccinated it was not safe to continue following the recommendation to social distance and wear a face mask. The Trust offered to start the planned work and take all measures to keep Mr E, Mr U and staff safe. This planned treatment did not conflict with government guidance at the time. We have seen evidence of the Trust completing risk assessments for Mr E. On 28 October 2021 it did a COVID Dynamic risk rating assessment and found Mr E to be at low risk and not in a high-risk group.
25. We fully appreciate Mr E had the right to decline treatment until he felt comfortable to start it. We do not think the Trust’s decision to discharge Mr E was wrong or that it failed to think about his physical or mental safety. It respected his right to decline treatment. We realise Mr U wanted the Trust to wait until they had the booster. While the Trust could have done this, by discharging him it let them choose when the time was right for them. The discharge was meant to be temporary until Mr E felt able to continue with the planned care.
26. Thirdly, we looked at whether the Trust provided Mr E with access to support when it discharged him.
27. The Trust’s CPA policy says before discharge the care plan should be updated to reflect how the service user’s needs will be managed in the community. It says consideration should be given to any ongoing care or support needed and possible future involvement with service users. It says a copy of the discharge care plan giving details of advice/information about how to access the service in future, should be given to the service user and GP.
28. Mr U says the Trust cut Mr E off at the worst time as it was approaching the anniversary of this mother’s death and it knew this.
29. We listened to what Mr U told us and understand why he feels discharging Mr E at this time of year was not the right thing to do. We can see from the care notes that the Trust were aware that Christmas time was particularly hard for Mr E. The Trust’s CPA policy makes it clear that a service user should not be discharged without considering their need for ongoing support from other services and their care plan should be updated. According to the policy, it is important for this not only to be considered, but for information on accessing these services to be shared with the service user and GP. We looked at whether the Trust did this.
30. We have seen evidence of the Trust updating Mr E’s care plan before he was discharged. The care plan includes information about what services are available and how to access them if needed (the crisis and contingency care plan). These services include organisations to offer support for dealing with grief and services that are available daily if a person needs to talk to someone. A copy of this was sent to Mr E and his GP. It says if his mental health deteriorates, Mr E can discuss this with the GP and a referral can be completed. The Trust also completed a risk assessment before discharging Mr E.
31. This tells us the Trust acted in line with its policy and gave information to Mr E to support his ongoing needs. We accept this decision came at a challenging time of year for Mr E and, due to his mental health, the decision was hard to process. We are reassured the Trust put appropriate advice in place to try to support Mr E until the time he was able to continue with the planned treatment.
Engagement
32. The Trust’s CPA policy says, ‘All possible efforts must be made by the Care Coordinator to stay in touch with the Service User and work at developing a relationship that will enable increased engagement…Service Users must not be discharged solely for disengaging or failing to keep a fixed amount of appointments’.
33. Mr U says Mr E did what the Trust asked him to do although this was difficult for him. He feels the Trust made a decision which punished him although he did nothing wrong. He says this is the first time Mr E has been discharged in 17 years.
34. From the care records we can see the CPN had regular contact with Mr E and the documented sessions show they had a good relationship. We have not seen anything to suggest the CPN failed to keep in touch or to develop a good relationship. We realise this is particularly important to Mr E as he had not always had with the same CPN’s and psychiatrists caring for him. We are also aware that for many service users engaging is not easy and the pandemic increased these challenges.
35. The care records show the Trust were trying to follow the agreed treatment plan and to start working with Mr E to support his anxiety and ability to interact with the community. The care plans show that it tried to encourage face-to-face support so this work could start. This indicates the Trust were working towards more engagement so Mr E could benefit from the service it was offering.
36. The notes from the Trust’s meeting on 13 October 2021 say Mr E reported low mood, anxiety and suicidal thoughts but had no plans to act on these. He was mostly isolated due to his mental health and COVID-19. It says it can offer graded exposure work but this requires face-to-face contact. It notes that if he cannot engage with this, it will consider discharge as it has nothing else to offer.
37. The policy makes it clear that a service user should not be discharged just because they are not engaging. We can see Mr E was engaging with his virtual appointments but did not feel ready for face-to-face therapy, which was the next stage of his plan. We think this put the Trust in a difficult position as it was offering Mr E face-to-face therapy that did not conflict with government guidelines. But, as we have said, Mr E had the right to decline this. We thought carefully about what the Trust should do in this situation. We do not think it was unreasonable for the Trust to discharge Mr E as he did not feel ready for the treatment, and there was nothing else it could offer. Our view is this would have been different if the Trust could offer services but did not, and the service user was wanting to access more support.
38. We are not critical of Mr E’s choice and have not seen anything to suggest the Trust were saying he had done anything wrong. We hope this gives Mr E and Mr U some reassurance. We are saying as the treatment offered was not accepted at the time, it was appropriate to discharge Mr E until this changed.
Communication
39. The Trust’s CPA policy says discharge should be discussed with the service user and any carers involved. It says the reason for discharge must be clear and the Trust should ask for the service user’s views.
40. Mr U says they only found out about the discharge decision from the doctor. He says there were no discussions before. He says the CPN called once saying there had been a meeting and if Mr E could not meet face-to-face with the care team by a certain date, he would be discharged. He says he asked if the Trust could wait until Mr E had his booster but the Trust ignored this. He says any discussions were one or two weeks before the decision at most and the Trust refused to go back and reconsider, despite the CPN promising this.
41. We looked for evidence to see if the Trust’s communication was in line with the policy requirements. The care notes show the Trust had a meeting on 13 October 2021 to discuss Mr E’s care. We referred to this above. We have seen evidence of the CPN calling Mr E on 15 October and explaining the care team had met, reviewed what support it could offer and decided that if he felt unable to have the suggested treatment, it would look at discharging him until he felt ready. The records say the CPN explained they had previously discussed how graded exposure work needed to be completed but this had not been started because of concerns with COVID-19. The notes say the CPN had been trying to start this work since March but appointments had been virtual only. Then, as requested, the Trust waited until Mr E had his second vaccine. The CPN says she had done two home visits but now Mr U wanted to wait until they had the booster.
42. The CPN also discussed this with Mr U at the time. The records note he expressed his concerns, wanted to make a complaint and for management to call him. The records confirm the Trust tried to make contact on 22 October 2021 and spoke to Mr U on 27 October. The notes from the telephone call on 27 October are detailed. Mr U wanted to speak to a manager or the psychiatrist before getting a discharge letter in the post. The CPN agreed to discuss this with the manager and psychiatrist. We have seen evidence of the CPN emailing these persons on 28 October to pass on what was discussed. Notes from 8 November say the CPN discussed the discharge and concerns with the psychiatrist who agreed that discharge was the right thing to do.
43. Our view is the Trust met the requirements of its policy as there is evidence of it discussing the discharge with Mr E and Mr U, explaining why it was planning the discharge and discussing the concerns with this. We have not seen evidence to support that Mr U only found out about the discharge from his doctor.
44. We appreciate Mr U feels the discharge was not a discussion. We accept that in the end it was the Trust’s decision, but we consider it did discuss this with them. We have seen evidence of the CPN noting Mr U’s concerns in detail and taking these back to their manager and the psychiatrist to consider. The records confirm the psychiatrist reviewed the concerns but still felt the decision was appropriate. As we noted above, it is a requirement for the psychiatrist to be involved in the decision-making.
Summary
45. We realise Mr U may find our decision disappointing. Although it is not the outcome he wanted, we hope it gives him some reassurance that as an independent organisation we listened and have taken his complaint seriously.
46. We know Mr E and Mr U decided not to be referred back to the Trust after having their boosters. Mr U explained Mr E struggled to see his doctor and felt uncomfortable going back because of the Trust’s decision. We are sorry to hear this stopped them from feeling able to get support. Mr U told us this resulted in Mr E being admitted to A & E as his mental health deteriorated. Mr U says it is important to them to know out of principle if the Trust got it wrong. As we have not seen signs of failings in the Trust’s actions or of it being unwilling to support Mr E again, we hope this will give them the confidence to be referred back if they want to do this.