Communication about care plan
19. Mr A complained the lack of clear planning makes it ‘very difficult for patients to feel like they have a clear plan or direction for their care’. He said Ms E made it clear to staff, at the beginning of her stay, how lack of clarity and communication is distressing for her.
20. The Trust explained how STEPS flexibly plans the content of group sessions around the immediate clinical needs of patients rather than using a standardised programme drawn up in advance. This means STEPS only decides the contents of the session one day in advance of it taking place.
21. The Trust said the clinical team at STEPS regularly reviews patients to assess individual clinical needs. It said this involves looking at the need for admission, readiness for discharge and progress towards treatment goals. It said the clinical team discuss this with patients and carers during ward rounds.
22. The Trust explained it had made reasonable adjustments for Ms E’s care. Regarding communication, for example, the Trust said Ms E received an agenda ahead of meeting her specialist eating disorder nurse. This was followed by a summary of points discussed in the meeting and agreed actions.
23. The DOH guidance outlines what support individuals need in secondary mental health services through the care programme approach (CPA). It says care plans should include several elements, such as:
• crisis and contingency plans • ‘setting out, measuring and reviewing specific outcomes’ • ‘identifying whether an individual has good relationships and support from family [and] friends’ • addressing physical health needs, and • assessing and reviewing medication issues.
24. Section 1.11.11 of the NICE guidance says to ‘develop a care plan for each person with an eating disorder who is admitted to inpatient care. The care plan should:
• give clear objectives and outcomes for the admission • be developed in collaboration with the person, their family members or carers (as appropriate), and the community-based eating disorder service…’
25. We can see evidence of care planning in the medical records soon after Ms E was admitted to STEPS on 12 September 2019. For example, on 14 September, a ‘crisis, relapse and contingency plan’ was developed that refers to her concerns and views. It notes that, for Ms E, ‘when having thoughts of self-harm, you have found getting out of the house and making plans with people a useful strategy’. This is in line with the DOH guidance.
26. We think clear objectives and outcomes for Ms E’s admission were documented in a series of care plan review documents. For example, we can see:
• on 12 September – several documents outlining why Ms E had been admitted as an inpatient, the reasons for assessing and monitoring her physical health (including medication), nutrition, and information about inpatient discharge, and • on 14 September – a document outlining how clinicians and staff would review Ms E’s care weekly (ward rounds), and how she could share her own view of her treatment.
27. Ms E signed off these documents. There is further evidence of these documents during her stay as an inpatient, some written as if they were from Ms E and she is quoted in several others.
28. We can see there were also weekly ward rounds which involved Ms E, clinicians and, occasionally, Mr A. They reviewed Ms E’s care and treatment and planned for the week ahead and/or longer, such as discharge planning. This is all in line with NICE guidance.
29. We think the records reflect how Ms E received regular and extensive care plan reviews during her time as an inpatient at STEPS. Our adviser says these records are clear in their objectives and outcomes, and had input from Ms E, Mr A and the clinicians involved in her care.
30. We do not underestimate how distressing and challenging this time was for Ms E and Mr A, as he was supporting her. In particular, they strongly believe no thorough care planning took place and there was a lack of clarity. We are sorry to hear of their concerns.
31. Based on the number and detail of the records, the signatures of clinical staff and Ms E, the Trust has acted in line with DOH and NICE guidance.
32. We recognise our decision here is not the outcome Mr A and Ms E were hoping for. We would like to assure them that we have carefully considered what they have told us when reaching our final decision.
33. We have found no failings in the way the Trust communicated with Ms E about her care planning. We are not upholding this part of the complaint.
Debriefs
34. Mr A complained the Trust did not undertake ‘proper’ debriefs after giving IM medication to Ms E. The Trust’s response said in instances where IM medication was used, it always offered Ms E a verbal debrief.
35. The Trust’s internal policy defines rapid tranquilisation as being ‘the intramuscular use of medication to quickly calm or lightly sedate, thereby achieving an optimal reduction in service user agitation’.
36. The rapid tranquilisation policy says after clinicians give rapid tranquilisation to a patient, they should monitor the person’s mental state, hydration, side effects and physical health observations, such as blood pressure, heart rate and level of consciousness.
37. The Trust’s policy goes on to say a ‘post incident review’ is to be carried out by a doctor and nurse immediately following the risk of harm. The Trust has explained to us that this is because of the potential for physical or emotional harm. It said this must be clearly documented in the notes.
38. The Trust’s policy also says to ensure ‘the service user [patient]… involved has the opportunity to discuss the incident in a supportive environment with a member of staff or an advocate or a carer’.
39. In terms of a debrief, the Trust says this is about offering emotional support following what is often a traumatic event for a patient. The Trust says this should be carried out by someone who knows the person well and has a therapeutic relationship with them. It says this should be done at a time that is right for the patient, so it can be difficult to say when this should be done.
40. The Trust gave IM medication to Ms E’s several times while she was an inpatient. We looked at the medical records to see the date the IM medication was given, the dosage and whether there was a debrief.
41. From the evidence, a doctor or nurse took physical observations soon after the incident. We think the notes show Ms E did receive some emotional support after the incident.
42. The notes are unclear as to whether a doctor and nurse conducted a joint review immediately after the incident. The records show when Ms E was given IM medication, staff were with her while her distress decreased but there is nothing more specific.
43. The Trust’s policy is very clear that a doctor and a nurse must carry out a review. Based on the evidence we have seen, we cannot see joint reviews were carried out. We think there is evidence showing the Trust has acted in line with other aspects of the policy, such as providing emotional support and taking physical observations.
44. On balance, based on the evidence, there are failings in the way the Trust carried out the debriefings. In line with the Trust’s own policy, a doctor and nurse should have undertaken the debriefs with Ms E, but the evidence does not show this took place.
45. We have gone on to consider the impact of this failing. Mr A told us Ms E was distressed by the lack of debriefs after being given IM medication.
46. We cannot begin to imagine the distress Ms E must have been going through. As we have outlined previously, we think there is evidence the STEPS team carried out debriefs, which provided Ms E with emotional support.
47. Therefore, while we recognise Ms E was distressed at the time of these events, we cannot say this distress was caused by the failings we have identified. We are partly upholding this part of the complaint.
Weight restoration and impact of anorexia
48. Mr A complained the Trust only focused on weight gain as part of Ms E’s recovery. He also said the Trust did not consider the impact of the distress Ms E experiences from her anorexia as part of her treatment.
49. The Trust’s response explained there can be a difference of opinion between the patient and the service as to what it can, or should, offer. It said STEPS’ clinical model for inpatients is not designed to address all a patient’s needs concerning their eating disorder. It said it is designed to achieve a specific goal, which was weight stabilisation in Ms E’s case. The Trust said the other issues were to be addressed through support and care in the community.
50. Our adviser has explained there are many aspects which need to be looked at when considering inpatient care for eating disorders and weight goals. They have told us that it is a complex matter.
51. Sections 1.11.1 and 1.11.3 of the NICE guidance outline the circumstances in which inpatient care is suitable, including when to continue with inpatient care and when to discharge. The guidance says:
• ‘Admit people with an eating disorder whose physical health is severely compromised to a medical inpatient or day patient service for medication stabilisations and to initiate refeeding, if these cannot be done in an outpatient setting.
• When deciding whether day patient or inpatient care is most appropriate, take the following into account:
o The person’s BMI or weight, and whether these can be safely managed in a day patient service or whether the rate of weight loss (for example, more than 1kg a week) means they need inpatient care.’
52. Both sections indicate that the main criteria for inpatient or day-patient care for an eating disorder is the level of physical risk.
53. In terms of the support given to people with an eating disorder, section 1.1.8 of the NICE guidance says: ‘Assess the impact of the home, education, work and wide social environment (including the internet and social media) on each person’s eating disorder. Address their emotional, education, employment, and social needs throughout the treatment.’
54. As set out above, we have seen Ms E was involved in her care planning and the Trust adequately communicated the aims and objectives to her. From the evidence we have seen, this included the impact on her:
• physical health (BMI) – there are several mentions in the notes about how Ms E felt when gaining weight and the effects of her medication.
• emotional and social needs – mental state examinations (which assess a person’s behaviour mental state at the time) happened frequently. Ms E’s social exchanges and involvement while she was an inpatient are also noted in the records, especially regarding what she enjoyed and what she had been struggling with.
• employment and education – the notes show Ms E had attended some Bristol Wellbeing College courses and had completed some online courses related to mental health.
55. Our adviser has reviewed the case notes. They could see no evidence to suggest the Trust had failed to consider the distress Ms E experienced because of her eating disorder.
56. One of the main reasons for Ms E’s admission as an inpatient was her level of physical risk. This was the same when she was initially admitted voluntarily to STEPS. Ms E’s other mental health needs and her physical needs were addressed throughout her treatment.
57. Having considered the evidence available, we think the Trust has met the requirements outlined in the NICE guidance. As a result, we find no failings in the overall way STEPS provided treatment for Ms E’s weight gain and addressed her other mental health needs.
58. We accept our view here is very different to Mr A and Ms E’s. This does not take away from their experiences and we do not underestimate any lasting impact this has on Ms E’s recovery.
59. Based on the evidence, the Trust has acted in line with the NICE guidance. We are not upholding this part of the complaint.
60. Understandably, the way the Trust accounted for Ms E’s autism also affects her treatment and Mr A said it caused her distress. We cover this in another part of the report.
Weight goals
61. Mr A said STEPS did not challenge the weight goal Ms E set herself. He says it would have been considered an underweight BMI.
62. Our adviser has explained leading specialists hold a wide variety of opinions about weight goals.
63. The NHS guidance says that the ‘normal’ or ‘ideal’ BMI range for most adults is between 18.5 and 24.9. The MARSIPAN guidance further classifies BMI into three risk categories:
• high risk – less than 13 • medium risk – between 13 and 15, and • low risk – between 15 and 17.5.
64. Our adviser referred to the European study, which includes data from Maudsley Hospital in London among others. In this large trial, a patient’s discharge weight was an average of around 17.5.
65. Sections 1.11.1 and 1.11.3 of the NICE guidance is applicable here. Our adviser explained if a patient is not at high risk physically from their eating disorder, treatment should be in the community, through outpatient or day care. We are using the category of ‘high risk’ from the MARSIPAN guidance (set out in paragraph 63).
66. The records show that Ms E and the Trust jointly agreed about her reaching 50kg. This works out as a target BMI of 17.5. According to the NHS guidance, this is still classed as ‘underweight’. The MARSIPAN guidance classes this BMI level as low risk (and at the limit of low and no risk).
67. In carefully considering the evidence, on balance, the weight goal Ms E and the Trust agreed is in line with the MARSIPAN guidance and the European study. We accept here that, as we have set out, this BMI would be underweight according to the NHS guidance and we can understand Mr A’s concern.
68. That said, the records show that in preparation for Ms E’s discharge, she wanted support from community teams to help her manage several issues, including maintaining her weight.
69. We can see there were attempts to put plans in place with the involvement of Ms E. We can see Ms E became more distressed closer to her discharge date. The records show the community team was unable to agree specific goals as it felt Ms E’s behaviour was too risky to be managed in the community at that time.
70. While Ms E’s discharge BMI is not considered ‘normal’, the evidence suggests that her physical risk had decreased to a low level according to the MARSIPAN guidance. Her discharge BMI level was also in line with the average BMI, as shown in the European study.
71. We recognise Mr A strongly believes the way Ms E’s weight goal was set was not right. We also recognise the guidance regarding this is varied.
72. Overall, we find no failings in the way Ms E’s weight goal was set. We hope the above explanations provide some reassurance that the Trust’s actions for this part of the complaint were in line with the relevant standards and information. We are not upholding this part of the complaint.
Autism
73. Mr A complained the Trust did not take into account how Ms E’s autism was causing her distress as an inpatient. For example, she was distressed about changed routines and sensory sensitivity. He said the Trust was not able to provide Ms E with more tailored treatment because of this.
74. The Trust explained it had sought advice from the Bristol Autism Spectrum Service (BASS) to make reasonable adjustments. It said it accepted the ward environment was likely to be very challenging to Ms E, especially due to the limited scope for individual privacy.
75. The Trust provided some examples of when staff had made reasonable adjustments, such as giving Ms E an agenda in advance of meeting her specialist eating disorder nurse. Overall, the Trust accepted the ward would have posed specific challenges for Ms E.
76. Section 15b of the GMC guidance says doctors ‘must promptly provide or arrange suitable advice, investigations or treatment where necessary’. Section 8.1 of the NMC guidance says nurses must ‘respect the skills, expertise and contributions of your colleagues, referring matters to them when appropriate’.
77. Our Principles of Good Administration say that organisations should ‘treat people with sensitivity, bearing in mind their individual needs, and respond flexibly to the circumstances of the case’.
78. We have seen evidence in the records to show the STEPS team attempted to meet Ms E’s needs. For example:
• The Trust contacted BASS for advice and the notes show it did receive some input, for example, about keeping to rules and boundaries.
• Ms E struggled with the temperature on the ward (she felt it was too hot), which distressed her. The staff attempted to fix the heater in her room, but eventually allowed her to change rooms, which helped her.
• On 26 September 2019, it was noted that Ms E felt ‘lunch was unbearable’ as her peer, sat opposite, talked throughout. Noise is difficult for Ms E to manage because of her autism. The Trust offered the opportunity for Ms E to continue lunch in its quiet room for that day only.
• The Trust gave Ms E a written summary following a ward round.
79. The above examples are in line with the GMC and NMC guidance. We can see the Trust sought advice from a specialist service to see what it could do to help Ms E. Its actions were also in line with our Principles of Good Administration as it was trying to act as flexibly as it could in response to Ms E’s needs.
80. We appreciate the environment on an inpatient eating disorder ward must have been very challenging for Ms E. We can see the Trust also accepted this. While we have seen some examples of where the Trust took steps to help Ms E, there were some instances during her stay that caused her to struggle. For example:
• changing her place at the table without telling her • cancelling groups without much notice, and • communication misunderstandings about meeting times (such as her keyworker meeting her earlier than planned).
81. We consider whether an organisation’s actions have fallen so far below expectations they are a service failing. In this instance, there were shortcomings in the Trust’s actions as there are times it could have done more.
82. When considering the evidence, we think these shortcomings did not fall so far below the level we would expect, so we cannot say they are a service failing. We appreciate Mr A and Ms E will find this disappointing. We are not upholding this part of the complaint.
Medication dosages
83. Mr A complained Ms E was given sustained, non-consistent doses of benzodiazepines, contrary to NICE guidelines.
84. Our adviser has explained Ms E was prescribed benzodiazepines (lorazepam) for two reasons. Firstly, her GP had prescribed oral lorazepam tablets before her admission to STEPS to manage her underlying anxiety. Secondly, IM lorazepam was used to manage her self-harming and absconding behaviour.
85. The MHRA guidance issued a drug safety update in 2007. This indicates the maximum recommended dose for lorazepam is 4mg in 24 hours.
86. The BNF recommended dose for short-term use in anxiety is between 1mg and 4mg daily, to be taken orally. This is relevant for the management of Ms E’s underlying anxiety. We have reviewed the medication charts and see the Trust never offered Ms E more than the daily recommended amount of oral lorazepam.
87. The BNF guidance for acute panic attacks (one a way of describing periods of Ms E’s intense distress) is to administer between 1.5mg and 2.5mg every six hours if required, by IM injection.
88. Having reviewed the medication charts, we see Ms E received several IM doses of lorazepam, usually 1mg or 2mg, for extreme distress. The records show this usage was within the recommended limits, except for one occasion when 6mg was administered in 24 hours (22 to 23 November). We do not think this is in line with the MHRA and BNF guidance.
89. We asked our adviser if there could have been any clinical impact because of this single higher dose over a 24-hour period. They said that before the MHRA reduced the maximum dosage to 4mg, it had been 10mg. They explained the reason for the reduction was to do with withdrawal symptoms, rather than because of its toxicity. Our adviser does not consider the higher dose was of clinical significance, although we recognise it may be alarming.
90. We appreciate this information may cause Mr A and Ms E further concern about the use of benzodiazepines. Except for one instance, the doses given were in line with the BNF and MHRA guidance.
91. In deciding whether there are failings, we consider whether an organisation’s actions have fallen so far below expectations they are a service failing. In this case, there was a shortcoming in that the Trust did not follow the guidance on one occasion.
92. We appreciate Mr A and Ms E’s concerns. We hope the advice provided by our adviser about the lack of clinical impact on Ms E will provide some reassurance to them.
93. Considering the evidence, we find no failings in the way the Trust gave benzodiazepines to Ms E.
Transfer to the mental health care facility
94. Mr A complained Ms E was transferred to a mental health care facility after being discharged as an inpatient from STEPS. This was against Ms E and Mr A’s wishes. They say this was an inappropriate place for Ms E to be discharged.
95. In its complaint response, the Trust explained it did not extend Ms E’s stay because the therapeutic goal had been achieved and there was limited clinical benefit for her to stay longer. It explained the clinical team was concerned that, instead of treating her eating disorder, they were managing her rising acute mental distress and subsequent behaviour (attempts to abscond and increasing use of sedation, restraints and so on).
96. The Trust recognised the decision to discharge Ms E to the mental health care facility was difficult. But, in considering the above factors, it felt a transfer to an acute psychiatric bed at the facility was the only available option.
97. The Trust said discharge into the community was not considered viable. This is because Ms E declined to work with the crisis team. She felt her autism would make it difficult to interact with different staff each day, which is how the service works.
98. Sections 1.11.4 and 1.11.5 of the NICE guidance say:
• ‘When reviewing the need for inpatient care as part of an integrated treatment programme for a person with an eating disorder:
o Do not use inpatient care solely to provide psychological treatment for eating disorders o Do not discharge people solely because they have reached a healthy weight.
• For people with an eating disorder and acute mental health risk (such as significant suicide risk), consider psychiatric crisis care or psychiatric inpatient care.’
99. Ms E reached the weight goal she and the STEPS team had jointly agreed. Our adviser explained achieving weight gain does not end with hospital discharge but continues during therapy after leaving hospital. The aim for Ms E was to carry on receiving support for her eating disorder in the community.
100. Even though Ms E had reached her target weight, this formed only part of the Trust’s decision to discharge her and not extend her time as an inpatient.
101. Another factor was the rise in Ms E’s risky behaviour, such as attempting to abscond from the unit and her increased acute distress needing IM medication. This was especially the case after Ms E learned of the decision to discharge her, which we can see she found very distressing. It was becoming difficult for the staff to manage her behaviour.
102. Considering the evidence, the decision to discharge Ms E to the mental health care facility (a general psychiatric unit) was in line with the NICE guidance. There are no failings here and we are not upholding this part of the complaint.