Crisis team
17. Before we decide if we should do a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not seen any signs that something has gone wrong.
18. Ms E complains that when the crisis team visited her on 12, 15 and 18 February 2022 they did not listen to her concerns.
19. In its complaint response the Trust stated it was expected that people may have needed to ask the same questions on different visits, because Ms E’s situation may have changed. It explained they may also need clarification or more detail to help them find the best way to support her.
20. Records show Ms E’s GP referred her to the crisis team on 11 February because they were worried about Ms E’s mental health due to reports of her swallowing cleaning products. The crisis team SOP says assessments should make sure the person using the service is actively involved.
21. The records show the crisis team visited Ms E on 12, 15 and 18 February. The notes show they listened to Ms E’s concerns about her physical health and the impact this has on her daily life. The records also show they discussed the GP’s concerns with Ms E and noted her opinion that these came from her mother and were untrue.
22. The records also show they asked Ms E what she thought would help her. She felt mental health services would not be of benefit to her because her concerns come from her physical health. The crisis team suggested a referral to the eating disorder service. Ms E agreed although she did not expect this to be helpful. We understand from our adviser there is nothing in the notes to suggest the crisis team did not listen to Ms E.
23. Ms E also complains that when the crisis team visited her on 15 and 18 February they did not give her options for her engagement with mental health services or offer access to community support groups or other health support.
24. It was not clear in Ms E’s complaint to the Trust that this was a concern she wanted it to address, so it has not given a response. But, we have considered it as it would have been unfair to ask Ms E to return to the Trust on this point.
25. We have reviewed the crisis team SOP and it says: ‘A mental health crisis is when someone is experiencing a period of acute psychological distress, associated with a mental health problem. The crisis may be a sudden deterioration of an existing mental health problem or they may be experiencing mental health problems for the first time.
The Crisis Service receives and manages those individuals whose needs for assessment, safety or treatment cannot be effectively delivered through primary care, or the recovery service.’
26. Our adviser explained a crisis team supports people who are currently experiencing a mental health crisis, as described in the SOP. We understand from our adviser it would not be appropriate for a crisis team to refer a patient to community support groups when they are in crisis. This is because the patient may not be able to tolerate groups while in crisis.
27. The crisis team SOP states it manages individuals whose safety and treatment cannot be managed through primary care (a GP). We understand from our adviser that referral to community groups would be done through primary care.
28. For options for engagement with mental health services, the crisis team SOP states the service makes clinical assessments to provide the least restrictive intervention (help) for a service user.
29. We can see from Ms E’s records that the crisis team took and recorded her views during its assessment. The records detail Ms E’s view that her difficulties are caused by her physical health, not her mental health. They say she does not think support from mental health services would be helpful to her. They also include a record of Ms E’s belief that her mother was responsible for raising concerns about her drinking cleaning fluids and that this is not true.
30. We can also see from the crisis team records that on 12 February it discussed a referral to the eating disorders clinic with Ms E, who agreed to the referral. The records show Ms E’s GP made the referral on 16 February, after discussing this with Ms E on 14 February.
31. With other health support, the records show that on 12 February the crisis team requested a consultant complete a medical review to see what support they could offer Ms E. The records show the Trust completed a physical health review on 24 February, when Ms E was an inpatient.
32. Considering the available evidence, our view is the crisis team acted in line with the SOP when visiting Ms E to assess her mental health. We cannot see any signs that the crisis team did anything wrong. There is nothing we need to ask the Trust to do on this part of the complaint.
Inpatient care
33. We have looked at what should have happened and what did happen. We have not seen any signs that something went wrong.
Freedom of movement
34. Ms E complains the Trust did not allow her free movement around the ward or to leave the ward.
35. In its response the Trust stated service users detained under the Mental Health Act need to have Section 17 leave written up by the ward consultant, before they can legally leave the ward. It explained there are a number of factors that are considered and the presentation and behaviour of the service user on the ward, including compliance with a treatment plan is also taken into account. When someone is first detained there is often a period of assessment to decide when it is safe for them to leave the ward.
36. The Mental Health Act, Section 17, allows detained patients to be granted leave of absence from hospital. Leave is an agreed absence, for a defined purpose and duration and is accepted as an important part of the patient’s treatment plan.
37. On 2 March the Trust agreed to Ms E being allowed four hours of unescorted leave each day. When she requested to use that leave, the Trust refused. The records show the Trust’s reasons for denying leave were that it was dark and this would be Ms E’s first leave.
38. We understand from our adviser that the Trust acted in line with the Mental Health Act when it waited six days to grant Ms E leave. This is because it was using the time to assess her. GMC’s Good medical practice (paragraph 15) also says doctors should properly assess a patient’s condition. We think the Trust did this.
39. It was also in line with the Mental Health Act for the Trust to deny Ms E leave when she requested it after dark. This is because it says leave can be subject to certain conditions in the interests of the patient.
40. Ms E feels the Trust did not allow her free movement around the ward. We have reviewed Ms E’s medical records. They show no evidence that Ms E was restricted in her movement around the ward.
41. Notes from the records on 25 February state she was ‘visible around the ward’ and ‘she has sat in the dining room and has been walking around the ward.’ On the 26 February notes state, ‘has spent time in the female area of the ward’ and ‘spent majority of the afternoon in communal areas and some of it in the garden.’ We have seen similar entries for each day Ms E was an inpatient at the Trust.
42. Considering the available evidence, our view is the Trust acted in line with the Mental Health Act. We cannot see any signs that the Trust did anything wrong and we will take no further action on this part of the complaint.
Wash facilities
43. Ms E complains the Trust did not provide access to the correct toilet or wash facilities for her stomach and bowel conditions. Miss E says because of her bowel condition she showers a lot and the shower was not close by and did not have a flexi-hose. She also uses the toilet very often.
44. In its response the Trust stated the bedrooms on the ward have ensuite facilities. It explained the sanitary ware must meet strict health and safety criteria to make sure it is no danger to service users. This includes making sure the fixtures and fittings cannot be used by service users to harm themselves and this is why there are no showers with flexi-hoses.
45. We understand from our adviser there are no guidelines that specify the type of wash facilities or toilet a patient should have access to. The records show Ms E was able to access a toilet and shower and used these on a regular basis. The records do not say Ms E raised any concerns at the time about the wash facilities not meeting her needs. If she had, we would have expected the Trust to consider this and whether it could make any changes.
46. Considering the available evidence, our view is the Trust provided Ms E with wash facilities she could access. We cannot see any signs that the Trust did anything wrong and we will take no further action on this part of the complaint.
Diet and supplements
47. Ms E complains the Trust did not provide her with the correct diet for her physical health conditions. She also complains it did not give her access to the supplements and alternative therapies she normally used at home.
48. It was not clear in Ms E’s complaint to the Trust that she was concerned about these points, so it has not provided a response. We have considered it as it would have been unfair to ask Ms E to return to the Trust on this point.
49. The MHA Code of practice states good nutrition and access to dietary advice is essential for healthy outcomes. It says patients should have their nutritional state assessed on admission and at regular times, using an accredited screening tool. It also says providers should offer food and drink that meets the needs of all their patients.
50. We can see from the available evidence that the Trust had a food and drink offer in place that met a variety of dietary requirements.
51. We can see from Ms E’s records on 24 February that the Trust did attempt to complete a Malnutrition Universal Screening Tool (MUST) assessment for Ms E. The records show Ms E declined to consent to the actions needed to complete the MUST, like having her height and weight measured and recorded. The Trust were correct not to complete the MUST screener as it needed Ms E’s consent to do so.
52. We can also see from Ms E’s records on 24 February that the Trust completed the admission clerking, which included a detailed conversation with Ms E about her physical health. We can also see the Trust completed a medical review with Ms E on 25 February, which again included a detailed discussion with Ms E about her physical health. The doctor completing the medical review did not identify any physical health needs requiring specific dietary considerations.
53. There is also no evidence in either of these entries that Ms E told the Trust she wanted a specific diet or discussed the use of supplements. The only reference to dietary need is an explanation from Ms E that at times she swallows soapy water and diluted acetone due to having mould or mushrooms growing in her body.
54. We can see from the records on 1 March that the Trust stopped Ms E’s supplements as it believed her abnormal vitamin D blood results were likely due to ‘over-supplementation.’ We can also see from the records the Trust removed soapy water from Ms E’s bedroom several times.
55. We understand from our adviser that the Trust was correct not to allow Ms E to continue to use the alternative therapies and supplements she had been using. This is because the Trust must manage the risk to a patient’s health while they are in its care. We can see from the records that on discharge the Trust returned Ms E’s possessions to her from the safe and storage room.
56. There is no sign that she raised a concern at the time about the Trust not returning supplements to her. And as we set out above, she did not make it clear in her complaint to the Trust that this was a specific concern. There is no evidence for us to take a clear view on this point.
57. Considering the available evidence, our view is we cannot see any signs of the Trust doing anything wrong with Ms E’s diet and supplements. There is nothing we need to ask it to do on this part of the complaint.
Discharge planning
58. We have looked at what did happen and what should have happened. There are signs the Trust did not do everything it should have when she left the hospital. But, we cannot say this had the negative impact Ms E describes.
59. Ms E complains the Trust did not provide her with any treatment plan when it discharged her.
60. The Trust response explains that on 24 February a doctor examined her to assess her physical health and found nothing to suggest more support was needed. It says on 25 February, it did a comprehensive series of blood tests and the results all came back as in normal ranges. It concluded doctors did not find a clinical reason to refer Ms E to another department for further investigations or treatment.
61. The Trust CPA Policy says, ‘upon discharge from a ward, all service users regardless of CPA status will be followed up at 48 hours and 7-day periods.’ It also states that on discharge there should be a crisis plan and contingency plan in place.
62. A crisis plan details the actions a service user and/or carer could take when they feel there is deterioration in their health and mental wellbeing. Contingency plans will detail the service/staff response to any deterioration in the service user’s health, wellbeing and/or risks.
63. The Trust Physical Health Policy states at the point of discharge from inpatient services, all physical health related abnormalities or findings should be shared as part of the discharge summary to the GP.
64. GMC Good medical practice paragraph 44 ‘Continuity and coordination of care’, states doctors must share all relevant information with colleagues involved in their patients’ care within and outside the team.
65. The records show the Trust completed a discharge summary, which it sent to the GP. The discharge summary includes a clinical summary of Ms E’s time as an inpatient. It details the Trust’s reasons for admitting Ms E and its reasons for discharge. It explains the Trust offered Ms E a trial of risperidone (an antipsychotic medicine) and diazepam (medication for anxiety), but she refused to take them at any point, so this was stopped.
66. Under ‘Advice to GP on physical health concerns’, the Trust’s discharge summary states Ms E has ‘longstanding beliefs about her physical health which you are well aware of.’ We can see from Ms E’s records the Trust did carry out physical health examinations on the 24 and 25 February and did not identify any further diagnosis or need for investigation. The Trust acted in line with GMC Good medical practice and the Trust Physical Health Policy, when communicating Ms E’s physical care needs to her GP.
67. Under ‘Advice to GP on mental health concerns’, the Trust’s discharge summary states, ‘Please be aware of this admission.’ This is not in line with the Trust CPA Policy because the Trust did not include a crisis plan or a contingency plan. There is also no record the Trust followed up with Ms E after 48 hours and seven-day periods, as per the Trust CPA Policy.
68. As we found that something may have gone wrong with the Trust’s discharge planning, we next considered if this had an impact on Ms E.
69. Ms E told us the impact on her of not having a discharge plan was she did not have any treatment for her physical health symptoms or a plan for community engagement. She explained this left her feeling lonely, isolated and sad.
70. We are very sorry to hear this. We considered whether there would have been a different outcome if the Trust had made a crisis plan and a contingency plan.
71. We understand from our adviser that not having these plans would have caused distress to Ms E and her family in an emergency or if Ms E’s mental health deteriorated. This is because it would not have been clear who they should contact for help. Ms E did not suggest this was the case when she explained how she had been affected. On reviewing Ms E’s records, we can see both Ms E and her mother had contacted the GP for help before when they needed it.
72. On reviewing the evidence, we cannot link Ms E’s distress to the Trust’s actions. This is because we have seen the Trust acted in line with guidelines with her physical health. We also cannot link Ms E’s lack of access to community engagement activities to the Trust’s actions. This is because Ms E was admitted for assessment and it is not part of the discharge requirements for the Trust to arrange community engagement activities.
73. We acknowledge Ms E felt lonely, isolated and sad after she went home from hospital. We understand this was a very difficult time for her. When we weigh up the evidence, we do not think this was because the Trust did not act in line with its CPA policy when it discharged her.
74. We recognise the difficulties Ms E’s health conditions caused her and the distress she experienced as a result. We understand this is not the decision Ms E was hoping for but hope our decision reassures her about the care the Trust gave her.