Delay in being seen by the memory service
20. Before we decide if we should do a detailed investigation of a complaint, we look at whether there are signs the events complained about had a negative effect which the organisation has not put right. We have found the Trust has made service improvements that put right what went wrong. We recognise the Trust did not tell Mrs R about these improvements when it investigated her complaint, so we understand why R was still unhappy and wanted to bring her complaint to us.
21. Mr R’s GP referred him urgently to the Trust for its memory service on 22 September 2021. The Trust was unable to offer him an appointment until 28 January 2022 due to its waiting list. Mr R was not seen by the memory clinic until 7 June 2022.
22. We have mainly focussed on the delay between Mr R’s referral to the Trust in September 2021 and the first appointment offered on 28 January 2022. This is because the delay between these appointments was not caused by cancellations or conflicting appointments.
23. Mrs R says the Trust failed to give Mr R an appointment with the memory service within an appropriate timeframe.
24. The Trust said that referrals were delayed due to the reduction in face-to-face appointments as a result of the COVID-19 pandemic. It also said it had a challenging time recruiting for the service and it relied on agency consultant cover which was inconsistent and extended the waiting list.
25. Our adviser referred us to standard eight of the MSNAP guidance. This says that a diagnosis should be given within the nationally specified target timeframe. England’s timeframe is within six weeks of referral. This guidance says if there are circumstances causing a delay, these reasons should be recorded and monitored.
26. Our adviser said that sadly this timeframe is not being met nationwide. They said organisations must try to reduce delays by putting in place a process with clear criteria for prioritising urgent referrals.
27. Our adviser said Mr R’s first appointment with the memory service took four months to be offered, which cannot be seen as urgent. They said this delay was not in line with guidance.
28. The Trust said when Mr R was referred, there was not a policy in place for how prioritise referrals and there is no record of Mr R being triaged. Our adviser said the Trust should have a local policy to make sure urgent referral patients are being seen as soon as possible.
29. As we cannot see any evidence of Mr R being triaged and there was no clear policy in place, we have seen a sign of service failure by the Trust.
30. Mrs R wants improvements to the service so other people do not go through what she and Mr R went through. Mrs R tried to resolve the complaint by hearing what service improvements had been made but we cannot see that the Trust explained how it had changed its service.
31. We have been in touch with the Trust to find out what service improvements it has made since Mr R’s experience.
32. The Trust has advised it has a new standard operating procedure in draft form that uses the following process:
• a multidisciplinary team referrals meeting takes place with a consultant psychiatrist, nurse consultant/advanced clinical practitioner (trainee), nurse assessor and team lead. They discuss the referral and prioritise according to presentation of symptoms, identified risk profile, socio-environmental circumstance and age. The decision is now documented on the electronic patient record.
• each referral is prioritised into the below three categories based on:
• crisis - age (such as under 65), significant cognitive decline in a shortened timeframe (one to three months) with no physical health complications leading to current presentation, ongoing physical and mental health conditions that have a significant impact on the person's ability, behaviours that may put the person in a position of significant vulnerability or risk. Factors include intentional or unintentional risk to self or others, substantial changes to abilities/inabilities in order to complete activities of daily living independently or with support, psychological factors such as mood, anxiety, previous mental health history, social support network (family, friends, social footprint such as activity).
A patient in this category will receive the next available crisis appointment and there are two available per week. This will be done by a medic, nurse consultant (trainee) or advanced clinical practitioner (trainee).
• soon - age (such as under 65), noticeable cognitive decline in an established time frame (three to 12 months) with no physical health complications leading to current presentation, ongoing physical and mental health conditions that are having a moderate impact on the person's abilities, behaviours that are noticeably changed and potential of increased risk to self or others. Factors included intentional or unintentional risk to self or others, noticeable changes to abilities/inabilities to complete daily tasks independently or with support, psychological factors such as mood, anxiety previous mental health history, social support network (family, friends, social footprint such as activity).
A patient in this category will be seen by the memory clinic within 12 weeks currently. This assessment would be completed by nurse consultant (trainee) or advanced clinical practitioner (trainee).
• routine – aged 65 or over, no identified or increased risk outside of usual day to day risk, regular function or mild decline in function that may require some additional prompts or support.
A routine patient would be seen in line with the current waiting list time by a nurse assessor.
This list of criteria is not exhaustive but are the most frequently seen in referrals and is used to decide on priority. This is dependent on information included in the referral and there are times where more information is needed to decide on a priority level.
33. The Trust said this procedure has now been developed and training has been delivered and completed with the nursing team. This is now in place and has been submitted to the Trust’s dementia transformation project for approval.
34. The Trust said to reduce the waiting list, it is using and developing the nurse led assessment pathway mentioned above. And, a locum psychiatrist, mid-grade medic, trainee nurse consultant and trainee advanced clinical practitioner who have the knowledge to assess dementia have been put in place to support reducing the waiting list.
35. The Trust has now developed a thorough policy to triage patients who are referred to it. With this triage process, those considered most urgent would be seen with the next available crisis appointment.
36. For those who do not meet the requirements for a crisis appointment, there is a clear process to assess the need for an urgent or routine appointment.
37. We are sorry that Mr R was not seen for a long period of time and we understand how both Mr R and Mrs R did not have the support they needed during this time. We are satisfied that the Trust has now made appropriate improvements to its service and developed a thorough local policy in line with what our adviser suggested. This also achieves the service improvements Mrs R wanted. We think the Trust has done enough to put things right and we will not be investigating this part of the complaint further.
The Trust did not do a memory assessment while Mr R was an inpatient
38. While waiting for an appointment with the memory clinic, Mr R was admitted to the emergency department on 6 May 2022. He had experienced some falls.
39. Mrs R says the Trust did not arrange for him to have his memory assessment while he was an inpatient. She says due to the delays in getting his appointment, the Trust should have done the memory assessment while he was in hospital.
40. On 8 May, ward staff made a dementia liaison referral for Mr R, but he was discharged from hospital on 10 May before he could be seen.
41. The Trust said it is not standard practice to carry out a dementia assessment while someone is an inpatient for other reasons.
42. Our adviser said there is no clinical guidance for doing a dementia assessment while a patient is in a general hospital. They referred to the NCCMH guidance which highlights the importance of a liaison mental health team for assessing, diagnosing dementias or signposting to memory service on discharge.
43. Our adviser said the Trust should have a clear pathway for patients with suspected dementia. They said the speciality doctor did attempt to see Mr R, but he had been discharged.
44. Our adviser explained that a liaison mental health team should be available to help while a patient with suspected dementia is an inpatient. We asked the Trust what pathway it has for someone who is inpatient, to be seen by the memory service. The Trust said any request to be seen by the memory service as an inpatient on the acute wards would routinely be requested through its mental health and learning disability liaison team. This team would assess whether a patient needed to be seen by the memory service and help make the referral.
45. We are sorry Mr R could not be seen while he was an inpatient. We hope this information reassures Mrs R that the Trust now has a clear pathway in place for patients who are an inpatient with suspected dementia, as recommended by the NCCMH guidance. As there is no national guidance to say a patient should be seen while an inpatient, we are satisfied that this process is appropriate. We will not investigate this further because we could not recommend for the Trust to do any more than it has to improve its service.
The Trust refused to approve a request for medication from the GP
46. Mrs R says their GP made a request to the Trust for medication to be prescribed to Mr R and it did not action this request.
47. The Trust said it did not receive a request from Mr R’s GP.
48. We reviewed the medical records and we could not see any request from Mr R’s GP. We could only see a letter from the GP asking the Trust for an update.
49. We have decided that any further investigation would not be practical for us to complete and we would not be able to offer Mrs R a satisfactory conclusion on this matter.
50. We are sorry we cannot do more on this point. As we could not see any evidence of the request on Mr R’s medical records, we are not able to say that the Trust received the request from Mr R’s GP. We are not saying this did not happen, it is just unlikely that we would be able to say with certainty what happened.
51. We are sorry to hear about Mr R’s experience and we recognise that the delay in getting an appointment resulted in Mr R and Mrs R struggling without the appropriate treatment and support.