Care plan and discharge
22. Before we decide if we should conduct 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. Having done so, we consider the Trust has already done enough to put right the impact of these events.
23. Ms H said the Trust discharged her from its community mental health services after not providing the appropriate level of psychological support and not looking into the root cause of her mental health issues.
24. The Trust said in response the decision to discharge Ms H was based on her inability to engage with the support being offered due to her alcohol use.
25. We have reviewed the records of Ms H’s appointments in the lead up to her discharge. It does appear that Ms H was struggling to engage with the support available. This would seem to support the Trust’s view that the decision to discharge Ms H was correct.
26. However, NICE guidance on BPD ‘managing endings and supporting transitions’, recommend that staff:
‘Anticipate that withdrawal and ending of treatments or services, and transition from one service to another, may evoke strong emotions and reactions in people with borderline personality disorder. Ensure that:
• such changes are discussed carefully beforehand with the person (and their family and carers if appropriate) and are structured and phased • the care plan supports effective collaboration with other care providers during endings and transitions, and includes the opportunity to access services in times of crisis.
27. Our mental health adviser said staff did not properly prepare Ms H in the lead up to her discharge, considering her BPD. The adviser said rejection is a big issue for people with BPD and staff did not show sensitivity towards this. The process behind the discharge was very abrupt.
28. The guideline also refers to the process of planning discharge for patients with BPD. It says:
‘When discharging a person with BPD from secondary care to primary care, discuss the process with them and, whenever possible, their family or carers beforehand. Agree a care plan that specifies the steps they can take to try and manage their distress, how to cope with future crises and how to re-engage with community mental health services if needed. Inform the GP.’
29. Based on the evidence we have seen, there are indications the Trust did not meet Ms H’s needs in the way it discharged her. The Trust did not adequately take her BPD into account when planning her discharge, in line with NICE clinical guidelines.
30. Ms H also complains she did not have a care plan in place prior to her discharge in August 2021, and so had no goals or expectations for her treatment.
31. The Trust acknowledged Ms H had no written plan of care. It said this would have helped clarify the expectations of both Ms H and her care coordinator and would have identified meaningful goals to progress towards.
32. Department of Health positive practice guidance states that:
‘Everyone referred to secondary mental health services should receive an assessment of their mental health needs. This initial assessment, which aims to identify the needs and where they may be met, may have alternative names such as screening (assessment) or triage (assessment). The outcome of the initial assessment should be communicated to the individual (in a way that they will understand) and the referrer promptly. If it is agreed that the person’s needs are best met by a secondary mental health service, a care plan should be devised and agreed with the service user and, where appropriate, their carer’.
33. Our mental health adviser said the care plan is supposed to be based on the patient’s needs following a mental health assessment and should be provided to every patient. It is a written record of the care agreed to meet needs. The adviser explained Ms H should have been involved in writing her care plan if she wanted to, and staff should check the plan regularly to make sure it still met her needs. The adviser said Ms H should have had a care plan review at least once a year or whenever her needs changed.
34. There are indications the Trust not creating a written care plan for Ms H was not in line with standards and guidelines. It is likely Ms H would have benefited from having a care plan because this would have allowed her to feel more in control and involved in her care and treatment.
35. The Trust said despite not having a care plan, it had provided psychological support in the form of goal setting, coping skills and stabilisation work utilising workbooks. It said there is evidence that Ms H initially was able to engage with this but over time struggled to sustain this engagement. It said in the lead up to her discharge, Ms H had not managed to review the information or practice the skills outside of her contacts with her care coordinator.
36. NICE guidelines on psychological support for people with BPD say:
‘When providing psychological treatment for people with BPD, especially those with multiple comorbidities or severe impairment, the following service characteristics should be in place:
• an explicit and integrated theoretical approach used by both the treatment team and the therapist, which is shared by the service user • structured care in accordance with this guideline • provision for therapist supervision. Although the frequency of psychotherapy sessions should be adapted to the person’s needs and the context of living, twice-weekly sessions may be considered.
37. Our mental health adviser said the Trust’s clinical records support that Ms H was receiving support such as goal setting, stabilisation work and coping skills from her care coordinator, but this is not specific enough, in line with the above guidelines, to address the root of her trauma issues.
38. In summary, the Trust did not provide Ms H with a written care plan or an appropriate level of psychological support in line with guidelines. This meant she struggled to engage with the support available, which influenced the Trust’s decision to discharge her. We have also seen indications the process of the discharge was not in line with guidelines.
39. Ms H told us her mental health suffered because of the Trust’s actions, and she lost faith in its service.
40. Our principles of good complaint handling say organisations should:
• listen to and consider the complainant’s views, asking them to clarify where necessary, to make sure the organisation understands clearly what the complaint is about and the outcome the complainant wants • respond flexibly to the circumstance of the case. This means considering how the organisation may need to adjust its normal approach to handling a complaint in the particular circumstances.
41. As well as providing a written response to her complaint, the Trust met with Ms H on three occasions from September to November 2022 to discuss her complaint and allow her to explain how the experience had impacted on her mental health. The Trust’s actions appear to be in line with our principles and seem to be a genuine attempt to restore Ms H’s faith in its service.
42. In its response, the Trust recognised that Ms H had not had a care plan which had affected her treatment and her ability to work towards specific goals. It did not fully accept that this was a contributing factor in Ms H’s discharge.
43. However, following this response, the Trust offered Ms H a further psychology assessment with a consultant psychologist and 20 therapy sessions. It also put measures in place to use performance reports to check that patients have care plans in place. The Trust said it would review the quality of these care plans on a regular basis.
44. Our principles for remedy say good practice with regards to remedies, means seeking continuous improvement, ensuring that changes are made to policies, procedures, systems, staff training or all of these, to ensure that the maladministration or poor service is not repeated.
45. In dealing with Ms H’s complaint, the Trust provided assurances that it had learned lessons and explained what it had done to put things right. It apologised for letting her down and reflected on what it could have done better.
46. We recognise that Ms H feels the Trust let her down and she lost faith in its service. We consider the Trust has shown accountability and has taken meaningful actions to put things right.
47. As an outcome to her complaint, Ms H wanted the Trust to take accountability for letting her down and apologise. She also wanted the Trust to put service improvements in place. We consider the Trust has already done this and has also provided Ms H with additional support once she made the complaint. As such, we will not be taking any further action on the complaint.
Loss of sensitive information
48. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there is an organisation that is better placed to deal with the concerns. Some complaints can be looked at by us, and also by other organisations. We have considered whether another organisation is better suited to giving an answer to the complaint and whether it can provide the outcome Ms H was seeking.
49. Ms H told us the Trust committed a data breach by losing a statement she wrote containing sensitive information about historic traumatic experiences she had suffered.
50. The Trust said in response that two separate Information Governance leads had performed a forensic audit of Ms H’s health record and all other health records accessed at the time of the incident. The Trust said it had also done a thorough search of the administration and reception areas at Greenfields but had been unable to locate the statement.
51. The Trust apologised to Ms H for the loss of the sensitive information. It also completed a self-referral to the Information Commissioner’s Office (ICO) and said it would raise Ms H’s concerns at its quarterly data protection steering group.
52. The ICO is an independent organisation that deals with complaints about how organisations have handled people’s personal information.
53. Ms H told us she had already complained to the ICO. We contacted the ICO and asked about the status of her complaint. The ICO told us it had investigated Ms H’s complaint and had made recommendations to the Trust to carry out.
54. We recognise that it would have been very difficult for Ms H to revisit the traumatic events of her childhood, and the knowledge that the Trust had lost this sensitive information would have had an impact on her mental health.
55. As this part of the complaint is within the ICO’s area of expertise and it has already made a decision, it would not be appropriate for us to investigate it.
56. We understand Ms H went through two separate events that affected her general experience with the Trust and led to her raising her complaint. We thank her for bringing her complaint to us and hope our work provides assurances that we have taken her concerns seriously.