Surrey and Borders Partnership NHS Foundation Trust

4. Mr N complains the Trust failed to correctly diagnose his wife, Mrs N’s Emotionally Unstable Personality Disorder (EUPD), when she was admitted to hospital in February 2023. Mr N says the Trust had enough information to consider EUPD at the time she was admitted. The Trust did not diagnose this until 11 April 2023.

5. Mr N thinks the Trust’s actions may have led to his wife’s death on 23 July 2023. He says the delay in diagnosis meant his wife’s admission was unnecessarily prolonged and her health deteriorated. He says there is a possibility her death could have been prevented had the correct diagnosis been made at the time of admission, rather than 10 weeks later.

6. Mr N says as a result of this delay her condition at best did not improve, and at worst, Mrs N may have deteriorated through incorrect treatment. Mr N told us an opportunity for a better outcome was lost.

7. Mr N has told us losing his wife has left him with significant grief and turmoil. He says he has been left financially worse off because of losing Mrs N’s pension income.

8. As an outcome for his complaint, Mr N wants an acknowledgment of failing from the Trust. He wants changes to take place, so this does not happen to others. He also seeks compensation of around £10,000.

9. Mr N’s medical records show her GP referred her to the Surrey Community Mental Health Team (CMHT) in January 2023. Mrs N was admitted to a hospital at Surrey and Borders Partnership NHS Foundation Trust on 2 February 2023. Mrs N was 71 at the time of events.

10. The Trust admitted Mrs N following a deterioration in her mental state. This is described in her medical records as low mood, anxiety and thoughts of seriously harming herself since the death of her mother in October 2022.

11. Prior to her admission, Mrs N attended a CMHT appointment on 24 January 2023. At this appointment the CMHT diagnosed Mrs N with mixed anxiety and depression, plus grief reaction. The CMHT arranged for daily support to be provided to Mrs N at home. It prescribed antidepressant medication and medication to Mrs N to help with her anxiety. The team also planned to consider an informal admission for her at its next meeting.

12. On 31 January Mrs N contacted the CMHT after she experienced a panic attack and requested additional support. The CMHT arranged a home visit to see Mrs N the next day.

13. On 2 February 2023 the CMHT visited Mrs N at home again. Records note Mrs N had a low mood and was significantly distressed. Mrs N described wanting to go to bed and not wake up to her clinician, along with escalating anxiety. CMHT recognised Mrs N’s symptoms as high risk and sought her consent to be admitted to hospital. Mrs N agreed to the admission.

14. The Trust admitted Mrs N on 2 February 2023 under its complex emotional needs pathway at hospital so it could carry out a specialist review of her mental health. This included assessments, daily monitoring, and discussions with those that knew Mrs N well. The Trust explained to Mr N in its complaint response that this allowed it to gather more accurate information about Mrs N’s presentation and develop an accurate diagnosis and treatment plan.

15. The Trust assessed Mrs N on 3 February 2023, 24 hours after she was admitted. It noted her past psychiatric history to include a previous diagnosis of mixed anxiety and depressive disorder, along with Mrs N’s two previous admissions to private hospitals.

16. Mrs N’s records show she was admitted in 1991 and 2007 to private psychiatric hospitals. These admissions related to attempts Mrs N made to take her own life. Prior to 2023, Mrs N had no previous admissions under the NHS or Mental Health Act.

17. In February 2023 the Trust reviewed Mrs N in ward rounds. We can see from her records it was still working towards a diagnosis of mixed anxiety and depressive disorder.

18. On 16 March 2023 the Trust reviewed Mrs N’s diagnosis. In a ward round meeting it discussed a new diagnosis of acute stress reaction with Mrs N and her family. It referred to Mrs N’s symptoms, which had been worsened due to the loss of her mother. It explained Mrs N’s presentation seemed to fit this diagnosis.

19. On Tuesday 28 March 2023, Mr N contacted the Trust to query whether a second opinion would be appropriate on his wife’s diagnosis, given this had recently changed. Mr N did not agree Mrs N had acute stress reaction and considered instead that she had a long-standing disorder.

20. The Trust responded to Mr N the same day, explaining its diagnosis had been discussed in Mrs N’s ward round and confirmed with a multidisciplinary team. It said this was a working diagnosis, which it had developed to help it and others, treat Mrs N to better understand her distress and presentation. It explained it was based on information shared by Mrs N and those that knew her, along with its own clinical observations.

21. Mr N sent his wife’s historical private medical records to the Trust on 11 April 2023. The Trust noted from these that Mrs N had a long-standing difficulty of managing her emotions, along with difficulties within her relationships. It recognised that her current presentation mirrored that noted in the 2007 private medical records. It planned to review Mrs N’s diagnosis.

22. We can see from Mrs N’s records the Trust reviewed this and diagnosed her with EUPD on 14 April 2023.

23. The Trust discharged Mrs N from hospital on 11 May 2023 after noting she had responded well to medication and her mood had improved. Mrs N was referred to the community mental health team for ongoing support.

24. Mrs N sadly died on 23 July 2023 from respiratory failure, pulmonary thrombosis, and deep vein thrombosis (DVT).

28. Before we decide if we should conduct 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 found any indications that something has gone wrong.

Failed to correctly diagnose EUPD in February 2023

29. Mr N’s main concern is the Trust failed to diagnose his wife’s EUPD when she was admitted to hospital in February 2023.

30. Mr N says the Trust were aware of Mrs N’s previous private hospital admissions. He thinks because of his wife’s history, the Trust should have known she had a long-standing disorder. Mr N believes the Trust should have done more to appropriately diagnose Mrs N sooner.

31. Mr N says the Trust should have requested Mrs N’s private records when she was admitted to hospital. He says this would have helped it to better understand his wife’s symptoms and her previous diagnosis of EUPD. Mr N told us his wife’s cause of death was due to her state of mind at the time she was discharged. He explained Mrs N had long periods of inactivity which he feels happened because of the Trust’s failure to correctly diagnose her and provide adequate treatment and support from the time of her admission.

32. In its response, the Trust said it afforded Mrs N working diagnoses which reflected its assessments during her time on the ward. The Trust denied it misdiagnosed Mrs N. It said its views of her presentation and diagnosis of Mrs N developed as she shared information, along with her response to medication and assessments on the ward.

33. The Trust said Mrs N did not stay on the ward for an unnecessary prolonged time. In its response, it said it felt Mrs N had an underlying personality element to her presentation during the early stages of admission. Without further evidence, the Trust said it would have been against best practice and national guidelines to confirm an EUPD diagnosis as soon as Mrs N was admitted.

34. NICE quality standard QS88 explains that borderline and antisocial personality disorders are complex and difficult to diagnose.

35. NICE guidance CG78 explains the range of emotional and behavioural problems experienced by people with EUPD can be very different. It says some people can maintain relationships and activities, but others may have very high levels of emotional distress involving self-harm, which result in repeated crises. The guidance explains ‘its course is variable and although many people recover over time, some people may continue to experience social and interpersonal difficulties.’

36. Our adviser said with the above guidance in mind, EUPD is very difficult to diagnose. He explained it is therefore key clinicians take their time to diagnose patients, particularly in times of crisis. Our adviser told us this is more important for patients who do not have recent history, or hospital admissions. With EUPD, he said clinicians are looking for a long history of problems.

37. Mrs N’s medical records show she was admitted to hospital with low mood, panic attacks and thoughts of self-harm. Mrs N’s recent crisis and symptoms were linked to the death of her mother in October 2022. Prior to this, our adviser said Mrs N’s mental health appeared to be stable.

38. We understand Mrs N was previously diagnosed with EUPD during historical private hospital admissions. Mrs N’s last private admission took place in 2007, over a decade before she was admitted to hospital.

39. We have carefully reviewed Mrs N’s medical records and have not seen evidence that Mrs N had any recent medical history similar to EUPD prior to October 2022. As noted in paragraph 34, guidance explains people may recover from EUPD. Based on what we have seen, we do not think it was unreasonable for the Trust to take its time to come to its own conclusion on Mrs N’s more recent presentation.

40. The Trust diagnosed Mrs N with mixed anxiety and depression, plus grief reaction. Mrs N’s records show this was after she reported symptoms of anxiety and depression had worsened since the death of her mother.

41. Our adviser explained this was a reasonable working diagnosis based on Mrs N’s symptoms and the information available in her recent healthcare records. We consider this was in line with GMC guidance which says clinicians must provide a good standard of care and practice and if assessing, treating or diagnosing patient, they must adequately assess the patient’s conditions, taking into account of their history…’. Taking into account our adviser’s comments, we do not find indication the Trust should have diagnosed EUPD at this time instead.

42. We know Mr N thinks the Trust should have obtained Mrs N’s private medical records to allow it to correctly diagnose her. We can understand why Mr N would query this, now it is known the Trust changed its diagnosis of Mrs N’s condition to EUPD once it had reviewed her historical private records.

43. We can see from Mrs N’s medical records she had capacity to provide consent and was able to represent herself and her condition at the time. We share our advisers view that it was appropriate for the Trust to place more weight on this and engage with Mrs N herself.

44. Mrs N’s records show that she was actively involved in her treatment during her time in hospital. For example, on 3 February clinicians noted Mrs to be compliant with medications. Mrs N also signed a treatment engagement plan. On 27 February, clinicians noted she interacted well with nursing interventions.

45. At the time she was admitted, the records also show Mrs N shared important information with the Trust about her health and history which she thought relevant, including personal trauma dating back to her childhood. However, we cannot see in Mrs N’s records she shared her previous EUPD diagnosis with the Trust, this was open for her to do so.

46. Our adviser explained it was appropriate for the Trust to involve Mrs N in its decision making, coming to a diagnosis based on her more recent presentation.

47. We understand the Trust discussed obtaining Mrs N’s historical private hospital records with Mr N, but Mr N advised he preferred them to be sent directly to him. Mr N requested Mrs N’s records in February 2023 and sent these to the Trust in April 2023, a few days after the private hospital provided them to him.

48. For the reasons explained above, we have not identified an indication that the Trust should have diagnosed Mrs N with EUPD sooner than it did. This means we see no indication of a failing here. We consider the Trust acted in line with the NICE guidance and GMC guidance mentioned above in this decision. This is because the evidence shows it was appropriate for the Trust to take its time to diagnose EUPD and come to its own conclusion based on Mrs N’s more recent presentation.

49. Although we did not see indication of a failing with the Trust’s consideration of Mrs N’s diagnosis, we thought it may be useful to share that our adviser explained even if the Trust had received the records sooner, with evidence of Mrs N’s historical EUPD diagnosis, it would have been unlikely to have altered its view at the time of her admission. This is because of how much time had passed since Mrs N received this from the private hospital. Our adviser said it was good practice for clinicians to not rush into clinical decision making and form their own view based on up-to-date information. We also share this view and hope this provides some degree of assurance to Mr N about the care provided to his wife.

50. We recognise that Mr N continues to be profoundly affected by what happened. We are grateful to him for sharing this experience with us and hope this statement fully explains the reasons why we will not take further action on his complaint.

1. We have carefully considered Mr N’s complaint about his concerns the Trust failed to correctly diagnose his wife, Mrs N’s mental health condition.

2. We have not seen any indications of failings on the part of the Trust and so we have decided not to look further at the complaint.

3. We know how difficult this time has been for Mr N and how much he has been affected by Mrs N’s sad death. We thank him for sharing the details of his complaint with us and hope our explanation below provides Mr N with some reassurance about Mrs N’s care.