The Trust should not have discharged Miss E from a Section 2 inpatient stay on 18 May
25. The Trust discharged Miss E on 18 May with accommodation at a bed and breakfast and support from the HTT. Miss E believes the Trust should not have discharged her. Only a few hours after her discharge, Miss E was attended to by the police, held under a Section 136 and also arrested for assault.
26. The Trust said it could provide no further support to Miss E as an inpatient. It explained inpatient admission is not recommended or appropriate for people with a diagnosis of Emotionally Unstable Personality Disorder (EUPD). This is what Miss E has. It said this should be managed through community mental health services. EUPD is a personality disorder, also known as borderline personality disorder. It can cause intense and fluctuating emotions with affect how an individual interacts with others.
27. NICE Guidance CG78 says: ‘Only consider people with borderline personality disorder for admission to an acute psychiatric inpatient unit for: • the management of crises involving significant risk to self or others that cannot be managed within other services, or • detention under the Mental Health Act (for any reason)’.
28. It further says that when considering inpatient care for a person with borderline personality disorder, actively involve them in the decision and: • ensure the decision is based on an explicit, joint understanding of the potential benefits and likely harm that may result from admission • agree the length and purpose of the admission in advance • ensure that when, in extreme circumstances, compulsory treatment is used, management on a voluntary basis is resumed at the earliest opportunity.’
29. The Trust assessed Miss E’s mental health when she attended A&E and identified she was in crisis. In line with NICE Guidance CG78, it was therefore appropriate to admit Miss E under Section 2 of the MHA.
30. On 17 May, the Trust completed a psychology review for Miss E. At this time, the Trust discussed how a prolonged inpatient stay would be unhelpful. Miss E’s medical notes show that she was in agreement with the decision to discharge her from the Section 2 admission on 18 May. Miss E’s medical notes for this time also show further discussion about how she would be supported by the HTT in the community.
31. As soon as the Trust decided Miss E was no longer in crisis, our adviser explained the correct action was to discharge her into the community with support. Miss E’s medical notes show the Trust had discussed and agreed these arrangements.
32. Based on NICE Guidance CG78, we have seen no indications of failings in the decision to discharge Miss E on 18 May. We recognise that this was a very difficult time for Miss E and do not underestimate the challenges she faced during this period of time.
the Trust failed to provide adequate psychiatric treatment/therapy
33. Miss E told us the Trust failed to provide her with adequate psychiatric treatment/therapy during two inpatient admissions, between 16 and 18 May and then between 21 and 27 May.
34. The Trust explained between 16 and 18 May it offered Miss E intensive support and intervention from the full multi-disciplinary team. This included reviews with nursing staff and a senior doctor, and one-to-one sessions with nursing and clinical staff, including the principal consultant psychologist.
35. During a session on 17 May, the Trust agreed it would speak to the HTT to plan a piece of work in the community with Miss E, to help with activity planning, structure and routine.
36. Between 21 May and 27 May the Trust had Miss E under one-to-one close observation as she was having suicidal tendencies.
37. The Trust’s occupational therapy department assessed Miss E on 25 May.
38. On the same day, Miss E’s medical notes show she took part in a group session with a principal clinical psychologist and an assistant psychologist. Her notes recorded that she participated by listening as she did not feel comfortable sharing with others in the group.
39. On 26 May, the Trust provided Miss E with further occupational therapy input.
40. Later, on 26 May the Trust provided Miss E with a one to one acute inpatient psychology session.
41. The Trust also offered her Dialect Behavioural Therapy (DBT), but Miss E did not want to continue with this. DBT is a type of talking therapy. It is based on cognitive behavioural therapy which is adapted for people who feel emotions very intensely.
42. Miss E had two short admissions and our adviser said there is evidence the Trust made sure she was safe. Our adviser further said that the Trust provided Miss E with appropriate one-to-one observations and safe and supportive therapeutic interventions.
43. A safe and supportive therapeutic intervention is engagement by way of structured observation, is an integral part of preventing or minimising the risk of harm to a person or people within an inpatient unit. The purpose of observation is to ensure the sensitive monitoring of the patient’s behaviour and mental state, enabling a rapid response to any change, whilst at the same time fostering positive therapeutic relationships through engagement. This may be achieved by establishing good rapport with patients, promoting their coping skills and being aware of their individual needs.
44. The Code of Practice says appropriate medical treatment does not have to involve medication or psychological therapy – although it often will. It further says there may be patients whose particular circumstances mean that treatment may be appropriate even though it consists only of nursing and specialist day to day care under the clinical supervision of an approved clinician in a safe and secure therapeutic environment with a structured regime.
Additionally, the Code of Practice says psychological therapies and other forms of medical treatment which require the patient’s co-operation to be effective are not automatically inappropriate if a patient does not wish to currently engage with them. It goes on to say such treatments can potentially remain appropriate and available as long as it continues to be clinically suitable to offer them and that they would be provided if the patient agreed to engage.
45. The Trust provided Miss E with a variety of therapy sessions and offered her further DBT sessions. We have seen evidence it did so in line with the Code of Practice. Therefore, we have seen no indications of failings in relation to the treatment it offered and provided to Miss E.
the Trust did not provide her with appropriate access to a shower between 16 and 18 May
46. Miss E told us the Trust did not provide her with access to a shower during her inpatient stay between 6 and 11 May. She said her room did not have a shower and the women’s communal shower was broken and out of order for her whole stay. She said that this meant she had to use the men’s shower which was aways dirty, with urine on the floor.
47. Miss E also told us that she had to resort to washing herself using the bathroom sink, instead of having a shower.
48. We acknowledge the shower was broken. We do not consider this in itself to be an indicated failing as we recognise things break. We therefore looked at what the Trust did about this at the time and in response to her complaint.
49. NMC’s The Code says nurses should make sure they deliver the fundamentals of care effectively. It also says nurses should work in partnership with people to make sure they deliver care effectively.
50. Further NMC’s The Code says nurses should respect, support and document a person’s right to accept or refuse care and treatment.
51. Miss E’s medical records show that on 11 May she told staff she had not showered or brushed her teeth for three days. The notes further say staff offered to take her to the bathroom to attend to her personal care. They note she refused and requested a shower. Miss E’s notes also record there were no showers available at the MHEAC or on the wards when she made this request.
52. Further notes from 11 May show staff told Miss E a shower was available at around midday and took her to the ward for a shower..
53. The Trust apologised for the broken shower in Miss E’s room. It further apologised for Miss E having to use a communal shower during her admission. It acknowledged Miss E felt this was not clean enough.
54. The Trust further said that domestic staff check the ward environment daily to ensure it is clean and tidy at all times. It said it will continue to review its current processes, aiming to improve the environment. It explained it had reviewed its maintenance programme and repairs are now assessed or fixed shortly after being reported.
55. From the evidence we have seen so far, staff offered Miss E an alternative when they realised the problem with the shower, in order to try and meet her care needs. We consider this was in line with NMC’s The Code, as they were trying to deliver the fundamentals of care. There is evidence staff did enough to try and support Miss E to maintain her personal hygiene. She was entitled to decline some of the options staff suggested.
56. We do not underestimate the difficulties Miss E faced when dealing with her personal hygiene and understand that this is important to maintain. We have not seen indications of failings here.
The Trust isolated her from her mental health team for eight months while it investigated her complaint
57. Miss E felt she was unable to access her mental health team for eight months from May 2022 until January 2023, while the Trust investigated her complaint. She said the Trust told her she was unable to have any access to her mental health team until it had completed the complaint investigation.
58. Miss E and her mother both explained the Trust unintentionally sent them an internal email which said they had both been over emailing staff about their concerns. Miss E believed the Trust told her she was unable to have any contact with any clinicians relating to her care.
59. The Trust acknowledged that in August 2022 it asked Miss E to withhold sending emails to the complaints team and different clinicians in the short term to allow the team to reflect on what her concerns were. The Trust explained the complaints team felt it was becoming difficult to explore Miss E’s concerns when they were continually receiving further concerns. It explained the pause was to allow them to review what support they may offer her moving forward.
60. Additionally, the Trust said it did not want to cause Miss E any further frustrations, as it would not be able to explore the complaints in a timely way, if she continued to send in further concerns. The Trust asked that Miss E use one point of contact to coordinate communication relating to her treatment and support.
61. During May 2022, Miss E had two Section 2 inpatient admissions for a mental health crisis. Additionally, in May, when Miss E was not an inpatient, the evidence we have seen, shows she had regular contact with the CMHT and the Trust’s A&E, while she was trying to access help and support.
62. We can see that Miss E had contact with her care co-ordinator from 9 June to 14 July and then from 12 September to 25 October. There was a gap in these sessions between July and September due to misunderstandings, not due to an indicated failing on the part of the Trust.
63. Miss E and her mother have accepted this gap.
64. Miss E told us she had weekly sessions with the CMHT from 28 July to 3 October.
65. On 30 August, Miss E had a phone call check in with her care co-ordinator.
66. Miss E saw her psychiatrist on 19 September. After this meeting, she received a letter entitled ‘Care Plan Review Letter.’
67. On 22 September, Miss E contacted the Single Point of Access telephone line, as she was struggling with her mental health. It made a note on her record and advised her to contact other services that may be able to provide her with support at the time. The Single Point of Access telephone service is open 24 hours a day, 7 days a week, 365 days a year. It provides advice and guidance to individuals with mental health issues. The service works to triage issues and assess the urgency of care needed. It can also be used to make appointments for the community mental health team.
68. On 23 September, Miss E attended her second appointment at the sleep clinic, followed by a meeting with her care co-ordinator and the personal budget link worker. Based on Miss E’s mental health concerns, her care co-ordinator referred her to the HTT.
69. On the same day, the Trust emailed Miss E. It confirmed its request for her to withhold sending emails to the Trust was short term, saying this was to protect her mental health, and to be able to keep track of her concerns and worries. The Trust’s email further said it was reviewing the support it might be able to offer her in the future.
70. In this email, the Trust told Miss E she should still schedule appointments when needed and access the services from the CMHT.
71. Later that day, Miss E Miss E took an overdose. She woke up the following day and received a telephone call from the HTT, followed by a home visit. This was following contact with the paramedics, after they identified Miss E had not told anyone she had taken an overdose. She was staying at her mother’s house at this time.
72. During the Trust’s investigation into Miss E’s complaint, it suggested her sessions with her care coordinator should be put on hold as they did not seem to be providing Miss E with the support she needed at the time. The Trust explained this was to stop Miss E from feeling more distressed and unhappy with the services she was receiving.
73. Additionally, Miss E had an assessment on 4 November with a specialist service for people with a personality disorder.
74. On 28 November, Miss E emailed her point of contact to ask for clarification after a meeting on 17 November. She queried a further meeting that she had been told about to discuss ongoing support and the possibility of a transfer of care.
75. The Trust sent its complaint response to Miss E on 9 January 2023, via email.
76. Miss E then emailed her point of contact on 15 January.
77. From the information we have seen so far, there is no evidence to suggest The Trust isolated Miss E from her care team while it investigated her complaint, between May 2022 and January 2023. The evidence we have seen shows she was able to access support during this time.
78. We recognise that this was a very challenging time for Miss E, when she was trying to access the support she needed. We do not underestimate the impact this had on her mental health.
79. We acknowledge how difficult it is to make and complaint and thank Miss E for bringing her concerns to us. We wish her well.