20. 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 for issues one to four.
Issues 1 and 2 – Inappropriate restraint, lorazepam injection and prevention of Miss U leaving hospital
21. Miss U told us she felt violated at times during her attendance at the ED. This was because security staff physically brought her back into the department when she tried to leave. She also told us she was restrained and given an injection of lorazepam against her wishes. We sought advice from our mental health adviser to help us establish whether Miss U was treated correctly.
22. Our mental health adviser explained that as Miss U was being assessed and treated for a mental health problem within the ED department, both MFT and GMMH had joint responsibility for her welfare. Each organisation has its own roles and responsibilities. In practice, the lines are often a bit blurred. When considering issues one and two, we have referred to both organisations as having joint responsibility.
23. The MCA says a person lacks capacity if at that time they are unable to make decisions for themselves because of an impairment or disturbance in the functioning of the mind or brain. It does not matter if the impairment or disturbance in permanent or temporary. Our adviser said it is well documented in the records that Miss U was very unwell and was deemed to not have capacity.
24. The MCA also says any actions done or decisions made, for or on behalf of a person who lacks capacity must be in their best interests. When Miss U tried to leave the ED, she was awaiting a formal Mental Health Act assessment. This was because clinicians felt it may be necessary to admit Miss U to hospital for her own safety and wellbeing.
25. Our mental health adviser told us that given Miss U’s lack of capacity and concern for her welfare, it was appropriate for security staff to prevent her from leaving the ED. They said this action was taken to make sure Miss U received the care she needed and was taken in her best interests.
26. We also asked our mental health adviser about the decision to administer lorazepam against Miss U’s wishes. This incident took place while GMMH were trying to find a bed for Miss U on a mental health ward. We have seen evidence in the records that Miss U was very agitated, upset and wandering around entering other patient’s cubicles.
27. The records show Miss U was first offered oral diazepam (a drug very similar to lorazepam but can be taken by swallowing). Miss U refused diazepam and the organisations decided it was in Miss U’s best interests to administer lorazepam via injection. Our mental health adviser said this was to try and calm Miss U’s agitated state and prevent harm to herself and potentially others.
28. Having considered the evidence available, we are of the view that both organisations acted in line with the MCA when they prevented Miss U from leaving the ED and administered a lorazepam injection without consent. We consider these actions were taken in Miss U’s best interests as she did not have capacity at the time of the incident.
Issue 3 – Inappropriate sectioning
29. Miss U told us she feels her sectioning was unnecessary and alternative options should have been explored further, such as home based treatment. The records show Miss U was detained under Section 2 of the Mental Health Act (MHA). Section 2 is used to detain a patient for the purpose of completing further assessments and/or treatment for up to 28 days.
30. Our mental health adviser explained how a patient can be discharged at any time in those 28 days if the consultant feels the section is no longer warranted. GMMH discharged Miss U after one week. The decision to section somebody (as per the MHA) requires agreement from two doctors and an approved mental health practitioner. One of these doctors must be a ‘section 12 approved’ doctor who is trained and qualified in the use of the MHA.
31. Our mental health adviser confirmed Miss U’s sectioning had the agreement from all of the correct people. These three people all agreed that Miss U was so unwell, she required detaining for further assessment and potentially treatment. Our mental health adviser said the records of Miss U’s highly distressed presentation in the ED mean this decision was appropriate and home based treatment was unfortunately not an option at this time.
32. As per the MHA, and advice from our mental health adviser, we consider the decision to section Miss U was appropriate given how unwell she was. We are also of the opinion that GMMH acted in line with the MHA when getting the right professionals to section Miss U. We recognise that Miss U was only in hospital for a short period of time, however we consider the actions taken by GMMH on the day of her sectioning were appropriate and in line with the MHA legislation.
Issue 4 – Inaccurate records
33. Miss U told us there was a diagnosis of paranoid schizophrenia on her medical records which was incorrect. She told us she worries about the effect this could have on future mental health care.
34. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the issues complained about had a negative effect which the organisation has not put right. Having done so we have found the Trust has already done enough to put right the impact of these events.
35. Our principles say where failings have led to an injustice or hardship, the organisation responsible should take appropriate steps to put things right. It also says remedies should be fair, reasonable, and proportionate to the injustice or hardship suffered.
36. We can see GMMH has recognised the inaccurate record in Miss U’s notes and has apologised for it. It has also taken steps to make sure the IT department amends the record and ensures the correct diagnosis of anxiety is documented.
37. We appreciate Miss U’s concerns regarding the incorrect diagnosis and the effect this could have on future care and treatment. Having considered the issue, we consider the Trust has acted in line with our principles and has taken appropriate steps to put things right by apologising for the error and amending the records.
38. Level one of our scale covers injustices such as Miss U’s, of worry arising from a single incidence of maladministration. We do not think we would achieve more than what the Trust has already done. Therefore, we will take no further action on this issue.
Issue 5 – Lack of communication about a possible needlestick injury
39. Miss U told us she requested her medical records as part of the complaints process. When she read these, she saw notes relating to a needlestick injury either she, or a security guard received when she was injected with lorazepam. Miss U told us nobody informed her about this incident.
40. Our nursing adviser told us that the responsibility for following the required protocol after the incident lay with MFT. This is because, although Miss U was being jointly cared for by MFT and GMMH, MFT’s ED staff both prescribed and administered the injection in MFT’s ED.
41. We have seen two records about this incident. The ED records include a very brief note saying a needlestick injury had occurred. Our nursing adviser said these ED notes are lacking significant details about the incident including who sustained an injury first, what the plan was following the incident and who was going to tell Miss U.
42. Good Medical Practice section 21 says clinical records should include the decisions made, actions agreed, and the information given to patients. We do not consider MFT followed this guidance when documenting the needlestick incident and the overall standard of the documentation is very poor.
43. The other record of the incident is included in GMMH’s notes. This record contains more detail about the incident, including a member of GMMH staff going to tell Miss U about the needlestick injury. It is noted that Miss U was sleeping and as she had not slept in several days, the decision was taken to not wake her.
44. MFT told us it did not consider Miss U well enough to understand and retain information about the incident while she was present in the ED. Therefore, it would have passed the responsibility of informing her onto GMMH. However, due to the very poor documentation from MFT, we cannot say whether this decision was taken or not. Our nursing adviser said if it had been clear in the records that MFT was passing responsibility onto GMMH for informing Miss U about the incident then this would have been fine, however there are no records saying this.
45. Due to the poor record keeping, we cannot say with certainty which organisation had ultimate responsibility for informing Miss U. When we spoke to MFT, it explained how lines of responsibility are often blurred with patients who are being jointly cared for by MFT and GMMH. We are of the opinion that the lack of clear lines of responsibility for joint patients, as well as the poor record keeping, resulted in an oversight where Miss U was not informed of a potentially serious incident.
46. To decide if we should conduct a detailed investigation into a complaint, we look at what outcome the person coming to us wants to resolve their complaint. Our Service Model Guidance says, in sections 3.57 to 3.65, we can resolve a complaint without conducting a detailed investigation if we can deliver the outcomes a complainant asks us to achieve at an earlier point in our case handling process.
47. Our principles say organisations should seek continuous improvement, and use lessons learnt from complaints to ensure that poor service is not repeated. It can do this by giving assurances that lessons have been learnt and explanations of changes made. Our principles also say organisations should acknowledge poor service and apologise for it.
48. We spoke to MFT and it has agreed to provide Miss U with an apology and evidence of what it is doing to make sure documentation is improved. Both MFT and GMMH have also committed to a longer term piece of work where they will align their policies around needlestick injuries to prevent confusion in the future. Both organisations have agreed to take learning from Miss U’s experience around making clear the roles and responsibilities of each team when looking after joint patients in the ED.
49. We are satisfied MFT has now agreed to take appropriate steps alongside GMMH in line with our principles, to learn from Miss U’s complaint and ensure poor service is not repeated. We consider we have resolved this part of her complaint.
Issue 6 – Lack of information and communication at the time of Miss U’s sectioning
50. Miss U told us she was not told she was being/had been sectioned and was therefore not allowed to leave the ED. She explained how if she had been aware of this then she would not have tried to leave and the distressing experiences with the security guards and the lorazepam injection could have been avoided.
51. Our mental health adviser explained how you cannot tell somebody they are going to be detained under the MHA if they have not yet had a mental health assessment. GMMH should have told Miss U that an assessment had been requested and the outcome of that might be that she is detained or not.
52. We carefully considered GMMH’s records from Miss U’s time in the ED. Unfortunately, there is no evidence in the records of staff explaining to Miss U that an assessment had been requested and she may be detained as a result of it. There is also no evidence in the records of what GMMH told Miss U about the actual decision to section her.
53. We cannot say for sure whether Miss U was given any information about her sectioning verbally. She was not considered to have capacity at the time so may have been given verbal information which she was unable to retain. However, we do not consider GMMH acted in line with Good Medical Practice section 21, as quoted in paragraph 41.
54. We consider GMMH should have kept accurate records as to what Miss U was, or was not told about the decision to section her. We recognise GMMH may have made a conscious decision to not inform Miss U due to her lack of capacity. However, we are of the opinion this decision and the reasons for it should have still been clearly documented in the records.
55. Due to the poor record keeping, we are unable to give Miss U a definitive answer on her concern. We cannot say with any certainty what she was or was not told about the decision to section her. We recognise this will cause an element of distress to her.
56. We spoke to GMMH and it has agreed to provide Miss U with a letter of apology for the poor record keeping, resulting in an unsatisfying outcome to our investigation of this point. As stated above, it has also committed to working with MFT to improve services for joint patients in the ED.
57. Miss U has informed us she is happy with the service improvements suggested by both MFT and GMMH. She is pleased that action is being taken to improve future patients’ experiences.
58. We are satisfied GMMH has agreed to take appropriate steps, in line with our principles for remedy, to put right the injustice of us not being able to give clear answers for Miss U. We consider we have resolved this part of her complaint.
59. We recognise Miss U’s experience in the ED was highly traumatic for her and caused a great deal of distress. We hope she is reassured that her concerns have been investigated and as a result, both organisations have committed to positive changes to improve services in the future.