Medical Records
15. Mrs U says the Trust included information in her father’s discharge summary and occupational therapy report that was untrue and in conflict with the information the social worker recorded in his care assessment. Mrs U has noted several examples of contradictions/ inaccuracies. She says the discharge summary contains unsubstantiated claims that her father was aggressive and a risk to himself and others, whereas the care assessment says he was ‘kind, considerate’ and had been ‘calm and engaged well with treatment on the ward with no concerns’.
16. The Trust say the clinical notes are detailed and indicate the clinical care provided was in line with expected standards. It says it accepts some of the psychiatric history collated over time may contain some factual errors regarding Mr O’s personal history, such as year of arrival in the UK and work history. It also misrepresented who was visiting him on the ward from his family. The Occupational Therapy report did not describe clearly which family members were being referred to and this should have been clearer, given the family situation. However, the report was otherwise judged to be of a good standard. It says it feels the discharge summary provides a reasonable summary of the electronic patient record entries and is in line with the expectations for clinical discharge summary content. The notes provided a reasonable account of risk behaviour including aggression that had been reported by others or directly observed.
17. The Trust tells us if a patient is being discharged to a care home, information including risk assessment and care plan etc. are normally sent to the care home. The care home would either request these or the ward would already be aware of the care home involved, liaise with them prior to discharge and share the appropriate information. It says in Mr O’s case, a discharge notification was sent to his nursing home on 13 December 2022 prior to Mr O’s discharge and it subsequently sent the discharge summary.
18. Paragraph 19 of GMC Good Medical Practice Guidance says ‘documents you make (including clinical records) to formally record your work must be clear, accurate and legible. You should make records at the same time as the events you are recording or as soon as possible afterwards.
19. Our psychiatrist adviser says the structure and content of the discharge summary is entirely appropriate and is in line with paragraph 19 of the GMC guidance above. The discharge summary provides a summary of Mr O’s demographics, date of admission and date of discharge, his mental health diagnosis(es), physical health diagnosis(es), and a summary of his history. It also provides a summary of Mr O’s progress on the ward following admission, risk assessment, medication changes, psychology input, physical health concerns during the admission, mental state examination findings at the time of discharge from the ward and medication prescribed at the time of discharge. The discharge summary also outlines the follow-up arrangements and contact details for the team that would remain involved with Mr O following his discharge from hospital.
20. The occupational therapy report contains similar information about Mr O’s reported behaviour to what is stated in the discharge summary. The Trust acknowledged in its written response there were some factual inaccuracies in the occupational therapy report, e.g. the year of Mr O’s arrival in the U.K and details of his work history, and who was visiting Mr O whilst he was on the ward. There is no indication this impacted Mr O’s care and treatment.
21. Our adviser says there is no indication or concern that the care that was provided by the Trust to Mr O made it more difficult for him to be placed in a suitable care home. There is documentation within Mr O’s clinical notes of his behaviour pertaining to risk to self and / or risk to others that had been either observed on the ward whilst Mr O was an inpatient or reported by others involved in Mr O’s care. This information will have been required and helpful when trying to decide on a suitable place of residence for Mr O at the point of discharge from hospital.
22. We are sorry to hear about Mrs U’s concerns regarding the information in her father’s records. We cannot see any indication the information treating clinicians recorded about Mrs O’s behaviour was inaccurate or inappropriate. As above, the Trust has acknowledged there were some factual inaccuracies about his personal history, and it has apologised, and advised these can be corrected if Mr O’s family contact the Information Governance Team directly.
23. NHS complaints standards say ‘wherever possible, staff explain why things went wrong and identify suitable ways to put things right for people. Staff give meaningful and sincere apologies and explanations that openly reflect the impact on the people concerned’.
24. We consider the actions the Trust have already taken are in line with NHS complaints standards and enough to put this right. We therefore will not take any further action.
Consideration of information from family
25. Mrs U says the treating clinician took her father’s wife’s version of events as fact and did not consider what he told them about his relationship with his wife and what it said in the rest of his notes. She says the psychiatrist insisted he was being paranoid and didn’t consider his concerns could be warranted.
26. GMC Good Medical Practice says:
31. You must listen to patients, take account of their views, and respond honestly to their questions. You must be considerate to those close to the patient and be sensitive and responsive in giving them information and support
33. You must be considerate to those close to the patient and be sensitive and responsive in giving them information and support
49. You must work in partnership with patients, sharing with them the information they will need to make decisions about their care, including: a)their condition, its likely progression and the options for treatment, including associated risks and uncertainties b) the progress of their care, and your role and responsibilities in the team c)who is responsible for each aspect of patient care, and how information is shared within teams and among those who will be providing their care
68. You must be honest and trustworthy in all your communication with patients.
27. NICE guideline CG136 says ‘give verbal and written information to service users, and their families or carers where agreed by the service user…undertake shared decision-making routinely with service users’.
28. NICE guideline NG108 on decision making and mental capacity says: ‘Information gathered from support workers, carers, family and friends and advocates should be used to help create a complete picture of the person's capacity to make a specific decision and act on it and ‘unless it would be contrary to the person's best interests to do so, health and social care practitioners should work with carers, family and friends, advocates, attorneys and deputies, to find out the person's values, feelings, beliefs, wishes and preferences in relation to the specific decision and to understand the person's decision-making history’.
29. Our adviser says there is evidence in the notes the treating psychiatrist appropriately considered Mr O’s point of view about his behaviour and what happened and his relationship with his wife throughout his hospital admission in line with GMC guidance.
30. The initial mental health assessment says it was difficult to assess Mr O’s capacity as he was giving different accounts of events which occurred and ‘requires more collateral information from family to formulate plan’. The notes show clinicians spoke with several members of Mr O’s family.
31. Our adviser says it was appropriate and in line with NICE guidance and paragraph 33 of the GMC guidance above for the treating psychiatrist to obtain information from Mr O’s family about his behaviour / what happened and to include this in the clinical notes. Whenever a patient is admitted to the inpatient setting with mental health difficulties, it is always helpful to obtain collateral history from the patient’s family and / or main carers.
32. The patient may not be able to provide much background information themselves, either through having a disturbed mental state and lack of awareness of this (insight), or if the patient has (as in Mr O’s case) cognitive impairment which will or might limit the amount of information they can provide the inpatient team and / or the accuracy of such information.
33. Our adviser says input from family members of patients following admission to the mental health setting is not only important in terms of helping to guide the assessment process and to inform a management plan for the patient. They also say it but may be helpful, and required, if there are concerns that the individual lacks capacity to make decisions relating to their care and treatment and capacity then needs to be formally assessed by the inpatient team.
34. We appreciate Mrs U’s strength of feeling about this, and we are sorry to hear about her concerns. From the evidence we have considered we can see the clinicians acted appropriately in the way they obtained information from Mr O’s family members and recorded this in the notes, and there is evidence they also considered his views. We therefore do not consider there is an indication of service failure.
Legal Power of Attorney:
35. Mrs U says the Trust tried to interfere in family matters in relation to the power of attorney. She says during a family meeting on 7 November, Dr A asked her father’s wife if she would like to have power of attorney and the social worker intervened to say it was her father’s choice.
36. The Trust say it did not find that the treating psychiatrist acted outside of the remit required of her in the role as the Responsible Clinician and Consultant Psychiatrist or find any examples where she interfered without reason in private affairs.
37. There is a two-stage process when assessing capacity to make a specific decision:
• Stage 1 – Is the person unable to make a particular decision (the functional test)?
• Stage 2 – Is the inability to make a decision caused by an impairment of, or disturbance in the functioning of, a person’s mind or brain? This could be due to long-term conditions such as mental illness, dementia, or learning disability, or more temporary states such as confusion, unconsciousness, or the effects of drugs or alcohol (the diagnostic test).
38. The MCA says that a person is unable to make their own decision if they cannot do one or more of the following four things:
•Understand information given to them •Retain that information long enough to be able to make the decision •Weigh up the information available to make the decision •Communicate their decision – this could be by talking, using sign language or even simple muscle movements such as blinking an eye or squeezing a hand.
39. On 2 November, the treating psychiatrist completed a review of Mr O’s mental state and capacity assessment for LPA. Our adviser says from the information documented; it is evident the treating psychiatrist appropriately assessed Mr O’s capacity in line with guidance. They demonstrated Mr O was able to understand the information around making a decision on whether he consented to an LPA being appointed, was able to retain the relevant information for long enough to make a decision and was able to communicate his decision verbally.
40. The notes show the treating psychiatrist identified Mr O lacked the ability to weigh up the risks and benefits of who to appoint as his LPA due to his presenting ‘paranoid ideation associated with his dementia and recent circumstances’ and concluded Mr O lacked capacity to decide on the LPA at this point.
41. In the psychiatrists note of the family meeting on 7 November, they say the social worker explained the Care Act Assessment and outlined the options of Lasting Power of Attorney (LPA) or best interest’s decision / deputyship. We cannot see any evidence in the notes that the psychiatrist brought the topic up or mentioned who should be the LPA.
42. We recognise the way in which things are said and how they are meant are open to interpretation and each person involved in the same conversation can come away with a different perception of its contents and what happened. One person’s perception of what was said does not invalidate another person’s opposing perception of the same comment.
43. Whilst we do not dispute Mrs U’s recollection, unfortunately, we were not present at the time to independently know what, and how, things were said. Whilst the notes say the social worker explained the LPA, we accept it is possible Dr A mentioned the LPA during this meeting. We are left without independent supporting evidence that would indicate to us that a service failure took place. We will therefore not take any further action in relation to this part of Mrs U’s complaint.
44. Whilst we have not seen any indications of failings overall, we recognise how important this complaint is to Mrs U and her family. We thank her for bringing her complaint to us for consideration and we hope our findings provide her and the family with some reassurance.