Contact with Mr H
25. Mr H had a longstanding diagnosis of schizophrenia and was being cared for under the CPA. Because of this, his CCO should have been in regular contact with him. This would have been in line with the Department of Health’s Policy and Positive Practice Guidance (the CPA guidance) and NHS England’s update to the prior CPA guidelines (Care Programme Approach NHS England Position Statement).
26. Our mental health nurse adviser said that how often Mr H should have been seen would depend on his needs, but this should have been monthly as a minimum. This appears to be the approach of the Trust, also, as Mr H’s CCO documented that they told him that they needed to see him once per month because he was under CPA.
27. The Trust’s CPA policy also outlines what actions should be taken when a person either refuses to engage with mental health services, or the service loses contact with a patient.
28. In cases of a refusal to engage with the service, the policy says that ‘there must be a timely discussion within the MDT and with the GP. Consideration should be given to the risks that the service user presents to him/herself (including risks of self-neglect) or others. And appropriate action taken’.
29. In cases where the Trust has completely lost contact with the patient, the policy states that ‘a meeting should be held by the MDT to discuss a new contingency plan’ and, if the patient is a risk to themselves, the Trust should have considered contacting local hospitals and the police. Following these steps, an action plan should have been developed.
30. On 13 December 2021, Mr H’s CCO visited him at home. According to the notes made at that time, he refused to engage with her during the visit and she ‘threw’ her telephone number into Mr H’s flat because he would not respond to her.
31. No further attempts to contact Mr H were documented until 15 March 2022. We understand that in January and February there were discussions about allocating a male CCO to his case. However, we would still expect his care to continue whilst this happened. There is no evidence the CCO was actively reviewing his care or chasing up this transfer, nor did they document making any attempt to contact Mr H.
32. This was not in line with the expectation of regular contact, as outlined in the CPA guidance. The approach was also not in line with the Trust’s CPA policy as there is no evidence Mr H’s CCO discussed this with the wider MDT, nor was there any consideration of the risks presented by him as a result of his non-engagement.
33. On 15 March Mr H’s new CCO documented that they planned to arrange a joint home visit with a support worker, but that this person was on leave for the next two weeks. They documented that they would keep trying to contact Mr H, but no further attempts were documented. On 29 March the CCO documented that they had discussed Mr H’s case as a ‘case for concern’ because he was not answering his telephone. There is no record of this discussion, or which professionals discussed this, in Mr H’s records.
34. The CCO attempted to contact Mr H again on the following dates:
• 30 March: the CCO attempted to telephone Mr H and left a voicemail for him.
• 8 April: the CCO sent a letter to Mr H advising of a home visit on 22 April.
• 22 April: a home visit was recorded. The CCO documented that they posted a note through his letter box asking him to contact the service.
• 29 April: a home visit with no answer from Mr H, staff left a note to say the Trust would discharge him from the service if he did not contact them.
35. On 23 May a support worker called the police to ask for a welfare check. Mr H was found dead in his flat the following day.
36. We have found that between December 2021 and May 2022 the Trust did not attempt to contact Mr H as often as it should have done. This was a failing in the care provided to him.
37. In addition, the Trust’s policy is very clear as to the steps its staff should take when a person is refusing to engage with the CPA process and what steps should be taken if the service loses contact with someone entirely.
38. When Mr H’s CCO documented that he was refusing to engage with the service in December 2021 they did not follow the CPA policy and did not attempt to make contact with Mr H again. The CCO failed to arrange an MDT discussion and did not produce any action plan for contacting him. This was a failing in his care.
39. From 30 March 2022 the Trust started attempting to contact Mr H again. After two failed home visits in April, it should have been clear the Trust had lost contact with Mr H. This meant the Trust should have followed its CPA policy and held an MDT meeting. It should also have engaged the stakeholders in Mr H’s care and made ‘every effort’ to contact him, including reaching out to his GP and/or Mr O. It should also have developed an action plan following these steps.
40. Whilst the CCO appears to have discussed Mr H’s case at a team meeting on 9 May, there was no documented MDT meeting about the loss of contact with Mr H, nor was there any appropriate plan to contact him documented. The Trust also did not reach out to Mr O or Mr H’s GP to attempt to contact him. This was a failing in the care provided to Mr H.
41. We have outlined the impact of these failings in paragraphs 68 to 84 of this report.
Risk assessment, relapse and care needs 42. Mr H had a severe mental health condition, and his care was managed under the CPA. Because of this, the Trust’s CPA policy says he should have had a full assessment of his needs in a number of areas including:
• mental state and behaviour • medication, side effects and compliance • physical health • social functioning and family relationships • managing nutrition and personal care • risk and safeguarding.
43. Prior to December 2021 the evidence shows Mr H’s CCO was assessing his functioning in these areas. From December 2021, however, there is no evidence he had an up-to-date care plan in place or that there was any consideration of these key areas of his care. This fell far short of both the CPA guidance and the Trust’s CPA policy.
44. Managing risk is an important area of consideration for patients under CPA. The Department of Health’s guidance ‘Best Practice in Managing Risk’ states that risk management should be aligned closely with the CPA process. This involves identifying specific interventions based on an individual’s support needs whilst taking into account safety and risk issues.
45. The Trust’s CPA policy also requires risk assessment as an essential component under CPA. The policy states that a dynamic risk assessment must be completed for all service users and that risks are not static, meaning regular reviews must take place in response to changing circumstances. We know that Mr H’s circumstances had changed because he had stopped taking his medication in July 2021 and was showing signs of relapse. This means his risk should have been reviewed regularly.
46. There is no evidence of any risk assessment being undertaken by the Trust at any point after November 2021. This is very concerning given the documentation about his signs of relapse and non-compliance with his medication.
47. Medication compliance also forms a key component of the Trust’s CPA policy, which states that this should form part of the CPA assessment and care provided. According to the Department of Health’s CPA guidance, medication non-compliance is a high-risk indicator of relapse.
48. Our mental health nurse adviser explained that Mr H’s CCO should have examined his mental state at each visit and educated him about the medication and its importance. Any concerns about compliance with medication should have been discussed with a doctor and, if appropriate, the team should have considered whether a different method of administering medication could help Mr H. For example, administering antipsychotic medication via an intramuscular injection.
49. In a detailed account of Mr H’s care, dated 2 September, his CCO identified that he no longer had carers supporting him with his daily living and he had stopped taking his prescribed antipsychotic medication. The CCO documented that he was ‘concerned [Mr H] may be relapsing’ due to distrustful statements made, non-compliance with medication, and his hostility towards his CCO and family.
50. Following this visit, his CCO visited him at home again with a doctor. The doctor documented a plan to continue to monitor Mr H and encourage him to take his prescribed medication. If he deteriorated further, the team was to consider a Mental Health Act assessment.
51. We can see the CCO took appropriate action in September and escalated these concerns. Mr H’s CCO continued to monitor his mental state and medication compliance up until November and contacted his GP about the concerns the team had. The final documented review of Mr H’s mental state, risk of relapse and medication compliance was on 9 November.
52. On 13 December Mr H’s new CCO visited him at home. The entry recorded by the CCO documented no consideration of his mental state, whether he was showing signs of relapse, or his compliance with his medication. The entry only referenced Mr H’s refusal to speak to the CCO and that she had telephoned Mr O to tell him his brother was well following this visit. This was the last contact any member of the Trust’s staff had with Mr H.
53. There were no documented considerations of Mr H’s current mental state, his risk of relapse or his medication compliance following this visit on 13 December, until he was discovered deceased in his flat in May 2022.
54. We have found that between December 2021 and May 2022 the Trust failed to review Mr H’s mental state, his risk of relapse, and his compliance with medication. This is particularly concerning as the work undertaken by the previous CCO between September and November 2021 clearly documented Mr H was not taking his medication and was showing signs of a relapse of his illness. He had been assessed by a doctor in September 2021 who had recommended ongoing monitoring of this and to consider a Mental Health Act assessment if Mr H deteriorated further.
55. We were also very concerned to learn that, instead of considering whether Mr H was relapsing and had become very unwell, the Trust’s staff instead considered discharging him from the service entirely when they were unable to contact him. The Trust has already acknowledged that this approach was not in line with its policies when it investigated this serious incident. We agree with the Trust that this fell far short of its CPA policy and was a further failing in the care provided to Mr H.
56. In summary, between December 2021 and May 2022 the Trust failed to:
• maintain appropriate contact with Mr H and follow its CPA policy when it could no longer make contact with him • review his level of risk • monitor and review his mental state and medication compliance • ensure Mr H had an up-to-date care plan that was being appropriately reviewed.
57. We outline the impact of these failings in paragraphs 68 to 84 of this report.
Serious incident investigation 58. NHS England’s Serious Incident Framework provides detailed guidance on how NHS services should learn from serious mistakes and prevent future harm. Although Trusts have their own policies for investigating serious incidents, the overarching framework for these policies is this guidance.
59. According to NHS England’s framework, the needs of those affected by the incident should be the primary concern of those involved in the investigation. We consider Mr O was someone directly affected by this incident, and so his needs should have been of primary concern to the Trust during this process. Most notably, he needed to be engaged in the process and made aware of the findings of the investigation in a timely manner.
60. The framework is also clear that, when undertaking an investigation, NHS service providers should:
• have ‘meaningful and sensitive’ engagement with affected patients or their families from the point at which the serious incident is identified to the closure of the investigation process • allocate a single person to engage with the family to provide a single point of contact • hold a meeting with family members early in the process to advise of what action is being taken, what to expect from the investigation, and provide a realistic and achievable timeframe for completion • give those affected the opportunity to comment on or respond to the findings of the report and include these comments as part of the quality assurance and closure process by the commissioner.
61. Following Mr H’s death, the Trust registered an incident on 23 May 2022 and waited for the outcome of the inquest, which happened on 29 June. The coroner recorded an open verdict. An open verdict means there was insufficient evidence to determine how a person’s death occurred. This was because Mr H had been deceased for some time before he was discovered, and his level of decomposition prevented establishing his cause of death.
62. After the Trust received the verdict, it initiated a local service investigation on 1 July. At this stage, Mr O had not yet been told his brother had died. The local investigation closed on 2 September.
63. In early October, Mr O contacted the Trust’s complaints department, and, on 5 October, a Serious Incident Review was requested by the Trust’s Head of Complaints, following discussions with the Trust’s legal team.
64. This report was completed and approved by senior members of staff by 14 March 2023. The report outlined serious failings in the care provided to Mr H, and the actions the Trust would take to prevent this happening again. This report was not shared with Mr O upon completion.
65. The Head of Complaints was not working for the Trust between February and November 2023. When they returned to this role, they discovered the report had not been sent to Mr O in their absence. The report was finally sent on 29 November, a delay of eight months.
66. We have found the Trust failed to comply with NHS England’s Serious Incident Framework. This is because we have seen no evidence that it:
• meaningfully and sensitively engaged Mr O from the start to the finish of the investigation • ensured there was a single point of contact for Mr O throughout the investigation • held a meeting with Mr O early in the investigation process to advise on what action was being taken, what to expect from the investigation, and to provide a realistic timeframe for completion • allowed Mr O to comment on or respond to the findings of the report before it was submitted to the commissioner.
67. Had the Trust implemented and maintained the communication required by NHS England’s Serious Incident Framework, it is more likely than not it would have provided Mr O with a copy of the report prior to submitting this to the commissioner.
68. This is because if Mr O knew there was a timeframe/deadline, properly understood the investigation and investigation process, and was invited to comment on the finished report before submission to the commissioner; this would have avoided the eight-month delay in advising him of the outcome of the investigation.
69. We have found the Trust’s actions fell so far short of NHS England’s Serious Incident Framework that it was service failure, and we have considered the impact this had below.
Impact 70. Mr O says his family is ‘haunted’ by the uncertainty surrounding his brother’s death. They do not know how he died, which means they will never know whether or not his death was likely peaceful or whether he suffered.
71. The state of decomposition also meant his family could not see Mr H before he was buried, having been strongly advised not to do so. Mr O says he now has a lot of uncertainty about whether they buried the right person because he was not able to verify the identity of his brother.
72. Mr O describes the emotional impact as traumatic and says that it continues to affect his mental health. He adds that the delays in issuing the final investigation report compounded this trauma, causing distress and uncertainty during this time.
73. We have found the Trust should have taken steps to ascertain Mr H’s whereabouts and wellbeing far sooner than it did. The key issue to consider here is at what point Mr H more likely than not died, and when the Trust should have undertaken a welfare check. These two key dates are essential to considering whether Mr H could have been discovered at a time when his decomposition was not so advanced.
74. Ordinarily, a person’s behaviour, such as a sudden lack of contact with the mental health team, could indicate when a person likely died. In this case, the nature of Mr H’s illness meant he was distrustful and hostile towards his family and the professionals supporting him. Because this lack of contact with the mental health team was normal for him, this does not give us any useful indication as to when he may have died.
75. Our pathologist adviser reviewed Mr H’s post-mortem, and the police statements used at the inquest. They told us that based on the information available, it is not possible to give an approximate date of death to a reasonable degree of confidence. This is because there are too many unknowns about the conditions in Mr H’s flat that could have affected the rate of his decomposition.
76. That said, our pathologist adviser has provided a broad timeframe and said they would expect that Mr H had been dead for at least two weeks before he was discovered. They also explained that a period of months cannot be entirely ruled out; however, a number of clinical features were absent that would be expected had he been deceased for several months. This makes a longer period of time less likely, but we cannot know, even on the balance of probabilities, where on this broad timeline Mr H’s death occurred.
77. Because we do not know exactly when Mr H died, we cannot say, even on the balance of probabilities, whether or not the level of decomposition could have been avoided had the failings not happened. This means we do not know whether his body could have been discovered sooner, and the uncertainty around his cause of death avoided.
78. What we can say is the uncertainty about whether the Trust’s failings prevented the family from knowing Mr H’s cause of death and saying goodbye to him when viewing the body is still a serious injustice to them. Mr O describes feeling ‘haunted’ by this uncertainty.
79. We understand that strictly speaking the Trust was not responsible for informing Mr O of his brother’s death. However, we also note that its serious investigation report identified an administrative oversight where Mr O’s details had not been logged as Mr H’s next of kin. Had this not been the case, it is reasonable to expect that the Trust would have told the police who Mr H’s next of kin was, and they could have informed him much sooner.
80. Mr O also describes feeling very distressed about knowing Mr H’s care was not in line with the expected standard prior to his death and whether he suffered during this time. This would understandably be very distressing to Mr O’s family and would have compounded the impact of this bereavement, making it difficult to find closure.
81. The Trust’s actions after Mr H died also compounded the injustice in this case. It had not recorded Mr O as his brother’s next of kin, meaning the police were unaware of Mr O and he did not find out his brother had died until August 2022. It also did not appropriately involve him in the serious incident investigation and failed to inform him of the outcome of the investigation for a period of eight months.
82. In summary, we cannot say whether or not the Trust’s failings prevented a cause of death being established. It is possible, for example, that he had only been deceased for two weeks. This would mean the level of decomposition would still have occurred even if the Trust had been visiting Mr H monthly. It is also possible he was deceased for longer than a month and could have been discovered sooner.
83. What we can say is that the Trust’s failings caused Mr O considerable distress and compounded the impact of this bereavement. He is left with uncertainty about how and when his brother died. Its actions after Mr H’s death further distressed Mr O and made it difficult for him to obtain closure following such serious failings.
84. The Trust acknowledged the clinical failings we have found in its Serious Incident Report. It has also put service improvements in place to prevent this happening again, including staff training and a review of the policies that were not followed during these events.
85. We recognise the Trust has taken this case very seriously and taken action to prevent the same failings happening again. It also held a meeting with Mr O in January 2024 and has apologised to him for the delay in sharing the Serious Incident Investigation Report.
86. Whilst we were encouraged to see that the Trust has already taken some action to put things right by improving its clinical services, it has not done enough to put things right for Mr O. The distress caused by the failings found extends far beyond what our Severity of Injustice Scale considers is appropriate to be remedied by way of an apology.
87. The Trust has also not yet acknowledged all of the errors we have found in its communication with Mr O during the serious incident investigation. It has apologised for the delay in issuing the report, but did not acknowledge the procedural errors that likely led to this.
88. The Trust has since implemented changes to its Serious Incident Investigation process to prevent these errors happening again. We were encouraged to see this proactive approach, though we not seen evidence to indicate when or how these improvements or will be implemented. We have also seen no evidence these improvements have been communicated to Mr O.