Psychosis pathway
21. Miss E says the team failed to progress her into the psychosis pathway following a telephone assessment on 25 February 2022, despite the symptoms she reported.
22. The records show Miss E had been discharged from the ILS pathway on 31 January 2022 as she was unsure if she was able to, or wanted to, resume the intensive treatment at the time. Following contact with the ‘Shropshire Access Team’, Miss E self-referred herself back to the service in February 2022 and underwent an assessment on 25 February. The outcome of this assessment was a referral to the psychosis team.
23. We can see the psychosis team advised Miss E would not be a candidate for that pathway at the time. Instead, the plan was to speak to Miss E and encourage her to self-refer to the ILS pathway, so that sessions could restart promptly. It was felt this would be a more effective treatment pathway.
24. We can see Miss E was initially unhappy with this outcome and did not wish to re-engage with the ILS. This was discussed with the management team, who confirmed the only current pathway open to Miss E was the ILS pathway. We were pleased to learn Miss E decided to engage with the ILS team on 23 March 2022.
25. The Trust advised us it did not have a documented process/guideline in place at the time of these events for referring patients to the psychosis pathway. However, it has provided us with the process followed, which has now been formally documented, which would have been considered ‘good practice’ at the time of Miss E’s assessment.
26. The referral guidance states that referrals that have been open to the ILS team for treatment within the last two years, where there has not been a significant change in need and the service user is wanting to re-engage, are able to directly self-refer. The ILS operates a fast-track system and when people are discharged before treatment has been completed, they are able to self-refer directly back onto the pathway and recommence treatment. This means that when people are ready to commit to therapeutic work, the Trust can resume treatment sessions quickly.
27. We considered this part of the complaint with our mental health nurse adviser. We understand that the ILS pathway offers treatment in line with NICE CG78, which would be most appropriate in Miss E’s case due to her diagnosis.
28. As Miss E had been open to the ILS team within the last two years, and there had been no significant change in need, we consider it was appropriate to advise Miss E to self-refer to this service so she could promptly re-engage with treatment. For these reasons, we will not be taking any further action on this part of the complaint.
Discharge planning for inpatient episode from 11 August to 23 August 2022
29. Miss E complains that the team failed to review this inpatient episode and check whether the discharge planning met a safe discharge.
30. NICE CG78 advises to consider those with emotionally unstable personality disorder (EUPD) 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 (1.4.1.2).
31. NICE CG78 also advises that the individual is actively involved in this decision, that the decision is based on a joint understanding of the potential harms and benefits of the admission, that the length and purpose of the admission is agreed in advanced, and to ensure that when compulsory treatment is used, management on a voluntary basis is resumed at the earliest opportunity (1.4.1.3).
32. NICE CG136 advises that discharge, or transition from one service to another, may evoke strong emotions and reactions in those using the service. For this reason, clinicians should ensure any discharges are discussed and planned carefully beforehand with the service user and are structured and phased. It explains that the care plan upon discharge should support effective collaboration with social care and other providers during endings and transitions and include details of how to access services in times of crisis (1.7.1).
33. NICE CG136 also advises that the discharge plans should be agreed with the service users and include plans in the event of any problems arising after discharge, it should also be ensured that there is a 24-hour helpline available for service users to discuss any problems that arise (1.7.2).
34. We have reviewed the inpatient stay and discharge planning with our psychiatry adviser.
35. We can see from the records Miss E was admitted to hospital informally following an overdose on 11 August 2022. Miss E was agreeable to the admission, and there is evidence this had been discussed with her, in line with NICE CG78. The admission was required as her period of crises meant there was a significant risk to herself which could not be managed at home.
36. Miss E was placed on a Section 5 (2) on 16 August as she wanted to leave the ward. This was revoked on 19 August by the responsible clinician after further discussions with Miss E. We consider this evidences management on a voluntary basis was resumed at the earliest opportunity, in line with NICE CG78.
37. Miss E agreed to stay once the Section 5 (2) had been revoked, and we can see from the records she engaged with her care and discussions about discharge planning including the plan for medication, ongoing access to care, and follow up reviews. Advance notice was given of the planned discharge, and they discussed the possibility of an earlier discharge providing there were no significant new risks. There were subsequent periods of wanting to leave the ward, and Miss E was discharged on 23 August 2022.
38. We can see from the progress notes that Miss E regularly engaged with the CRHT and made use of the resources available to her post discharge. We will provide a further view of the post-discharge arrangements in the next section of our report, and on care planning later in our report.
39. Overall, there are indications that the care provided during this inpatient stay and the discharge planning were in line with the NICE guidance we have referenced above. For this reason, we will not be taking any further action on this part of the complaint.
Review of discharge follow up arrangements with CRHT
40. Miss E complains that the team failed to review the discharge follow up arrangements with the CRHT from 23 August 2022, and if 117 aftercare arrangements were in place and followed.
41. The Trust has explained that a 117-aftercare meeting could not be arranged prior to Miss E’s discharge on 23 August 2022 due to her imminent wish to leave the ward. At the time she was admitted informally, and therefore staff could not prevent her from leaving the ward to allow time for a 117-aftercare meeting to take place 42. MIND provides advice on Section 117 aftercare. It explains that some people who have been kept in hospital under the Mental Health Act can get free help and support after they leaver hospital. Aftercare is the help people can get in the community after they leave hospital, it can cover health care, social care, and supported accommodation.
43. Patients can get free aftercare under section 117 if they have been detained:
• For treatment under Section 3 • Under a hospital order under Section 37 • Following a transfer from prison under Section 47 or 48 • Under a hospital direction under Section 45A.
44. It also explains that patients have a right to section 117 aftercare after they leave hospital, whether they leave hospital immediately or stay on as a voluntary patient. This advice is taken from the Mental Health Act 1983.
45. Miss E was detained for a short period under Section 5 (2). After considering this with our mental health nurse adviser, we understand that Miss E would not have been eligible for section 117 aftercare, in line with the Mental Health Act.
46. Whilst Miss E was not eligible for this support, we have reviewed the discharge and follow up arrangements that were put into place. When Miss E was discharged on 23 August, she was handed over to the ILS pathway team, and both 72-hour and 7-day follow ups were planned.
47. NICE CG78 says when discharging a person from secondary care, discuss this with them, and agree a care plan that specifies the steps they can take to try and manage their distress, how to cope with future crises, and how to re-engage with community mental health services if needed (1.3.9.1).
48. At the point of discharge, we can see a care plan was put into place for follow up and review as well as ongoing support from CRHT and re-engaging with the ILS pathway, in line with NICE CG78. For this reason, we have decided not to take any further action on this part of the complaint.
Prescription of Haloperidol
49. Miss E complains that the team failed to assess her properly, and so she was incorrectly prescribed Haloperidol.
50. In response to the complaint, the Trust advised that it was agreed following discussion between Miss E and the responsible clinician that she would prefer to keep taking Haloperidol as it was helping to control her symptoms.
51. We have reviewed the medical records with our psychiatry adviser. We can see a progress note from 3 August 2022 details a review with the consultant psychiatrist. Miss E had informed the psychiatrist she wanted more Haloperidol as it “stops her head from racing and eases her”. They spoke about why Miss E had wanted to come off this medication a year ago, and the psychiatrist explained that it is best to be on only one antipsychotic. They agreed to continue with Aripiprazole at that time.
52. On 4 August, Miss E had a home visit from the CRHT. During this visit she expressed that she did not agree with the medical review and said that Haloperidol made her feel better. Miss E was admitted to hospital under an informal admission initially on 11 August. On 12 August, Miss E was seen by the consultant and they discussed that stopping Haloperidol may have resulted in the deterioration in her mental state.
53. Miss E asked the nurses for Haloperidol on 14 August. She made a similar request on 16 August as she felt it was much more effective in challenging her thought processes. Miss E spoke with the team on 17 August where they discussed her treatment plan and a change in medication. They agreed to switch from Aripiprazole to Haloperidol, and it is noted Miss E was pleased with this plan. The progress notes say the change in medication had been discussed across the week. They also had discussed previous medication changes. Miss E underwent an electrocardiogram (ECG) on 18 August, and it was agreed it was safe to continue with a prescription of Haloperidol.
54. On 21 August, Miss E had a discussion with the site manager. She explained that she was going to stop taking her Haloperidol. Miss E was discharged on 23 August.
55. During a call with the CRHT on 24 August, Miss E said that the Haloperidol had been helping her. She also reported this in her 72 hour follow up. On 25 August, Miss E presented to A&E due to swelling in her legs and pain. She reported that she may have to stop taking Haloperidol due to the side effects.
56. The progress note states a phone call took place on 1 September 2022 between Miss E and the consultant psychiatrist. Miss E explained she had decided to stop the Haloperidol and had instead been taking the Aripiprazole daily for the last five days (from an old supply). She explained she had done this because of swelling, oedema, and weight gain. She reported feeling better, but said the Haloperidol helped more. The consultant psychiatrist agreed to continue with Aripiprazole and stop the Haloperidol.
57. NICE QS88 says antipsychotic medication can be prescribed for people with borderline or antisocial personality disorders for short-term crisis management, or treatment of comorbid conditions. The BNF for Haloperidol explains that weight gain is considered a common/very common adverse effect of the medication.
58. Overall, we have not identified any indications something went wrong when prescribing Haloperidol for Miss E.
59. We can see that Haloperidol was prescribed in the context of treating Miss E’s presentation at the time, her beliefs were leading to increased suicidal thoughts. Our psychiatrist adviser explained that antipsychotics are recommended for use in patients with Miss E’s diagnosis.
60. From the interactions we have outlined above, we can see a review of medications was completed during the admission. Miss E underwent a physical health check, and an ECG, to confirm tolerability for the medication. Miss E was involved in the decision making, and the clinical team listened to her concerns and preferences, and her consent was obtained when making medication changes. Haloperidol was then discontinued when intolerable adverse effects were reported.
61. For these reasons, we will not be taking any further action on this part of the complaint.
Provision of an independent mental health advocate (IMHA) to attend a 117-review meeting
62. Miss E complains the team failed to provide access to an IMHA to provide her with support for a section 117 review meeting, following her discharge from hospital on 19 January 2023.
63. We can see from the records that the clinical psychologist working with Miss E contacted the social work team on 19 January to arrange a multi-disciplinary team/professionals meeting to agree on a management plan for Miss E.
64. On the same day, the CRHT held a meeting to formulate its own management plan for Miss E regarding her behaviour towards mental health services and planned to utilise a joint working approach to involve all services working together to manage any escalation in Miss E’s presentation.
65. We cannot see that Miss E was placed under section during this admission, and so we understand Miss E would not have been eligible for section 117 aftercare, in line with the Mental Health Act. This means there would be no requirement for a section 117 review meeting.
66. Despite this, it remains that a multi-agency professionals meeting had been scheduled to discuss Miss E’s ongoing management. The Trust has acknowledged there was a delay in a professionals meeting being arranged, and this was due to staff changes in the social work team. The meeting was arranged for April 2023.
67. With regards to a representative attending to support Miss E, MIND explains that you must be a ‘qualifying patient’ to have the right to an IMHA. Miss E did not meet the criteria to be considered a ‘qualifying patient’, and therefore did not have the right to an IMHA.
68. Our mental health nurse adviser explained that even though Miss E did not qualify for IMHA support, she could have been advised to ask a friend or family member to provide her with support during this meeting. We have not seen any evidence in the progress notes that Miss E was offered any support for the meeting in April 2023, and we have also not seen any evidence that Miss E requested support for this meeting. We consider this was a shortcoming in the Trust’s actions.
69. We understand that the meeting did not go ahead as planned, as Miss E did not wish to continue at the time. We do not know the reasons for this, but we recognise the lack of support could have been a contributing factor.
70. In a letter to Miss E dated 26 September 2023, the Trust acknowledged there had been a misunderstanding around advocacy support. Additionally, the action plan contained within the Trust’s SI report involves a recommendation to ensure any further needs are reviewed and addressed prior to future meetings.
71. We can see the Trust advised Miss E she can always attend any future meetings with someone she believes will be able to support her, if she does not feel able to attend independently. We hope Miss E feels reassured by the Trust’s comments, and that she can access support for any future meetings, should she feel she needs it.
72. We consider the Trust has addressed this aspect of the complaint in line with the NHS Complaint Standards. This is because the Trust has provided a fair and accountable response, and has acknowledged what went wrong and what can be done differently in future to further support Miss E.
73. For this reason, we will not be taking any further action on this part of the complaint.
Help for extreme gender identity disorder
74. Miss E complains that the team failed to review what help and/or therapy was offered to her for extreme gender identity disorder.
75. In response to the complaint, the Trust explained that the extreme gender identity disorder service is considered a specialist service and is not offered by mental health services. The mental health services support service users around reviewing stressors in their life which has an impact on their mental health and how they manage this safely. Mental health services cannot offer specialist gender reassignment or breast surgery psychological therapy as they are not commissioned or trained for this. In line with this, the psychologist advised Miss E to contact the service directly herself if she wished to re-establish support and contact with the service.
76. We understand from Miss E’s records that she was already open to the gender identity disorder service, and she was concerned having not heard from the service in some time. Miss E raised these concerns with her psychologist on 1 March 2023 who signposted her to contact the service to raise the concerns. The psychologist also offered to discuss this further with Miss E in her upcoming appointment.
77. The GMC’s Good Medical Practice guidance says that doctors must promptly provide suitable advice where necessary (15b) and should refer a patient to another practitioner when this serves the patient’s needs (15c). It also says doctors must be honest about their experience and current role (66), and that they must make clear the limits of their knowledge (68).
78. We can see the clinical psychologist has acted in line with this guidance by explaining to Miss E that she could not directly help with the concerns she had raised, as it was not her area of expertise. As Miss E was already open to, and seemingly engaging with, these services, a new referral would not have been required. The advice we have received from our mental health nurse adviser supports the view that the psychologist provided appropriate advice by encouraging Miss E to contact the service to re-engage, and advising what to do if she did not get a response.
79. For these reasons, we will not be taking any further action on this part of the complaint.
ILS pathway – care plan and risk assessment 80. Miss E complains that the ILS pathway has failed to develop adequate care plans and assessments during the period August 2022 to January 2023.
81. In response to the complaint the Trust gave its view that routine care plans and risk assessments had been completed during both admissions, and they were individualised to meet Miss E’s needs. It also explained that the CRHT team developed a plan to support Miss E during a crisis, to ensure a consistent compassionate approach by staff.
82. The Trust added that whilst there was no detailed community care plan developed between the psychologist, care co-ordinator, and Miss E, unsuccessful attempts had been made to conduct a review and establish what the goals for treatment/therapy were due to varying levels of engagement from Miss E.
83. NICE CG78 says care plans should be created from a multi-disciplinary approach and should identify short-term and long-term goals, they should include a crisis plan which identifies self-management strategies and establishes how to access services when this is not enough and be shared with the service user and their GP (1.3.2.1). The care plans should support effective collaboration with other care providers during endings and transitions and should include the opportunity to access services in times of crisis (1.1.6.1).
84. The Trust’s CPA standard operating procedure explains that the care co-ordinator should do everything that is reasonably practical to ensure that service users are active participants in their CPA, aware of its aims and objectives, and informed at all times of changes to their care provision. The care co-ordinator should ensure a comprehensive, multidisciplinary, and multi-agency assessment of the person’s health and social needs is carried out, including an assessment of risk and any specialist assessments.
85. With the aid of our mental health nurse adviser, we have carefully considered if the care plans and risk assessments created and conducted during this period are in line with relevant guidance and proportionate to Miss E’s needs.
86. The medical records show that care plans were completed upon admission in August 2022 and January 2023. We can see comprehensive crisis team care plans were developed, which involved the psychologist and care co-ordinator. There is also evidence that the community mental health team developed a crisis contingency plan as part of a multi-disciplinary team meeting. The medical records also show evidence of risk assessments during these admissions, which have been reviewed and updated frequently. They are comprehensive in terms of detailing Miss E’s level of risk, her specific triggers, and what helps in times of crisis.
87. We acknowledge the Trust’s explanation as to why there is no detailed community care plan. We can see evidence within the records that attempts were made by the care co-ordinator to engage Miss E in the process without success. We consider these efforts were made in line with the Trust’s CPA standard operating procedure.
88. Overall, we consider there are indications that the care plans and risk assessments developed during this time following an assessment of Miss E’s presentation and needs have been done so in line with the guidance outlined above. For this reason, we will not be taking any further action on this part of the complaint.
Information shared with taxi driver and police control room
89. Miss E tells us a police officer advised her to not use taxis, and the team broke her patient confidentiality by phoning the police and asking them about this. Miss E says she was forced into a taxi, and the driver had been given her name and address.
90. The Trust’s investigation concluded there had been no breach of confidentiality around Miss E’s care and treatment needs. Police were called on 19 January 2023 due to an assault on two staff members and for this reason, staff had to provide Miss E’s name, date of birth, and issues around the incident to the police on a ‘need to know’ basis so that the assault and its context could be investigated. It also concluded that no information about Miss E’s care and treatment was given to the taxi driver called to take her home.
91. We will address these concerns separately.
Police control room
92. The Trust’s incident policy defines an incident as “an unexpected or adverse occurrence which gives rise to actual or possible physical or emotional injury, serious illness, death, property loss or damage, complaints and/or dissatisfaction of the service”. It explains that it is important incidents are reported and investigated in a consistent way.
93. We can see from the incident form that the events of 19 January 2023 met the policy’s definition because there was an actual physical injury caused, both to Miss E and to staff. It was reported to the police due to the physical assault of staff members.
94. The police report does not indicate any additional information was given regarding Miss E’s care and treatment. It simply describes the incident which occurred.
95. We consider this is in line with the Trust’s incident policy, and with the GMC’s guidance on confidentiality, which says to use the minimum necessary personal information – the team did this by simply providing an account of the incident which occurred, and no additional information about Miss E’s care.Taxi driver
96. The GMC’s guidance on confidentiality says:
• Use the minimum necessary personal information • Appropriate information sharing is an essential part of the provision of safe and effective care • If a patient who has capacity to make a decision refuses to permission for information to be shared with a particular person or group of people, it may be appropriate to encourage the patient to reconsider (if sharing would be beneficial to the patient’s care and support). Doctors must, however, abide by the patient’s wishes.
97. We have carefully reviewed Miss E’s medical records and we can see in the days leading up to the incident on 19 January, Miss E had informed a member of staff of the police recommendation, and that she required patient transport if she was to be discharged.
98. On 19 January, it is noted “handed over to staff who will look at taxi transport rather than the hospital transport due to waiting times”, and “patient was discharged without further issue and left via taxi”. The crime report states “… has then been placed into the back of a taxi and left the hospital.”
99. We recognise that the team would have needed to give the taxi driver Miss E’s basic details to transport her to her intended destination. We have not identified any indications that additional information about Miss E’s care and treatment was shared with the taxi service or driver. Only the minimum necessary information was given to be able to complete the journey.
100. It appears that the decision was made to transport Miss E by taxi due to long waiting times for patient transport. We consider this decision was made in Miss E’s best interests, to take her home as soon as possible, following the incident on the ward. For this reason, we consider there are indications the team acted in line with GMC guidance, as information was shared as an essential part of the provision of safe and effective care.
101. It is evident Miss E had stated her preference, and recommendation from the police, that taxis were not used as a mode of transport to and from hospital. Whilst we do not have formal independent evidence which confirms this, we do not disbelieve Miss E. We also do not know if she was asked to reconsider her decision regarding taxi transport when it became apparent the patient transport had long delays.
102. We understand this must have been a great concern for Miss E, given her contact with the police and the other events which have happened in her personal life. There is no evidence that any information above and beyond what was necessary to transport her home was shared. For this reason, we have not identified any indications something went wrong here. We hope Miss E finds this information reassuring.
103. If Miss E remains concerned that there was a breach of confidentiality, she should raise these concerns with the Information Commissioner’s Office (the ICO). The ICO is best placed to deal with concerns raised by members of the public about an organisation’s information rights practices. Conduct of the assigned consultant clinical psychologist
104. Miss E complains she experienced bullying behaviour from the consultant clinical psychologist who was involved in the care she received through the ILS pathway.
105. When investigating this aspect of the complaint, the Trust requested more information from Miss E about the behaviour of the psychologist. It also spoke with the psychologist in question, the care co-ordinator, and the operational team leader. The Trust’s report concluded that written entries within the records are respectful and show evidence of care and compassion. It did not identify any evidence of persistent undermining, harassment, or targeting abuse towards Miss E.
106. The GMC’s Good Medical Practice guidance says that clinicians should be polite and considerate (46), they should treat patients as individuals and respect their dignity and privacy (47), and they should treat patients fairly and with respect, whatever their life choices and beliefs (48).
107. We have reviewed the section of the SI report which focuses on this part of the complaint. It is clear that the clinical psychologist has set out the expectations of the ILS pathway Miss E was on and explained the consequences of not attending appointments. There is no evidence that the clinical psychologist treated Miss E unfairly or without respect during the call.
108. Having reviewed Miss E’s progress notes for the period August 2022 and May 2023 we have not identified any indications of bullying, abuse, or harassment towards Miss E. It appears that all clinical staff involved in her care have acted in line with the GMC’s Good Medical Practice guidance.
109. We acknowledge that we were not present at the time to independently know what, and how things were said. We accept that staff attitudes may not have been as expected. We also recognise that in some instances, 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.
110. We recognise that Miss E may have perceived these comments as threatening, and that she may have felt, at times, that staff were treating her unfairly.
111. We are left without independent supporting evidence that would indicate to us a service failure took place, and for this reason we do not consider it would be beneficial or proportionate to investigate further. We are unable to add anything more to what has already been explained.
112. We do not intend this decision to diminish Miss E’s feelings, nor the experience she had, we recognise it was extremely challenging for her and that she has a different view of events to both the Trust and our Office.
Factual inaccuracies within medical records
113. Miss E has concerns about the information contained within her medical records and has complained about the way the Trust handled her request to correct them.
114. We can see Miss E contacted the Trust on 12 April 2024 to request to go through her records with a member of Trust staff, and note every point of ‘inaccuracy, lie, and act of omittance’.
115. The Trust responded on 19 April 2024. In this email, it apologised that Miss E is unhappy with the information held within her medical records. It explained to Miss E that under the Data Protection Act 2018, she is entitled to have factual errors in her record amended. This would include data such as her name, address, and place of birth. Where a request is made to change information from the health record, but the change is not factual, then it would not be appropriate to alter the records as these contain professional opinions made at the time of recording.
116. We understand that patients and service users have the ‘right to rectification’ if an organisation holds inaccurate information about them. Guidance from NHS Transformation states that a patient would need to provide evidence of the information they believe is incorrect and provide evidence of the correct details/information they wish to be recorded.
117. We cannot see that Miss E has provided the Trust with specific information about each entry she believes to be inaccurate within her medical records. Until Miss E does this, the Trust cannot fulfil its responsibility to liaise with the clinicians who made the entries, to determine if the information is factual and accurate and whether the professional opinions were justified based on the evidence available at the time it was recorded.
118. We also understand Miss E has the right to ask that an ‘addendum’, a comment or entry, is added to her medical records to show she disagrees with the professional opinions, and what she thinks it should say. This may be an alternative option for her to pursue.
119. Overall, we cannot see any indications that the Trust has refused to address Miss E’s complaint about factual inaccuracies within her medical records. It has responded appropriately to the request Miss E made, as it has explained what changes can be made in line with the relevant legislation. This is in line with the NHS Complaint Standards. It is open to Miss E to make further representations to the Trust to challenge the information held, and if she remains unhappy to pursue this complaint via the ICO.