Treatment 11. Mrs R told us the Trust failed to provide her father with effective mental health support in the months leading up to his accidental death in May 2022. She says specifically it discharged him home several times despite him saying he was suicidal.
12. The Trust’s Crisis team is a team that provides a rapid response and assessment of mental health crisis in the community with the possibility of offering comprehensive acute psychiatric care at home until the crisis is resolved, and usually without hospital admission.
13. Its standard operating procedure says when carrying out an initial mental health assessment for a patient staff should cover in detail: the presenting complaint, risk to self and others including historic risks where known, and the views of family members and other supporters where this is possible to do so, especially where risks have been present and there is a sudden decrease or denial of risk.
14. Mr Y had three assessments with the Crisis team at the Trust in March 2022. He also had further assessments in May with the Crisis team and the local mental health team who provide general mental health support in the community. We have considered each of these assessments in the blocks in which they were undertaken.
15. On 22 March a community psychiatric nurse (CPN) from the Crisis team triaged Mr Y by completing an initial assessment over the telephone. During this assessment, Mr Y expressed suicidal intent and said he felt he needed to be hospitalised. The CPN explained to him that he needed a further assessment before this could happen and arranged for him to have the further assessment.
16. A CPN from the Crisis team visited Mr Y in his home the next day to complete a more detailed mental health assessment. They noted in the assessment that Mr Y expressed suicidal intent as he said he lacked enjoyment in life due to ongoing physical symptoms of tinnitus. This was not explored any further at this time. Based on the assessment the Crisis team decided not to accept Mr Y onto its caseload because he was not presenting in an acute mental health crisis as it was thought his problems were longstanding.
17. Our adviser explained that although the Trust followed its procedures to carry out an assessment, the assessment itself in Mr Y’s case was brief and lacking in information. They said it was not what they would expect to see from a full assessment in line with the Trust’s procedures above. This is because there was little evidence of any exploration of other clinical features besides the ones he presented with. There was no record of discussion about psychotic or depressive features, or his past psychiatric, personal and forensic history. They said the ongoing treatment plan was also brief as the only plan going forward was for Mr Y to discuss his medication with his GP and attend community activities.
18. On 24 March Mr Y attended the emergency department (the ED) after ingesting Dettol. Once he was medically fit, the Crisis team triaged him again and admitted him the following day to a mental health crisis accommodation.
19. We therefore consider, the mental health assessment on 23 March was not in line with the Trust’s procedures and is likely to have been a contributing factor in Mr Y reaching crisis point the following day and attempting suicide, having been left without any specific support.
20. Mr Y attended the ED again on 1 May expressing suicidal intent. He had a full mental health assessment, and the Crisis team planned to follow up with him on 5 May. He was also safety netted at this point as the Trust gave him the Crisis team’s contact details if he needed to contact them before the follow up. Our adviser explained this assessment was in line with the Trust’s procedures and had a better level of detail of what was discussed with Mr Y about his condition, history and risks.
21. Unfortunately, the follow up on 5 May did not go ahead due to staffing issues. On 6 May, the local mental health team assessed Mr Y and noted that he had capacity and was able to make his own decisions. Our adviser explained this was a full assessment including a discussion about Mr Y not being a risk to himself or others as he wanted to engage with services for his anxiety. We therefore consider this assessment to have also been in line with the Trust’s procedures as it considered all aspects of Mr Y’s presenting complaint including psychiatric, medical, family and social history.
22. The Trust put in place a plan to refer Mr Y to an anxiety and depression group and noted he had already self-referred to talking therapies and had an appointment booked for 10 May which he advised he would attend. He was also encouraged to attend community groups he had attended in the past and enjoyed. He was safety netted with discussion around family support and contact numbers for the Crisis team were given.
23. We consider this was a robust plan and in line with the Trust’s procedures as it considered Mr Y’s risk factors and explored options for support. On 7 May, Mr Y had a review meeting, with a family member present regarding his prescribed medication. The Crisis team planned to discuss this with Mr Y’s GP. The review concluded that Mr Y did not present as acutely mentally unwell, and he had been assessed to have capacity and the ability to make decisions himself.
24. Overall, the Trust’s actions in managing Mr Y’s mental health support during May 2022 was in line with the Trust’s procedures above as it considered all aspects of his mental health history, presenting symptoms and risk factors. It also gave him support options.
25. We consider that in March 2022 the Trust did not complete a full and detailed mental health assessment for Mr Y which may have contributed to him attempting suicide the following day. We consider it did provide the level of assessment and support in May 2022 as set out in the Trust’s procedures.
26. As we have identified a failing in March 2022, we have gone on to consider the impact this had on Mr Y, who, we were sorry to hear, sadly died on the 10 May following an accidental fall.
27. Mrs R told us seeing her father with no support in the final months before his accidental death caused her a great deal of sadness and distress as he changed from the father she knew. She says this haunts both her and her immediate family as her father in his final months felt he was not worthy of being cared for and made suicide attempts during this time which she says were cries for help. She told us she wants an acknowledgement of failings, an apology and service improvements.
28. In its final response the Trust apologised for Mr Y’s experience. However, has not fully recognised the impact this had on Mrs R as Mr Y’s immediate family, who told us in the final months of his life his lack of mental health support changed him from the father she knew, which caused her much distress and sadness.
29. Therefore, we consider the Trust has not addressed the failings we have found or put things right. As we do not consider the Trust has done this, we will uphold this part of Mrs R’s complaint and make recommendations at the end of our report.
Access 30. Mrs R complains the Trust did not allocate face to face appointments for her father to ensure his assessment was thorough and cancelled scheduled appointments. She told us that the level of care from the Trust in relation to her father’s appointments in April and May 2022 left him feeling anxious and unworthy of support.
31. The Trust’s Crisis team’s standard operation procedure says the assessment process is usually completed by two members of staff from the team, may take up to two hours where necessary. Most assessments completed by the team will be conducted at the individuals’ home or wherever the crisis is occurring, this may be a relative or friend’s home.
32. We have seen evidence in the records, the Trust organised appointments with Mr Y at the end of April 2022 but unfortunately all three of these appointments did not go ahead due to various business support and staffing issues at the Trust. We have seen the Trust then contacted Mr Y by telephone on 1 May but as Mr Y was feeling unwell due to his medication, the home visit was not arranged and Mr Y declined further home visits as he advised he was no longer in crisis. Sadly, later that day, Mr Y attended ED expressing suicidal intent and in crisis.
33. As a result of the visits not going ahead, there was a delay in the Trust providing care and support to Mr Y.
34. We therefore consider the Trust did not act in line with its own procedures, as no face-to-face appointments took place for Mr Y in April and May until he presented in crisis at the ED on 1 May with suicidal intent. We consider this identified failing is likely to have resulted in this ED attendance as Mr Y did not have a full assessment when he should have, as set out in the Trust’s procedures.
35. We have therefore gone on to consider the impact this had on Mr Y’s daughter, Mrs R. As we have explained above Mrs R has told us seeing her father with no support in the final months caused her a great deal of sadness and distress. She wants an acknowledgement of failings, an apology and service improvements.
36. In its final response the Trust apologised for Mr Y’s experience. However, as explained above it has not fully recognised the impact this has had on Mrs R.
37. Therefore, we consider the Trust has not addressed the failings we have found or put things right. As we do not consider the Trust has done this, we will uphold this part of Mrs R’s complaint and make recommendations at the end of our report.
Communication 38. Mrs R complains the Trust did not liaise with other services to ensure her father’s individual needs were met. She told us the Crisis team did not refer father to the local mental health team for ongoing mental health support despite him needing this. Mrs R has told us her father was only given support during times of crisis.
39. The Trust’s Crisis team’s standard operation procedure says on discharge patients can expect liaison and involvement with community teams where required and referrals completed to appropriate services to access ongoing care and treatment.
40. We have seen evidence in the records that Mr Y received support from the Crisis team from August 2021, but the local mental health team was not informed of his case until his GP made a referral to its service on 24 March 2022.
41. Our adviser explained a local mental health team can provide longer term mental health support than the Crisis team. They explained Mr Y would most likely have benefitted from a referral to the local mental health team at an earlier opportunity so that long term support could have been put in place for him. The Trust also identified this in its investigation following Mr Y’s death.
42. We therefore consider the Trust did not act in line with its own procedures as it missed opportunities to refer Mr Y to the local mental health team for longer term support, not just seeing him when he was already in crisis.
43. We have explained that Mrs R told us seeing her father with no support in the final months caused her a great deal of sadness and distress. She wants an acknowledgement of failings, an apology and service improvements.
44. Again, as explained above the Trust has only apologised for Mr Y’s experience and it has not fully recognised the impact on Mrs R. Therefore, we consider the Trust has not addressed the failings we have found or put things right. As we do not consider the Trust has done this, we will uphold this part of Mrs R’s complaint and make recommendations at the end of our report.