Contacts with Trust 23 September and 16 October
12. Ms O contacted the Trust on 23 September to express concerns about Mr A’s wellbeing. Mr E told us Mr A was having a difficult time with drug dealers living in his flat so Ms O thought it would be a good idea to call the Trust to let staff know.
13. Mr A called the Trust on 16 October and asked to be admitted to hospital as he had thoughts of self-harm and suicide and did not feel safe. Mr E says the Trust should have immediately raised a safeguarding concern.
14. The Trust said when any contact is made from a service user to the duty desk, the call handler will ensure they update the medical notes on the system, but staff will also send an email to the care coordinator, so they are made aware.
15. The Trust said although it acknowledges Mr A was being proactive asking to be admitted to hospital, there was no urgency in Mr A’s contact on 16 October and the communication from him was received as an enquiry.
16. The Trust said it had no concerns when Mr A did not answer a call back from his care coordinator as he would often not answer his phone and then call back at a later date. It said the care coordinator was not concerned as although the medical notes stated he was feeling suicidal, Mr A said he did not have any specific plans. The care coordinator said he clearly observed the request Ms O had made that Mr A not be told she had called the Trust.
17. Safeguarding guidance says, ‘adult safeguarding means to work with an individual to protect their right to live in safety, free from abuse, harm and neglect’. It defines an adult at risk as ‘any person who is aged 18 years or over and at risk of abuse, harm or neglect because of their needs for care and/or support and are unable to safeguard themselves’.
18. Safeguarding guidance also states ‘one of the most important principles of safeguarding is that it is everyone’s responsibility. Each professional and organisation must do everything they can to ensure adults at risk are protected from abuse, harm and neglect’.
19. Safeguarding guidance lists the types of abuse, harm or neglect including financial or material abuse which is described as, ‘theft, fraud and exploitation, coercion in relation to an adults financial affairs or arrangements, including pressure in connection with property or financial transactions, or the misuse or appropriation of property, possessions or benefits. This can include “cuckooing” where a person’s property is taken over for illegal activities’.
20. Safeguarding guidance sets out the minimum level of competency required for all staff working in health settings. It states all staff should:
• have the ability to recognise potential indicators of adult abuse, harm and neglect • know what to do if there are concerns about adult abuse, harm and neglect, including who to contact, where to obtain further advice and support and have awareness of how to raise concerns • know about the importance of cooperation, sharing information (including the consequences of failing to do so) • have willingness to listen to adults at risk, families and carers and to act on issues and concerns.
21. the person raising the concern should:
• be open and honest and not promise to keep a secret • share information without consent if it is in the public interest in order to prevent a crime or protect others from harm • report concern following your safeguarding adult policy and procedure.
22. The Trust’s safeguarding policy applies to all staff. It states, ‘the member of staff who is informed about the incident is responsible for informing the most senior member of staff on duty and taking immediate necessary action to ensure the safety of those involved’.
23. Ms O called the Trust on 23 September to report Mr A had heavy drug users staying in his home. She told the call handler she was concerned about her son’s welfare. Ms O asked the call handler not to tell Mr A she had called.
24. The call handler recorded the details of the call on the patient record system noting Ms O’s request not to disclose the call to Mr A. There is no evidence in the records to suggest the Trust took any further action following Ms O’s call.
25. Mr A called the duty phone on 16 October and asked if he could be sent to hospital as he was feeling he might self-harm and had been thinking about killing himself. The call handler asked Mr A if he knew how he might do it or if he currently had the means to do it. Mr A said he did not know but he did not feel safe.
26. The call handler suggested they could talk about how he was feeling. Mr A said he had friends he could talk to. Mr A wanted to know if he could be sent to hospital, but he knew he probably could not because there was no funding or beds available.
27. The call handler said it would be a process, and they could talk. Mr A declined to talk any further and ended the call. The call handler sent an email to the care coordinator summarising the call.
28. The next record is dated 25 October and is a note advising Mr A had died. The care coordinator noted they had not heard from Mr A but were due to see him relatively soon.
29. The care coordinator also noted they had called Mr A back on 16 October after receiving the email from the duty staff member but there was no response from Mr A. This call was not recorded in the progress notes on 16 October.
30. We reviewed the records with the help of our psychiatrist adviser.
31. Our psychiatrist adviser told us Ms O’s call was crucial. Ms O had shown concern about known drug users in Mr A’s house. This was a situation clearly putting him at risk. They said Ms O’s call provided important information and should have alerted the Trust to consider a vulnerable adult situation. Safeguarding guidance states staff should have the ability to recognise potential indicators of adult abuse, harm and neglect.
32. On 16 October, there was an opportunity for the call handler to explain funding would not be an issue regarding a potential admittance to hospital. They needed to discuss reasons for admittance to hospital with Mr A. There is no evidence of the call handler understanding the call in the context of previous alert by Ms O or any professional curiosity in exploration.
33. The care coordinator should have considered passing concern on to the crisis team to do a welfare check after receiving no response to his call to Mr A on 16 October. This is outlined in the safeguarding guidance which states staff should know about the importance of sharing information.
34. There is no evidence in the records to indicate anyone tried to understand what was happening with Mr A. Overall, there should have been a more assertive exploration of Mr A’s situation and a well-documented decision about safeguarding.
35. In response to the complaint, the Trust stated the care coordinator had recognised 36. Ms O’s request for Mr A not be told about her call. Ms O found this comment to be further distressing and felt it apportioned blame to her in some way. In accordance with safeguarding guidance the Trust could have shared information without her consent as it would have been in Mr A’s best interests.
37. We have identified failings in recognising and raising a safeguarding issue following reported concern for Mr A’s safety by Ms O and himself. We go on to consider the impact of this failing later in our report.
Risk assessment
38. Mr E complains Mr A’s risk assessment was over a year out of date. He says had the risk assessment been updated to reflect his current situation, there may have been a different outcome for Mr A as the Trust may have taken his call for help on 16 October seriously.
39. Mr E says there was a period of change which the Trust did not pick up on. He told us Mr A had not been attending appointments, and Ms O had called the Trust with concerns. He said Mr A himself had called asking for help. He says it is hard to understand why the Trust did not update Mr A’s risk assessment following this.
40. The Trust said the minimum time period a risk assessment would be updated is annually unless there was any significant change in presentation, care level or a significant change in identified risks.
41. Whilst there had been some fluctuations in Mr A’s wellbeing during this period of care when he had two deteriorating episodes of psychosis, the Trust said for a long period of time there was a static nature to Mr A’s risk.
42. The root cause analysis report carried out by the Trust noted Mr A’s risk assessment and crisis, and contingency plan were not in date. It said the consultant focused on documenting the assessment of risk on Mr A’s progress notes. It stated Mr A’s risk had remained static for many years and whilst not in date, the risk assessment remained relevant.
43. Government guidance for assessing and managing risk in mental health services says, ‘the risk management plan should include a summary of all risks identified, formulations of the situations in which identified risks may occur, and actions to be taken by practitioners and the service user in response to crisis. Where suitable tools are available, risk management should be based on assessment using the structured clinical judgement approach’.
44. The risk assessment dated 8 October 2015 and updated on 15 June 2017 gave the overall risk for Mr A as low. The risk assessment says Mr A attended weekly psychotherapy and had regular reviews. It states if there were any clinical changes it would be evident in intensive therapy work and Mr A would contact the team as necessary.
45. Our psychiatrist adviser told us there is no evidence of clear reference to risk management in Mr A’s progress notes or during CPA reviews dated 11 October 2018 and 1 July 2019. They said the risk assessments are not well written, lacking specific risk formulation, history and plan.
46. Following Ms O’s call to the Trust on 23 September there was an opportunity to recognise the situation had changed for vulnerable adult safeguarding purposes even if the overall risk had not changed. This call should have prompted a deep review of the situation to see if the risk needed to be reviewed.
47. We have found the assessment and documentation of risk management to be poor and not in accordance with government guidance for assessing and managing risk in mental health services. We go on to consider the impact of this potential failing later in our report.
Second step
48. Mr E complains the Trust did not maintain adequate contact with Second Step to identify safety concerns during this period. He says this is particularly relevant because a close friend of Mr A’s had contacted Second Step to raise concerns about his wellbeing. He says had there been contact between the Trust and Second Step this would have made the situation clearer and increased the case for some form of intervention.
49. Mr A’s support worker from Second Step attended an appointment with him in July 2019 to meet with his care coordinator. The Trust said it was evident during this appointment Mr A and his support worker had a positive and trusting relationship and they met regularly. The care coordinator was aware Mr A was having regular input from Second Step.
50. Mr A’s art psychotherapist at the Trust said whilst Mr A attended art therapy groups they did not have any concerns requiring them to liaise with Second Step and in general, it would be rare they would have to contact Second Step in relation to any client.
51. The records from Second Step show Mr A’s friend had emailed the service on 7 October with concerns about his safety. This was escalated to a senior member of staff who made a call to Mr A on 18 October to assess the concerns.
52. The senior member of staff asked Mr A about his wellbeing and safety and concluded there was no immediate concern for his welfare.
53. Second Step carried out its own investigation and under ‘communication with the Trust’ it stated a risk decision was reached that there were no immediate concerns for the wellbeing of Mr A and therefore no need to contact the Trust.
54. The NHS Constitution, ‘key principle 5’ says, ‘the NHS works across organisational boundaries. It works in partnership with other organisations in the interests of patients, local communities and the wider population.’
55. Our psychiatrist adviser told us Trust staff had the opportunity to liaise and further investigate with Second Step. Although Second Step had concluded there was no immediate concern for his welfare, the email from Mr A’s friend on 7 October may have provided enough information to the Trust to consider further escalation.
56. As we have already mentioned in our report, we have seen no evidence of the Trust’s staff attempting to ‘connect the dots’ to fully understand the seriousness of Mr A’s situation. The Trust was aware Mr A had support from Second Step, and this would have been a reliable source of further information about his wellbeing which it could have explored.
57. We have seen no evidence the Trust consulted with other colleagues in line with GMC’s Good medical practice. We go on to consider the impact of this later in our report.
Impact
58. We next considered the impact of the failings we have identified. Mr E and Ms O told us they feel Mr A has been severely let down and died unnecessarily. They say they have suffered distress and pain as they will never know for certain what might have happened had more been done for Mr A.
59. We saw the Trust did not raise a safeguarding concern, update Mr A’s risk assessment, liaise with colleagues to understand the severity of his situation or demonstrate any professional curiosity. We asked our psychiatrist adviser for help in understanding the impact these potential failings may have had on Mr A.
60. It is very hard to say inaction by the Trust contributed directly to Mr A’s death. When considering if we can link the failings we have identified to Mr A’s death we have to take into account Mr A’s previous history and engagement with mental health services. In light of his history, we cannot say with all certainty Mr A would not have died of a drug overdose. We can say the Trust missed opportunities to increase the likelihood of a better outcome for Mr A.
61. We cannot directly link the failings to Mr A’s death. We recognise it will be distressing for Mr E and Ms O to know there potentially could have been a better outcome for Mr A. We therefore make recommendations to the Trust to address this.