27. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. When we see signs something may have gone wrong, we also look at whether there are signs the event(s) complained about had a negative effect which the organisation has not put right.
28. We have done this and whilst we saw some signs of the Trust not acting in line with the relevant guidelines, the Trust has proactively taken steps to apologise and put those things right. Where this has happened, we do not think further investigation could add anything further to what the Trust has already done. We will now explain the reasons for our decision.
Care Programme Approach
29. Mrs U complains the Trust did not inform her that Mr U was subject to the CPA or follow the CPA guidelines to involve her in his care planning in September 2020.
30. The Trust said it was sorry there was no evidence to suggest a collaborative approach with Mrs U in September 2020. It also apologised for not including information about CPA in the care plan and not sending the care plan to her.
31. There is no explicit legal duty under the NICE service user experience guidelines that say next of kin must be informed when someone is placed on CPA. The guidelines say wherever possible, carers should be involved in care planning, decision making, and information sharing as appropriate, and this should be in agreement with the service user. It does not say that carers must be told about CPA. For this reason, it is not an indication of a failing that the Trust did not explicitly tell Mrs U about the CPA.
32. However, regarding Mrs U being involved in care planning in September 2020, the same NICE guidelines strongly encourage involvement of family and carers in planning care and providing support, with the patient’s agreement. There is no evidence to suggest Mr U did not agree with Mrs U’s involvement in his care planning. As such, we would expect her to be involved. The Trust have already accepted there was a failing in this and apologised.
33. The Trust also accepted the care plan was not shared with her at that time. She received the care plan when she later requested it in October 2020.
34. We appreciate Mrs U has explained that as a result of not being involved Mr U and his family were not offered appropriate support to manage his escalating challenging behaviour, resulting in a breakdown in the family and Mrs U’s ability to care for him.
35. We therefore considered what support the Trust offered to Mr and Mrs U to help manage Mr U’s increasingly challenging behaviour at this time, and whether this was in line with the NICE service user experience guidelines. We can see Mrs U was asking for more support as Mr U’s behaviour was difficult for her to manage. We can see Mr U wished to be cared for at home, and cannot see Mrs U was against this, albeit she wanted the additional support.
36. All the law and guidelines on mental health care we have referred to include a principle of least restrictive care. This means every effort should be made to support people in the least restrictive environment, such as their own home, avoiding unnecessary hospital admissions.
37. The NICE service user experience guidelines say carers should be involved in decision-making, care planning and information sharing as appropriate and in agreement with the service user. These guidelines say care plans should be developed jointly with the service user and support them to develop strategies to promote and maintain independence and self-efficacy where possible.
38. Mr U had a care plan from September 2020, but it was being updated by a new CPN when he reached crisis and needed hospital admission in January 2021. The care planning was in line with the guidelines because it considered the risks to Mr U and looked at what support could be offered to promote his independence at home and reduce his challenging behaviour. Mrs U was involved in the care planning from December 2020 onwards. Her views were taken into consideration, with a focus on medication review and support at home, which appeared to be Mrs U’s preference at the time. Various professionals were involved, such as Mr U’s GP, outreach workers, CPN, and social worker.
39. We sought independent clinical advice from a mental health nursing adviser who confirmed the Trust’s care planning and support was as expected in line with guidelines. We understand Mr U’s family life was impacted by his behaviour, but we can see the Trust offered support to try and improve this.
40. We can see Mrs U told the CPN she believed Mr U’s behaviour had worsened following an earlier change to his medication. As we have indicated above, we would expect the family’s views and concerns to be considered. We can see his medication was proactively being reviewed on a one to two weekly basis to try and reduce his challenging behaviour in the lead up to his hospital admission on 21 January. Respite was also offered to try and support Mrs U in her caring capacity at home, which reflects that the CPN could see Mrs U was finding her caring role difficult to sustain. Outreach support was also in the process of being arranged at the time of Mr U’s hospital admission, to help give Mrs U some respite whilst Mr U stayed at home. As such, we have seen work was done as part of the support plan, and on a weekly review to reflect Mr U’s changing needs and we see no failing in this.
41. We do appreciate the COVID-19 pandemic affected some of Mr U’s face-to-face services, as Mrs U expressed concerns about visits from a support worker being changed to telephone calls, which she felt would be ineffective. The pandemic is known to have had a significant impact on face-to-face services due to social distancing measures, which meant some in-person services become virtual or telephone services temporarily to limit the risk of COVID-19 spreading, particularly amongst frontline staff and vulnerable people. However, overall, we can see appropriate action was to take to plan support.
42. Additionally, we would expect a clear plan for any crisis point within the plan. The NICE service user experience guidelines say there should be clear crisis and contingency planning as part of an up-to-date care plan. This includes early warning signs of deterioration, clear actions the patient and carers can take, and contact details for who to reach in a crisis such as the care co-ordinator, the CMHT, out-of-hours crisis service, and GP details. There should also be timely access to a crisis resolution and home treatment team (CRHTT) or equivalent for urgent assessment and intensive home treatment as an alternative to hospital admission.
43. Both physical and mental health conditions can have an element of unpredictability, which is why crisis and contingency planning are so important. There is evidence that the new CPN offered Mrs U a printed copy of the existing crisis and contingency plan when she first contacted her on 4 January.
44. Mrs U contacted the family GP when she reached crisis point, which is a suggested point of contact in a crisis. We understand the GP was very concerned about Mrs U’s safety due to Mr U’s threats which could be heard in the background of the telephone call on 20 January. We are not looking at the actions of the GP within this complaint. However, we understand the GP was aware of Mr U’s history of challenging behaviour as they were actively involved in medication reviews to try and reduce this. Paramedics also attended and Mr U was admitted to hospital for mental health assessment. As such, we can see there was appropriate planning in place to allow support in crisis periods.
45. It was only when Mr U’s behaviour escalated with threats of physical violence that the emergency services were contacted to intervene. Mrs U had not reported any threats of physical violence towards her on 4 or 15 January to the CPN, although Mr U had shown aggression towards property that had posed a risk of harm to others. She had frequently discussed Mr U’s interest in sharp objects such as knives and tools and verbal aggression, and this was documented in the risk assessment. This was also documented in his earlier care plan from September. Apart from her interest in respite, Mrs U does not appear to have suggested Mr U should not be cared for in the family home, and her views about what might help, such as changes to his medication and face-to-face support, and we can see these were considered and acted upon.
46. There does not appear to have been other contact between Mrs U and any services which presented an opportunity to consider an urgent need for CRHTT input in the lead up to this incident. During her last contact with the Trust prior to hospital admission on 15 January the risk assessment was completed. No immediate risk was identified, though Mr U’s challenging behaviour was documented. Mr U was said to be engaging with services.
47. In summary, whilst Mrs U may not have been explicitly told the care planning was part of the CPA, there is no indication that she was not included in care planning in January 2021. She was offered appropriate support in line with all relevant mental health guidelines. She reached out to an appropriate service in crisis, which was her GP, and this prompted police and paramedic intervention due to Mr U’s increasingly aggressive behaviour. This ensured he could be taken to a safe place for mental health assessment and reduce the risk of harm to himself or others when he was making threats of violence towards other people, due to his mental state at the time. We think the Trust did act within guidelines, except for the earlier lack of collaboration it already acknowledged, but we cannot see this contributed to Mr U’s deterioration in January 2021.
48. We understand this was a traumatic experience for Mr U and his family, and we are satisfied the Trust was in the process of updating the care plan in collaboration with them to try to prevent incidents such as this one and supporting Mr U to remain at home. NICE service user experience guidelines include crisis and contingency planning, in recognition that a mental health crisis or carer breakdown cannot always be anticipated or prevented. Mr U received timely support, though we understand Mrs U would have preferred this incident to have been avoided if it was possible. We do not doubt this was a challenging experience for Mr U’s family, and we are sorry it was their experience.
Deprivation of Liberty Safeguarding (DoLS)
49. Mrs U says the Trust did not inform her about the Deprivation of Liberty Safeguards (DoLS) application as his lasting power of attorney (LPA). The Trust agreed it did not do this and said it submitted the application in error.
50. A DoLS is put in place when a person is under a ‘deprivation of liberty’ as the only way to meet their needs, for example, an involuntary admission to hospital for assessment or treatment where they are not free to leave.
51. As the DoLS application was withdrawn, we are pleased to note Mr U was not restricted in his freedom. We understand both Mr U and Mrs U were very upset when they were first told about the DoLs application. The Trust have accepted this and apologised. It said it would speak to the staff member concerned to allow them to take learning from this, and the ward staff in general. We think this is in line with the principle of showing fairness and accountability in our NHS complaint standards. This is because the Trust showed accountability for what went wrong by apologising to Mrs U and taking action to ensure this does not happen in future.
52. As we think the Trust has taken appropriate steps to apologise to Mrs U and improve the service for future patients, in line with our NHS complaint standards, we have decided there is nothing further we can add to put right this error.
Discharge decision-making
53. Mrs U says the Trust did not correctly consider Mr U’s capacity to be discharged to residential care in March 2021. She also says the Trust did not include her in discussions about Mr U’s discharge plan until the day before he was due to be discharged. The Trust maintain they did involve Mrs U as the discussions about post-discharge care took place at an MDT on 11 February 2021 which she attended. It also says the discharge planning social worker assessed Mr U’s capacity to make the decision about his care home placement after discharge.
54. The records show that on 2 February, Mrs U was consulted with as his LPA and she said she did not believe Mr U had capacity to make decisions about his health, welfare, property or finances due to his condition. A mental capacity assessment was completed on 4 February.
55. The assessment included Mr U’s views and Mrs U’s views as his main carer about the available options. It concluded he had mental capacity because he was able to understand the relevant information for the decision, and retain this information, weigh it up, and communicate his decision. It recognised his capacity may fluctuate.
56. An NHS continuing healthcare checklist was also completed, which is a screening assessment to see whether Mr U may have been eligible for NHS funding for his care upon discharge from hospital. This checklist indicated Mr U should have a full assessment for funding.
57. On 11 February, Mrs U’s views were discussed at a multidisciplinary team meeting (MDT). The doctor agreed with Mrs U and said Mr U lacked insight and a decision would be made in his best interests. The CPN was concerned about the ability of a residential care home to manage Mr U’s needs but agreed that he lacked capacity to make the decision himself.
58. Mr U was asked about his views on 15 February. He said he wanted to go home but he recognised his wife struggled with his anger and said he did not know what he wanted, other than what was best. His views were discussed in an MDT on 18 February.
59. On 22 February, Mr U told a nurse he was not sure whether he should go home, He acknowledged he could take his anger out on his wife and was falling out with their two children. He said he felt he may be best going to a care home because he wanted to do what was best for his wife. He remained unsure about his decision.
60. He spoke to his social worker on 24 February and said he would prefer to go into a residential care setting because of his difficulties managing his frustration and anger at home. The social worker assessed he had the capacity to make this decision. They spoke to Mrs U, and she confirmed she was not coping with him at home despite having done her best to support him over the past 12 months.
61. Mental capacity can fluctuate. The code of practice says an assessment should only assess a person’s capacity to make a decision when it needs to be made. It may be possible to put off the decision until the person has the capacity to make it.
62. We can see throughout February there were different views on whether Mr U had capacity, but this is not unusual. We can see that at times when was considered to have capacity, Mr U appears to have weighed up the impact his behaviour was having on his wife, and his view reflected what she had told different professionals about struggling with his behaviour at home and unable to cope. The Trust felt he had capacity and planned to identify a specialist dementia care home for Mr U. Mr U seemed positive about the decision. For example, Mr U was reportedly excited about decorating his new room at the care home on 3 March after being supported to research the home and what it looked like.
63. We sought independent clinical advice about the capacity assessment, and our mental health nursing adviser confirmed the relevant information was considered as part of Mr U’s assessment, including Mrs U’s views, as per the Mental Capacity Act.
64. A suitable care home assessed and accepted Mr U on 2 March. The Trust and Mr U attempted to phone Mrs U to update her but were unable to reach her. The Trust contacted Mrs U on 4 March to confirm the discharge date, which was 5 March. Our mental health nursing adviser noted that short notice can occur because of limited bed availability in specialist care homes.
65. Accordingly, whilst we fully appreciate that practically Mrs U will have had one day’s notice of the discharge, we can also see she was included in the planning and lead up to this event. We also note appropriate regard was given to Mr U’s ability to make his own decisions as part of this planning.
66. Whilst the decision to move to a particular care home was made with short notice, the overall decision to move into residential care was assessed over one month before the discharge plan was confirmed. We appreciate the confirmation of Mr U’s discharge may have felt sudden to Mrs U, but we are satisfied the Trust took appropriate time to consider Mr U’s capacity and Mrs U’s views about what should happen after discharge, to prepare them as best it could for future care.
67. In conclusion, there are no signs anything went wrong with Mr U’s care planning and support between September 2020 and January 2021 in the community, or from January to March 2021 in the hospital, which has not already been put right in line with our NHS complaint standards. We think We acknowledge Mr U and his family experienced great difficulties because of his increasingly challenging behaviour, which resulted from dementia and was therefore not within his control. It had a significant impact on his family life, which we were sorry to hear about. After careful consideration, we are assured the Trust followed the relevant guidelines to offer appropriate support to the family, both in the community and in hospital. For this reason, we have decided not to investigate this complaint further.