Misdiagnosis
14. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the Trust has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone wrong.
15. Mrs E says the Trust misdiagnosed her son’s psychotic crisis as autistic behaviour on 24 March 2024. The Trust maintain their approach to his clinical presentation and diagnosis was appropriate.
16. The Trust said Mr A was assessed at the Emergency Department (ED) and some ongoing psychosis was identified along with issues in his supported accommodation. It stated there was no clinical indication that Mr A required mental health admission, and he was kept in until appropriate accommodation was found for him.
17. We have looked to see if there were any indication of a misdiagnosis on that date. According to the Trust’s website, the psychiatric liaison team, provide psychiatric assessments and treatment to people who may be experiencing distress whilst in hospital. Furthermore, the Trust’s Operational policy – Psychiatric Liaison Services (March 2019) (the Trust’s policy), states senior liaison clinicians and Liaison Practitioners are responsible for the effective assessment of service users. Therefore, we would expect either a senior liaison or a liaison practitioner would assess Mr A, and we can see that happened when he was assessed by a liaison practitioner on admission.
18. We appreciate Mrs E believes Mr A was having a psychotic crisis, and this was misdiagnosed. We could not identify any relevant guidelines other than the Trust’s policy, which explains assessments are made by the Menal Health Liaison Team (MHLT).
19. Our adviser explained that psychotic crisis is a subjective term. They further explained, a patient may have symptoms of psychosis, but this does not mean they are in a crisis. Patients who usually are in a crisis, are a risk to themselves and others. If that is the case, the appropriate action is to detain them under the Mental Health Act 1983.
20. We have looked to see if there were any indications of psychotic crisis on 24 March 2023. According to the available records, Mr A was taken to the ED by ambulance in the morning. His clinical assessment found he was low risk to himself and from others, but medium risk to others. Our understanding is this related to his supported accommodation and the events that had occurred there. The plan was for him to be reviewed by the Menal Health Liaison Team (MHLT).
21. In the afternoon of the same day, he was assessed by a psychiatric liaison (member of the MHLT) who reviewed Mr A’s medical files and spoke to him. Mr A appeared tired but was polite and pleasant. The notes state, Mr A was willing to engage and had good eye contact throughout the assessment and appeared euthymic (happy). He had normal speech tone, rate and volume and was coherent and there was no evidence of elated mood. The notes mention recent aggressive behaviour at his supported accommodation but no risk to himself or others was identified by that time.
22. The Psychiatric Liaison’s impression of Mr A’s presentation was he had a history of autism and questioned whether he was bipolar. It noted his challenging behaviour was related to his supported accommodation. The plan was to discharge him back to his supported accommodation but because the accommodation refused to accept him, he was admitted to hospital until suitable accommodation was found and Mr A was happy with that.
23. We appreciate in the morning of 24 March 2023, Mr A appeared to be agitated. However, by the afternoon, when he was reviewed by the liaison practitioner, he appeared coherent and polite and no risk to himself or others was identified. Therefore, there are no indications Mr A was in a state of crisis when reviewed on 24 March 2023. Similarly, we have seen no suggestion that any signs of crisis were misappropriately attributed to his autism.
24. To reassure ourselves, about whether there were indications of a crisis that were missed, we have also reviewed how he was the following day on 25 March 2023. The records show he was reviewed by the same psychiatric liaison who found he had capacity and maintained reasonable insight. The notes state his presentation was consistent with his Asperger’s and autism diagnosis and there were no psychotic or mood symptoms. It did identify inconsistencies with Mr A’s medication and a medication review was planned. From the available notes, there is no indication he was in a crisis.
25. We appreciate Mrs E’s view is the Trust misdiagnosed his psychotic crisis as his symptoms of autism on 24 March 2023. As explained above, having psychosis and having a (psychotic) crisis is not the same. Having carefully looked at the records, we can see the Trust reflected on his behaviour (symptoms) and saw no indication of a crisis. Therefore, whilst we appreciate Mrs E believes symptoms of psychotic crisis were misdiagnosed as autism, we can see the Trust has fully acknowledged his background of autism and we have seen no basis to suggest signs of psychosis were misreported as this.
No assessment by psychiatric consultant
26. Mrs E says he should had been reviewed by a consultant psychiatrist on 27 March 2023. Mrs E’s view is the MDT on Monday 27 March 2023, relied on the original assessment on Friday 24 March 2023, which in her view misdiagnosed his psychotic crisis.
27. The Trust said Mr A’s presentation and history was discussed on 27 March 2023, during an MDT which included a consultant psychiatrist.
28. We note, have already explained in the point above, there was no indication Mr A was in a crisis on 24 March 2023, and therefore, there is no indication of a misdiagnosis of his presentation. Therefore, we have looked to see if Mr A should have been reviewed by a consultant psychiatrist on Monday 27 March 2023.
29. According to the Trust’s policy, consultant psychiatrists’ main duties are clinical leadership for diagnosis and effective management plans. Reviews of ward patients, specialist pharmacological advice, high level assessment of risk and complex presentations (severe attempts of self-harm etc), MHA assessments and supervision of lower grade doctors. Therefore, we would expect a consultant psychiatrist, to review patients (high risk cases) and to have input into other patients’ care and management.
30. The records show Mr A’s case was reviewed at a board (MDT) meeting on Monday 27 March 2023, which includes input from a consultant psychiatrist. Our adviser explained Mr A was admitted to hospital on social and not clinical grounds. This is because he was in hospital until suitable accommodation was found for him and not because he was mentally unwell or in a crisis. Therefore, our understanding is he was waiting to be discharged once appropriate accommodation was found. This would not require an assessment from a consultant psychiatrist as this was not a high-risk case.
31. We would expect Mr A’s care to have the oversight of the consultant psychiatrist, and we can see this was done. According to the advice we received, an in-person review would be best practice, however, they clarified because Mr A was in hospital on social grounds, not doing so is not against the policy. Therefore, given Mr A was not in any risk or crisis at the time, and because his admission was on social grounds, we have no concerns that his review was done in an MDT setting.
32. We appreciate in the following days Mr A’s mental health deteriorated, and this would cause distress to Mrs E. We were extremely sorry to hear that. We hope this consideration provides assurance that no signs of earlier crisis were missed.