Medication 24. The Department of Health’s published guidelines on the Care Programme Approach (CPA) outline what local CPA policies should include. This guidance states that care planning is central to the CPA and that individuals under the CPA should have a care plan for their medication. This guidance is clear that medication non-compliance is a high-risk indicator of relapse, and care should be planned accordingly. This should include reviews of a patient’s medication, when indicated.
25. The Trust’s CPA policy outlines that Mr N’s care co-ordinator was responsible for creating and maintaining his care plan. The review of his care plan is referred to as a ‘CPA review’ and must be held face-to-face. The policy states that a CPA review must be held: • every six months • if there is a significant change in the service user’s circumstances • before discharge from CPA or secondary mental health services.
26. Although there is no explicit timeframe for medication reviews by a doctor, Mr N should have had a CPA review every six months, or sooner if his circumstances significantly changed. This review should have included a review of his medication care plan.
Support 27. NICE guideline CG136 outlines the essential components of good service user experience in NHS adult mental health services. In line with these guidelines, the Trust should have:
• built trusting, supportive, empathic and non-judgemental relationships as an essential part of Mr N’s care • informed Ms N of her right to a formal carer’s assessment of her needs and how to access this • developed a care plan and crisis plan with Mr N, and ensured he and Ms N had access to this • considered Ms N’s needs when Mr N was in crisis, and ensured these were met where safe and practicable to do so.
28. The Trust’s CPA policy also states that all service users must have a care plan given to them, and that any patient with a history of ‘behavioural disturbances’ needs a care plan that includes strategies to manage this. This is referred to as a ‘behavioural support plan’. These strategies should have ‘focus[ed] on recognition of early signs of impending behavioural disturbance and how to respond to them’.
29. The CPA policy also states that Mr N should have had a crisis plan that included early warning signs of a crisis, coping strategies, and information about 24-hour access to support. The policy is clear that a copy of this plan should have been given to Mr N.
30. The Trust’s CPA policy outlines in detail the support that is expected to be provided to carers when a person is under the CPA. The policy states that carers are entitled to:
• have their concerns listened to and respected • be given information about the CPA and care planning • know who to contact in an emergency • receive prompt and positive responses to requests for help.
Crisis intervention
31. The Department of Health’s guidelines (Best Practice in Managing Risk) state that risk management is a core component of mental health care and the CPA. As a basic principle, there is a clear professional duty of care to a service user who presents with a high risk of harm to others due to a mental health problem. The guidelines also say that reducing the risk of self-harm is part of a practitioner’s fundamental duty.
32. The Trust’s CPA policy is also clear that risk assessment and risk management is a fundamental aspect of care for individuals being supported under CPA.
Chronology of care 33. In October 2019, Mr N began experiencing a relapse of his mental health symptoms. On 5 October the Crisis Team assessed him at home. The notes of this assessment reflect the team were considering a Mental Health Act assessment. The notes also show that Ms N had told the team she could not cope with Mr N any longer. She was advised to call the police for advice if he left the house.
34. The Crisis Team completed a home visit as planned on 5 October. The team managed to conduct a brief risk assessment, in line with the Department of Health’s guidelines, and agreed to support Mr N. They also documented that a more comprehensive assessment could not take place due to a lack of engagement from Mr N. The Crisis Team outlined a plan to:
• review Mr N’s medication, with a view to restarting antipsychotic medication and provide medication to assist sleeping • further visits from the Crisis Team would be twice a day • engage Mr N with help to abstain from cannabis • attend GP appointments and provide crisis support numbers.
35. The visiting members of staff then called the team’s consultant psychiatrist, who prescribed a sleep aid to be delivered to Mr N that evening. Sadly, he was arrested and detained under the Mental Health Act 1983 later that day. He was admitted to hospital on 7 October.
36. We have found that when Mr N was in crisis in October 2019, the Trust listened and acted on this appropriately. Unfortunately, he was detained by the police before the Crisis Team could take further action. Because Mr N had not been under the CPA for several months, he did not have a care plan or crisis plan, and there was no requirement for him to have had these at that time.
37. Ms N strongly disagrees with the Trust’s account of what happened, and we recognise her frustration that the Trust’s version of events does not align with her recollection of what happened.
38. In October 2019 Mr N was prescribed new medications whilst in hospital. He was discharged from hospital having been prescribed escitalopram, an antidepressant and anti-anxiety medication, and aripiprazole, an antipsychotic medication.
39. From 10 October the Crisis Team became involved in supporting Mr N’s discharge from hospital. He was discharged from hospital on 14 October. He did not attend his 72-hour follow up appointment and this was rearranged for 25 October.
40. Mr N was discharged under the CPA, which meant his care co-ordinator should have developed a care plan for him. This should have included a care plan for his medication, and he should have been given a copy of this as per the Trust’s CPA policy. The Trust did not complete a care plan for Mr N, which was a failure to complete a fundamental aspect of his care.
41. During a home visit by a mental health nurse on 25 October, Mr N reported he had halved his medication due to the side effects. The nurse documented he ‘presented with a great deal of physical discomfort’ and he told the nurse that if this continued, he would be unable to carry on taking the medication. The nurse also noted Mr N was smoking cannabis and showing ‘mild signs of relapse’.
42. Following this appointment the nurse spoke with a doctor who advised that Mr N attend A&E if his side effects became unbearable. There is no evidence this was communicated to Mr N.
43. Mr N missed outpatient appointments in October, December and January. He attended a rescheduled appointment on 17 January with support from his mother. During this appointment Mr N reported he had ‘self-reduced’ his medication because he felt that he did not need it. No further details were recorded, and no action was taken regarding this.
44. During this appointment, Ms N reported she had felt unsupported during her son’s last episode of crisis, and that she needed help if things got ‘out of control’. At this point it should have been clear to the Trust that Ms N was Mr N’s carer and that she needed more support.
45. The CMHT did not document any consideration of Ms N’s needs as a carer, nor did it inform her of her right to a formal carer’s assessment. It did not signpost her to any support services and there is no evidence the CMHT provided Mr N and Ms N with a crisis plan, a care plan, or any written information about his mental health condition. This was not in line with the Trust’s CPA policy or NICE guideline CG136.
46. At this stage the CMHT also knew Mr N had previous instances of contact with the criminal justice system when in a mental health crisis, and that his prior behaviour had posed a risk to himself and others. Therefore, in line with the Trust’s CPA policy, it should have developed a behavioural care plan. This did not happen.
47. Mr N did not attend his next planned appointment on 27 February. On 13 March the CMHT recorded that it had discussed Mr N’s case with a doctor and agreed to arrange a new appointment to develop a care plan. On 19 March the CHMT spoke with him over the telephone. There is no evidence a crisis or care plan was formulated and sent to Mr N following this call.
48. On 13 March the CMHT documented that Mr N had missed an appointment on 27 February, and that he needed a care plan. It spoke with him over the telephone on 19 March and he reported he was taking his medication.
49. At this point it had been almost six months since Mr N had been discharged from hospital. He did not have a care plan for his medication, nor had any documented review of his medication taken place. His care co-ordinator should have arranged a face-to-face CPA review prior to 14 April, as per the Trust’s policy, but this did not happen.
50. We recognise Mr N missed appointments during this period, however, NICE Quality Standard QS188 (coexisting severe mental illness and substance misuse), quality statement four, recognises that people with both severe mental ill health and substance misuse struggle to engage with appointments and they can be vulnerable if left without support. It recommends following up with patients whenever they miss an appointment. We have not seen any evidence that this happened when Mr N failed to attend his appointments.
51. The Trust also knew that Ms N was involved in her son’s care and that she could be a useful resource in helping him to engage. It did not explore how she could support Mr N with his attendance at these appointments. The Trust could have done much more to support Mr N’s engagement with the team.
52. Our Psychiatrist Adviser stated that the fact Mr N was not reviewed by a physician during this period was not representative of good and safe clinical practice. Furthermore, the fact he had no care plan or review from his care co-ordinator fell far short of the Trust’s CPA policy.
53. On 14 April Ms N’s telephone bill shows she made calls to the CMHT. The short call durations on her telephone bill indicate these calls were not picked up by the team. She called the CMHT again on 29 April to raise concerns about Mr N’s wellbeing and explained the Trust had not returned her previous telephone calls. During this call Ms N reported feeling very afraid of her son and that his behaviour was unusual. The CMHT asked her to get Mr N to call its team, and Ms N said this would be difficult due to his paranoia.
54. Ms N’s telephone bill shows she called the CMHT again later that evening and the call lasted for 43 minutes. The Trust did not make any record of this telephone call.
55. Ms N called the CMHT on three occasions on 6 May, as evidence by her telephone bill; however, the Trust only recorded one telephone call that day. In the call notes, the Trust recorded Ms N was scared of Mr N and was hiding in a car park. Ms N reported that Mr N had been smoking cannabis and putting pasta sauce all over the walls. She was advised to call the police if she felt afraid. The CMHT documented a plan for Mr N’s care co-ordinator to contact him the following day.
56. Mr N’s medical records reference a discussion took place at a team meeting the following day, but there is no record of what was discussed or who was involved in this discussion. His care co-ordinator rang Ms N that day. She reported her son was blocking her from leaving the house and she had been unable to go to work. She also reported she had slept in a car park that night due to being afraid of Mr N.
57. At 6pm on 7 May Mr N’s care co-ordinator attended his house. They noted he was laughing inappropriately but reported no concerns. Ms N’s account is that her son was behaving bizarrely but that his care co-ordinator was not taking his signs of relapse seriously. Ms N also says her attitude was dismissive of her concerns.
58. The CMHT updated Ms N later that evening and advised her to call the police if she felt afraid. Ms N told the CMHT that the police had been unable to help when she had called them previously. The CMHT continued to advise her to call the police, twice on 7 May and once again on 8 May. On 8 May Mr N was arrested and detained under the Mental Health Act 1983 following an instance of alleged criminal damage.
59. From 29 April the Trust knew Mr N may be experiencing a mental health crisis, and that Ms N was not coping with this. Our Psychiatrist Adviser also said that in the days leading up to 8 May, it was clear from the Trust’s notes that Mr N was experiencing psychosis and required an urgent medical review.
60. From 7 May the Trust also knew that the advice to call the police might not be helpful as Ms N had told the team the police had repeatedly declined to intervene. The Trust offered no other advice as to how to manage Mr N’s mental health crisis, which fell short of providing positive responses to Ms N’s requests for help.
61. The Trust did not develop any care plan or crisis plan for Mr N, and it had not provided any information or support to Ms N regarding her role as his carer. This meant there was no plan for how to manage Mr N’s behaviour and Ms N was given no support options other than to call the police.
62. Our Mental Health Nurse Adviser commented that asking Ms N to contact the police was not appropriate because this was not a police matter, it was a mental health crisis. They added that the CMHT could have done more to signpost Ms N to more appropriate support services whilst her son was in crisis. This fell far short of the support requirements set out in the Trust’s CPA policy and NICE guideline CG136.
63. On 8 May, Mr N was detained under the Mental Health Act 1983 and admitted to hospital. A psychiatrist prescribed aripiprazole again and his presentation began to improve significantly.
64. The Trust was due to hold a CPA meeting on the inpatient ward on 1 June, prior to Mr N’s discharge from hospital that day. This did not go ahead, however, and a final ward round took place instead. During this ward round, the Trust’s psychiatrist emphasised that Mr N should discuss any medication concerns with the CMHT before making any changes. The CMHT was not advised of the ward round and did not attend.
65. At this stage, Mr N’s medication had been fully reviewed whilst in hospital. However, he required a care plan and care co-ordination under the CPA when in the community. This should have included a care plan for his medication.
66. The CMHT attempted to visit Mr N on 2 June but he was asleep. No further attempts were made to contact him until more than two weeks later. This was not in line with the Trust’s CPA policy.
67. On 19 June and 28 July, the CMHT spoke with Mr N via telephone, and he confirmed he was taking his medication. There is no evidence his care co-ordinator created a care plan to support Mr N with medication compliance.
68. The next contact the CMHT had with Mr N was on 14 October, when he confirmed he was taking his medication. This was the last contact prior to his arrest for attempted murder in November. Following Mr N’s discharge from inpatient care on 1 June, the CMHT did not see him face-to-face again at any point up until his discharge from the service four months later.
Our findings on medication 69. We have found the Trust failed to create a care plan for Mr N’s medication, and review this when there were changes or after a period of six months. Furthermore, there is no evidence that the CMHT reviewed his medication at any point whilst in the community, despite clear indicators of non-compliance and relapse. Our Psychiatrist Adviser said this was not representative of good and safe clinical practice.
70. This was a failure to undertake an essential and fundamental aspect of planning Mr N’s care. From 25 October 2019 there were clear indicators that Mr N was not taking his medication as prescribed and was showing signs of relapse. However, no review of his medication or care plan took place in the community. The Trust also did not undertake a CPA review at any point in the six months following his discharge from hospital in October. This amounts to service failure.
71. The Trust also failed to create a care plan and appropriately monitor and review Mr N’s medication, and his medication compliance, as part of that care plan following his discharge from hospital in June 2020. This was not in line with the Trust’s CPA policy and the Department of Health’s guidelines and was a further failing in his care.
Our findings on the support provided to Ms N 72. We have found that from 25 October 2019 until 14 October 2020 the Trust failed to:
• inform Ms N of her right to a formal carer’s assessment and how to access this • develop and review a care plan, behavioural support plan, and crisis plan with Mr N and ensure he and his mother had copies of these • consider Ms N’s needs when her son was in crisis, and ensure these were met where safe and practicable to do so • provide prompt and positive responses to Ms N’s requests for help when Mr N was in crisis • give Ms N any information about the CPA or care planning.
73. These omissions fell so far short of the Trust’s CPA policy and NICE Clinical Guideline C136 that it amounts to service failure.
Our findings on crisis intervention 74. When Mr N had a mental health crisis on 5 October 2019 he had not been under the CPA for several months. He and Ms N had attended an Emergency Department on 4 October because his mental health had deteriorated. The hospital’s Psychiatry Liaison Team referred Mr N to the Crisis Team.
75. Unfortunately, Mr N’s medical records show his mental health crisis escalated quickly, and he was detained under the Mental Health Act 1983 before the Crisis Team could do more to assess his level of risk and offer further support.
76. We can understand why Ms N wanted the Crisis Team to detain Mr N for his safety, and the safety of others; however, it did not have the power to do this during the visit. This is because only specially trained mental health practitioners can make this decision. The team assessed Mr N’s level of risk and put a plan in place to manage this until he could be assessed further. We acknowledge Ms N disagrees with the Trust’s account of what happened during this assessment.
77. We have found the Crisis Team undertook a brief risk assessment and put a risk management plan in place that was appropriate to Mr N’s needs at that time. Unfortunately, he was arrested and detained under the Mental Health Act 1983 before it could take further action. We have found that the Trust’s actions were appropriate on 5 October.
78. On 7 May 2020, the CMHT assessed Mr N at home. Our Mental Health Nurse Adviser said that good clinical practice would have been to undertake a mental state examination, which is an important aspect of any mental health assessment. There is no evidence this happened, and our adviser also said the plan formulated following this visit was basic and lacked sufficient detail.
79. Our Mental Health Nurse Adviser also highlighted that there is no evidence the CMHT conducted a risk assessment. This was the purpose of the visit, as outlined in Mr N’s medical records. The risk assessment should have evaluated his likelihood of engaging in harmful behaviours, determining the immediate danger to him and others, and led to an appropriate risk management strategy.
80. There is no record of any formal risk assessment taking place following the CMHT’s visit on 6 May. Additionally, the nurse did not document an appropriate assessment of Mr N’s mental state, and the documented plan developed lacked sufficient detail to manage his presentation. This fell far short of the requirement to manage Mr N’s level of risk, as per the CPA policy and the Department of Health’s guidelines, and was a failing in his care.
Our findings on Mr N’s discharge 81. The Trust’s CPA policy states that a CPA review should take place before any patient is discharged from CPA or secondary mental health services. As per the policy, this should have happened face-to-face.
82. The Trust completed a serious incident investigation, which included a detailed consideration of Mr N’s discharge in October 2020. It identified that the CMHT did not follow the CPA policy when discharging Mr N from its service. This is because it had not seen him face-to-face at any point since his discharge from hospital in June and had not taken appropriate steps to contact Mr N and review him when he did not attend his scheduled appointments in June, July, and August.
83. Furthermore, the serious incident investigation documented that Mr N had a new care co-ordinator allocated in June and this person reported they had not been aware that Mr N was under the CPA. Mr N had also not been advised that he had a new care co-ordinator. The Trust’s investigation found this was due to failings in the handover practices of the CMHT at that time.
84. In addition, the Trust’s investigation also highlighted that the CMHT had not engaged Ms N in her son’s last episode of care because her role as his carer had not been handed over to his new care co-ordinator.
85. We have found that Mr N should have had a CPA review and should have been seen face-to-face by the CMHT before it decided to discharge him from its service. Between June and October 2020, his level of risk was not appropriately reviewed, his care co-ordinator was not aware he was under the CPA, and Mr N was never seen face-to-face. The Trust then discharged him back to the care of his GP without a CPA review. This fell so far short of the Trust’s CPA policy that it was a failing in the care provided to Mr N.
Serious investigation report 86. NHS England has a published framework for investigating serious incidents in NHS services. This framework states that when undertaking a serious incident investigation, the needs of those affected should be of primary concern to those involved in investigating serious incidents. It adds that patients and their families should be supported and included throughout the investigation process.
87. Involving families in this process is important because, as per the NHS England framework, ‘often the family can offer invaluable insight into service and care delivery and can frequently ask the key questions’.
88. In line with NHS England’s framework, the Trust should have:
• met with Ms N early in the process to advise on what would happen and allow her to express concerns and ask questions • explained to her how she could contribute to the report and given her the opportunity to comment on it before closing the investigation and submitting the report to the commissioner • disclosed only relevant confidential personal information with consent, only disclosing information without consent if overridden by public interest and approved by a Caldicott Guardian and legal advice • described how the victim(s) and their family/families had been involved in the process • outlined the support provided to the family after the incident.
89. The Trust’s complaint response to Ms N, dated 17 March 2022, outlined that prior to the investigation it spoke with her, but it did not advise her it would include background information within the report. It apologised for this and said that it would ensure family members were made aware of this prior to writing reports in future.
90. This reflects a lack of consideration of by the Trust regarding its responsibility to ensure it only disclosed relevant confidential information with consent. We have seen no evidence it obtained consent to share the confidential information it included in the final report. Whilst we are not suggesting this information was not relevant, it was important that the Trust ensured it had considered consent when disclosing this confidential information.
91. We have also seen no evidence it attempted to seek consent from Mr N or that it informed Ms N this information would be included in the report. This fell short of NHS England’s framework for serious incident reporting.
92. With regards to the Trust inappropriately including its opinions about Mr N and the events that had taken place in its report, we have not seen evidence that it did. The majority of the report outlines what happened based on the records kept at the time. This will inevitably include some degree of professional opinion as recorded by the staff, and it was appropriate to include these as part of the investigation.
93. The report also appropriately included the views of the staff members involved in the events. This was essential to understanding how the events unfolded and what underpinned any failings identified.
94. The evidence shows the Trust did not inappropriately include its opinions in the serious investigation report. There are no value-based judgements of Mr N or what happened in the report; rather, the report outlines the facts of what happened and how the events led to the serious incident. This narrative appropriately included the perspectives of the Trust’s staff.
95. The Trust did not reference Ms N and her son’s perspectives throughout most of the serious investigation report, however. The only reference to Ms N’s perspective is one sentence in the terms of reference to the report which says: ‘the patient’s mother has also shared that she has concerns about the care provided to her son by the CMHT’. There is no reference to Mr N’s view on what happened.
96. In contrast, the report contains numerous references to the staff members’ perspectives on what happened.
97. Under the Engagement and Participation section of the serious investigation report, the Trust outlined that it spoke with Ms N on 19 and 26 January 2021. There is little documented about what was explained, and no documentation of any support being offered to Ms N during this process.
98. There is also no documentation to reflect the investigator told Ms N how she could contribute to the report, or that the Trust would give her the opportunity to comment on the report. Instead, the notes say Ms N was told she could ask questions once the investigation was completed. This was not in line with the NHS England framework.
99. We have found the Trust contacted Ms N to speak with her about the serious incident investigation. This was approximately part way through the investigation; however, we can see that it had first contacted Mr N and then made several attempts to contact Ms N before it was able to speak with her. Therefore, this delay was unavoidable and the contact with Ms N at this stage was in line with the NHS England framework.
100. Following this, the Trust’s complaint response says Ms N felt unable to engage in a video call with the investigator. We recognise this attempt to engage Ms N, however, she was not given any further opportunity to contribute to the report. This was not in line with NHS England’s framework.
101. We have found the Trust’s actions fell far short of the NHS England framework in the following areas:
• it did not ensure the needs of those affected were the primary concern of the investigation • it relied almost exclusively on the accounts and perspectives of the Trust’s staff • the report failed to document what support had been offered to Mr N and his family during the process • it failed to consider the confidential nature of the information in the report, advise Ms N this information would be included, and obtain consent to share this information • it did not give Ms N the opportunity to contribute to the report or review it before the report was submitted to the commissioner.
102. The failure to appropriately engage Ms N in the process, as per the NHS framework, is what more likely than not led to the report relying almost exclusively on the perspectives of the Trust’s staff members and only including one reference to her view.
103. We have found the Trust’s actions did not align with the framework set out by NHS England and this amounts to service failure.
Impact 104. Ms N, as her son’s carer, would inevitably have experienced some degree of stress and worry due to her son’s mental health difficulties even if all the care provided had aligned with local and national guidelines. That said, had the Trust acted in line with NICE guideline CG136 and its CPA policy and provided appropriate support to her, a significant amount of the stress, anxiety, worry and fear she experienced could have been avoided or mitigated.
105. Had Ms N been provided with information about her son’s condition, a care plan and a crisis plan, this would have empowered her to know what to do in a crisis and how to help her son between October 2019 and November 2020. During this period Ms N had to live with the stress and worry of not knowing how to help her son, or what to do if he experienced a relapse or mental health crisis.
106. We have also seen that between 29 April and 8 May 2020, Ms N repeatedly reached out for support with managing Mr N’s mental health crisis. She describes intense distress and ‘terror’ at his behaviour and the lack of support or intervention during this time. She says she was unable to live a normal life or go to work. She describes how Mr N physically blocked her from leaving the house, she woke up to him standing over her bed watching her sleep, and having to sleep in her car due fear for her safety. Mr N also removed much of the furniture from the house, smeared food all over her walls, and was responding to things that were not there. It is understandable that this would have been terrifying for Ms N.
107. The Trust should have done more to support Ms N during this time. As we explain in more detail below, had Mr N’s care co-ordinator acted on this information appropriately on 29 April, it is more likely than not he would have been promptly admitted to hospital and this prolonged period of intense fear and distress could have been avoided. Instead, the Trust dismissed Ms N’s concerns, failed to make a record of several of her telephone contacts, and repeatedly provided advice that it knew was not helpful. This significantly exacerbated what was already a very difficult and distressing situation.
108. With regards to whether Mr N’s arrests in May 2020 and November 2020 could have been avoided, our Psychiatrist Adviser explained that from the end of April 2020, Mr N’s mental state began noticeably deteriorating. They expressed concern as to why it took a week to review Mr N after his mother contacted the CMHT on 29 April. Our adviser explained this was too long to wait to review someone with Mr N’s presentation and history, and he should have been prioritised for an urgent medical review on 29 April.
109. Our Psychiatrist Adviser explained that had Mr N been urgently reviewed by a doctor following his mother’s contact with the CMHT on 29 April, his mental state would more likely than not have been assessed, his risk profile reviewed, and his mental health medication reviewed and/or optimised.
110. Our Psychiatrist Adviser also reviewed Mr N’s documented presentation at that time and advised that based on his’s mental state, his behaviour, and his presentation in the family home, Mr N would have warranted recommendation for admission to hospital at the time of the urgent medical review. If Mr N had refused admission to hospital, our Psychiatrist Adviser explained that a Mental Health Act assessment would have been clinically justified and appropriate. They added that in their view, Mr N would more likely than not have been detained under the Mental Health Act 1983 at that time if he had declined an admission to hospital.
111. On the balance of probabilities, we have found that had Mr N’s care co-ordinator acted appropriately on the information given to her on 29 April, and an urgent medical review been undertaken, Mr N would more likely than not have been admitted to hospital for treatment and his arrest on 8 May could have been avoided. This is a very serious injustice that will understandably cause Ms N distress.
112. With regards to the incident in November 2020, our Psychiatrist Adviser explained that because of the poor level of contact with Mr N between June and October 2020, there is virtually no reliable evidence of his mental state during these crucial months before the stabbing. Their view is that this was not representative of safe care.
113. Our Psychiatrist Adviser said it is possible these failings contributed to Mr N’s mental health decline and his subsequent arrest for attempted murder. This is because had he been given safe and appropriate care his mental health may have been much better managed, and it is possible he would not have experienced such a serious relapse of psychosis in November 2020.
114. However, the Trust’s failings in documenting Mr N’s care and contacting him during this time mean we do not have sufficient evidence on which to base a robust decision. Whilst the Trust did have some telephone contacts with Mr N, where he reported he was fine and taking his medication, this type of contact was not sufficient to make a safe and informed judgement about his level or risk or his mental state.
115. We also cannot say that had Mr N not been inappropriately discharged from the CMHT on 23 October, that he would not have gone on to be arrested in November.
116. What we can say is that there is a tangible possibility that this very sad outcome could have been avoided. However, we cannot say it is more likely than not this would have happened. This lack of certainty is largely due to the Trust’s failings in Mr N’s care resulting in insufficient evidence on which to reach a robust conclusion. This is a very serious injustice, and one that we have no doubt has caused, and will continue to cause, Ms N significant distress.
117. We also acknowledge that the poor experience provided to Ms N during the serious incident investigation also caused her distress during an already stressful time.
118. We have considered Ms N’s claim of financial loss related to the criminal damage that occurred in May 2020. With regards to the damages to her property caused by the police having to force her front door to detain Mr N on 8 May, we think that this could have been avoided had the CMHT acted on 29 April. Ms N has provided evidence in the form of a bill, dated 8 June, for a locksmith attending on the 8 May to secure her property which cost her £240. This represents a financial loss to Ms N that stems directly from the failings we have identified.
119. With regards to the damage to her neighbours’ property, we empathise with Ms N and understand why she felt obligated to reimburse her neighbours for this. We recognise that in doing so she was doing what she felt was in Mr N’s best interests. That said, because Mr N was an adult when this happened, she was not liable for these costs. Had she declined to reimburse her neighbours for this, they could not have pursued her via the courts for these damages. Therefore, we cannot say that the Trust’s failings in Mr N’s care led directly to Ms N incurring this financial loss.
120. The Trust has not acknowledged failings in the following areas of Mr N’s care:
• failure to create a care plan to appropriately monitor, review and support Mr N’s medication compliance • failing to provide appropriate support to Ms N and her son, and not considering her needs as his carer • failing to assess Mr N’s level of risk and put an appropriate plan in place to manage this on 7 May 2020.
121. The Trust’s complaint response to Ms N, dated 17 March 2022, was a missed opportunity for it to reflect on the service provided and how this contributed to the distress experienced by both parties.
122. Whilst it was appropriate to reference aspects of Mr N’s behaviour that may have contributed to his relapses, for example his missed appointments, the complaint response failed to consider the Trust’s duty to co-ordinate and provide safe and responsive care under the CPA. The response reads as though little consideration was given to the Trust’s responsibility to engage Mr N and placed an unfair emphasis on his non-attendance at these appointments. It also failed to proactively identify the areas where its service fell far short of its own policies and national guidelines.
123. The complaint response did acknowledge and apologise for not advising Ms N about the inclusion of background information in the serious incident investigation report, and also for largely omitting her and Mr N’s perspectives in the report.
124. The Trust has also acknowledged the failings that led up to Mr N’s discharge and has apologised for these. It has also taken steps to improve its service in relation to the process followed before discharging patients from the CMHT.
125. Overall, whilst we acknowledge the Trust has taken some steps to improve its service since Mr N’s arrest, we are not satisfied that it has acknowledged the extent of the failings in his care, the lack of support provided to Ms N, and the serious emotional injustice directly arising from these. It has also not addressed the financial loss Ms N incurred.