Communication and involvement in care
22. Mrs Y says the Trust failed to communicate with the family and the perinatal team during Ms B’s admission. She considers they were both prevented from any involvement in Ms B’s care until 19 February when she had left the ward.
23. Mrs Y says at previous hospitals, the clinical teams treating Ms B included family and the perinatal team in their weekly reviews. They established an overview and understanding of who she was and enabled the teams to identify signs to look for in recovery.
24. Mrs Y believes this resulted in a loss of significant information relevant to Ms B’s diagnosis, treatment, and risk management. She says that none of the clinical team ever sought to elicit information or help from the family in terms of understanding how Ms Armstong presented “normally”. By not doing this, they believe there was an absence of any criteria by which to measure any improvement or decline in her condition.
25. Mrs Y explains her view that the perinatal team were the only team that had been involved throughout Ms B’s treatment, and therefore had a consistent clinical overview that would help inform treatment plans.
• Family
26. The importance of family involvement in a patient’s care and treatment following admission to a psychiatric ward is outlined in NICE CG136. It tells us that the patient should be asked if, and how, they want their family to be involved in their care. Family involvement is also in keeping with the GMC’s Good Medical Practice guidance, in relation to being considerate to those close to the patient and being sensitive and responsive in giving them information and support.
27. We understand including family regularly in a patient’s episode of inpatient care is beneficial for all involved, as the family know the patient better than the inpatient team, and can provide valuable information about their history, presentation, and progression. During the admission it is evident that Ms B had contact with various family members, including her mother and father, her partner, and both of her children. The family maintained regular contact throughout the inpatient admission.
28. However, we cannot see if Ms B was asked if, and how, she wanted her family to be involved in her care. We cannot see from the records that Mrs Y or any other family members were invited to the weekly ward reviews with the consultant psychiatrist.
29. We understand this had been important for Ms B in previous admissions, and by not involving the family, we consider the Trust did not act in line with NICE CG136. We will address the impact of this later in our report.
• Perinatal team
30. The Trust’s policy on transfer between mental health teams states there must be effective communication between clinical teams, the patient, and others involved in their care to ensure a safe transfer.
31. NICE CG136 states that those who have received community care prior to their hospital admission should be routinely visited whilst in hospital by the health and social care professionals responsible for their community care. We also understand, in line with GMC guidelines on working collaboratively with colleagues and ensuring safe transfer of patients, it would have been good practice for Ms B’s perinatal care co-ordinator and/or her consultant perinatal psychiatrist to be invited to each weekly ward review that Ms B had.
32. We recognise that Ms B had been under the care of the perinatal team since March 2017, and for this reason, it is more likely than not this team knew Ms B very well with regards to her mental health history and presentation.
33. We can see that Ms B’s perinatal care co-ordinator and consultant perinatal psychiatrist were present at the MDT meeting on Mother and Baby Unit 2 on 23 January where it was decided she would be transferred to Acute Psychiatric Ward B.
34. We can see from the records that Ms B’s perinatal care co-ordinator visited her on 26 January, and on the same day, we can see evidence of a verbal handover from the consultant psychiatrist on Mother and Baby Unit 2 to the consultant psychiatrist on Acute Psychiatric Ward B.
35. On 30 January, there was a verbal handover between the clinical psychologist on Mother and Baby Unit 2 and the clinical psychologist on Acute Psychiatric Ward B.
36. Ms B was then transferred to Acute Psychiatric Ward C on 31 January. The guidelines outlined in point 31 and 32 state the importance of effective communication between clinical teams, and our psychiatric adviser explained we would expect to see timely communication at the point of transfer between the team on Acute Psychiatric Ward C and the perinatal team about this change. We cannot see that the perinatal care co-ordinator was informed of the transfer, at the time of the transfer.
37. On 5 February, Ms B’s perinatal care co-ordinator visited her on the general adult inpatient ward. It was agreed that the care co-ordinator would attend Ms B’s next ward review with her consultant psychiatrist.
38. On 7 February, a medical review was arranged to take place on 19 February, with Ms B’s perinatal care co-ordinator, consultant perinatal psychiatrist, and representatives from her family attending.
39. In the next ward review on 12 February the plan to begin the discharge progress was discussed with Ms B without representatives from the perinatal team or Ms B’s family. The Trust has acknowledged this was a shortcoming in communication.
40. On 19 February, Ms B’s perinatal care co-ordinator and consultant perinatal psychiatrist were present at the MDT review and discharge meeting. We can see evidence they were part of the discharge discussion and planning.
41. Overall, we have not identified a service failure in the communication between the clinical team on Acute Psychiatric Ward C and the perinatal team. The perinatal care co-ordinator and consultant perinatal psychiatrist were involved at key points during the admission, i.e. at the point of transfer and discharge and when concerns were raised by the family on 5 February.
42. We recognise there were shortcomings in communication at the point of transfer on 31 January, and in not inviting Ms B’s care co-ordinator to the ward review on 12 February. We consider these were shortcomings and not failings because the perinatal team were made aware of the transfer and visited Ms B shortly afterwards on 5 February, and because they were invited to attend the MDT review and discharge meeting on 19 February to contribute to the discharge discussion and onward care planning.
43. Although we have not identified a service failure, we understand the shortcomings will have had an impact on Ms B and Mrs Y. We can see the Trust has taken steps to learn, and we will detail these later in our report.
Care plans, risk management, and record keeping
44. Mrs Y raised concerns that the Trust did not manage Ms B’s risk of suicide effectively. She says the family reported their concerns about her risk of suicide, but the Trust did not take this seriously or act upon their concerns. She feels there is much evidence recorded which showed the risk of suicide remained high and this was not reflected in the records.
45. Mrs Y explains that observations on the ward between 31 January and 12 February concur with what the family, were seeing. However, the medical notes from 12 February onwards begin to express opinions of clinicians which contradict their own observations and knowledge of Ms B at that time. Mrs Y believes that from 12 February 2018, any signs or evidence of distress were ignored or contradicted. She says although there are comprehensive levels of distress in the clinical notes, the evidence of observations by staff took priority over what the true reality was.
46. Mrs Y explains that Ms B was making long distressed phone calls most nights to her father, where she told him that nothing had changed, and no-one was listening to her. Mrs Y says Ms B had lost her appetite, and although she was watching television, she was not engaging with it, she had also stopped reading for the same reasons. The family say despite this, there is no mention of sleepless nights, loss of appetite, or ability to engage within the records. Mrs Y also reports that they noticed a significant deterioration in Ms B’s physical presentation.
47. The Trust’s response to the complaint stated risk assessments had been adequately completed, but acknowledged the format did not always allow for the complexities of the case to be well captured. It considered the risk assessments assessed risk of suicide, self-harm, and any risk to Ms B’s children, as well as recording mood fluctuations and thoughts. Therefore, it concluded that risk management was proportionate to Ms B’s presenting risk.
48. The Trust also stated the care plans completed during the admission detailed specific therapeutic and care goals, which were measurable, achievable, and realistic.
49. Further to this, the Trust acknowledged it was not always clear from the notes to what extent the ward staff considered the family’s view and that the medical records have not always reflected the family’s opinions expressed at meetings with regards to their concerns about risk and assessment. It also acknowledged that it was unable to ascertain for some of the clinical notes when events had taken place. It advised this would be fed back to the clinical team leader and raised in quality governance meetings.
50. We have reviewed the risk assessments and care plans which were completed during Ms B’s admission, as well as the general management of Ms B’s level of risk, with our psychiatric adviser and our mental health nurse adviser.
• Care plans
51. The Trust’s Care Programme Approach (CPA) guidance explains that the CPA encompasses an assessment of needs, goals and safety, a risk assessment, a care plan co-produced with the patient and anyone else they want involved, and a care co-ordinator. It supports communication with the care team and all relevant parties, and regular review of the care plan to ensure it is addressing the assessed needs of the patient.
52. The CPA guidance says care plans should include a clear formulation of the patient’s problems, and they should include an agreed approach on supporting the patient towards recovery and detail who is involved and what this looks like. Care plans should detail how the patient will be supported, including managing risk and crisis. The guidance says patient and carer/family views should be included in the shared decisions of care and recorded, and like risk assessments, care plans should be reviewed at times of change in presentation, or in response to a crisis.
53. In reviewing the care plans for the period of care we are investigating, we cannot see there is any mention of a plan around Ms B’s mental health, her baby, or family involvement. Our mental health nurse adviser explained they would expect to see this included.
54. There is no evidence that Ms B or her family participated in developing or contributing to the care plan. Many sections of the care plan are incomplete, such as sections on crisis plans, contingency plans, what matters to Ms B, what she would like to happen, strengths and coping strategies, and how they will measure success against the goals set.
55. The care plan was updated prior to discharge on 16 and 19 February, and this appears to have some input from Ms B, particularly around her level of risk. However, this is minimal, and it is noted that she was not provided with this care plan and did not sign it. It mainly includes clinical notes written about Ms B and therefore lacks a thorough assessment and understanding of her needs.
56. For these reasons, we do not consider the care plans were developed or updated in line with the Trust’s CPA guidance. We will address the impact of this later in our report.
• Risk assessments
57. The Trust’s Clinical Risk Assessment and Management guidance explains that good record keeping, communication, and appropriate sharing of risk information are vital components in the management of risk.
58. The guidance advises risk assessment, risk management plans and care plans must be robust and comprehensive. It says risk assessments should be completed at the point of initial assessment, and at every CPA review. They should also be reviewed at any point when a patients’ presentation or situation/circumstances changes.
59. It explains that the risk assessment must consider the whole picture and recognise how each risk factor impacts. The views of the patient, their family, and other key people must be considered in the risk assessment as they may have different perceptions, and their account will inform the accuracy of the risk assessment, as well as enabling the staff to develop trust and an understanding of the need for a shared responsibility for safety.
60. Further to this, the guidance says all patients must have a co-produced crisis plan that has been developed with the patient and their family as appropriate.
61. With regards to risk assessments, we can see the risk assessment was reviewed on 24 January, 31 January, 5 February and 20 February 2018. There is evidence of regular review of, and update to, the consideration of risk and the risk assessment itself throughout the admission. However, as acknowledged by the Trust, there is minimal evidence of the family’s view of Ms B’s risk being considered and recorded.
62. We can see that at the time of admission on 24 January, Ms B was commenced on six times hourly observations on the ward. This was reduced to four times hourly on 25 January but increased to six times hourly again on 27 January. This remained in place until the next transfer on 31 January.
63. Upon arrival to the ward on 31 January, Ms B was placed on four hourly observations. This appears to have been reduced, although we do not know when as observations were noted to be increased on 5 February in response to concerns raised by the family. This remained in place until 9 February when they were reduced due to observed settled behaviours and reduced risk level.
64. We recognise Mrs Y’s concerns that the medical records do not reflect what the family saw. The entries in the medical records detail what the nursing and medical team observed in real time. They have provided an objective view based on how Ms B was presenting at that moment in time. We accept this may have been different to how Ms B presented to her family.
65. There is evidence within the medical records that when Ms B’s partner made a phone call to the care co-ordinator on 5 February regarding concerns about her presentation during a recent visit and suicidal thoughts, the care co-ordinator made a plan for Ms B to have a review. These concerns have also been noted by the ward team, and it is recorded that observations were increased back to up four hourly due to her level of risk.
66. Overall, we consider there is evidence that risk assessments were completed in a timely manner at appropriate intervals during the admission. Our psychiatry adviser confirmed the risk assessments have proportionately considered the historical and current risks of self-harm, suicide, safeguarding concerns, and risks to Ms B’s children.
67. We consider there is evidence the inpatient team responded appropriately to Ms B’s presenting level of risk. Risk assessments were reviewed at the point of admission, when Ms B’s presentation had reportedly changed, and at the point of discharge.
68. With regards to concerns raised by the family about Ms B’s level of risk. Other than the phone call of 5 February, we cannot see any other entries where the family had raised concerns with the team. Based on the information provided by Mrs Y, we recognise it is possible concerns were raised but not recorded. This is something the Trust has acknowledged within its responses to the complaint, as it has recognised the format of the risk assessments did not allow for the complexities of the case to be documented.
69. We consider this is a service failure, as there is no evidence the views of the family have been taken into consideration when carrying out the risk assessments. This is not line with the Trust’s Clinical Risk Assessment and Management guidance. We will address the impact of this later in our report.
• Misrepresentation
70. We acknowledge Mrs Y has concerns about an entry in the medical records detailing a conversation between herself and Ms B’s consultant on 16 February 2018. Mrs Y states she was extremely upset and angry with the decision for Ms B to use a crisis bed over the weekend (as an alternative to home leave) and expressed her concern that she considered Ms B to be a very high risk. She disputes using the term ‘psychotic crisis’.
71. The Trust has acknowledged Mrs Y expressed concerns about the approach but said it was unable to comment further on them due to a lack of evidence. Despite this, the Trust represented these concerns in the RCA report, detailing Mrs Y’s account of the call and her recollection of events.
72. We were not present at the time to independently know what, and how, things were said. We recognise that in some instances, each person involved in the same conversation can come away with a different perception of its contents and what happened. One person’s perception of what was said does not invalidate another person’s opposing perception of the same conversation. We acknowledge in this case that there are opposing recollections of the phone call that took place and what was said.
73. We recognise that the exact words used are important to Mrs Y, as she was conveying her significant concerns about Ms B’s discharge. We have considered whether this changes what happened on this occasion. Whilst we cannot be certain what was said exactly, we can see that Mrs Y’s concerns about the discharge were noted in the records. This does not change our position on what message was conveyed during the call and it is for this reason we do find it necessary to decide which account takes precedence.
74. We are left without independent supporting evidence that would indicate to us a failing occurred, and we are unable to add anything more to what has already been explained. We do not intend this decision to diminish Mrs Y’s feelings, nor the experience she had. We recognise this is a source of frustration for Mrs Y, and that her recollection of the call is not represented within the medical records.
Medication
75. Mrs Y says Ms B’s care plan was not followed when she was admitted to the ward on 24 January as her medications were changed.
76. Mrs Y explains that three different combinations of medications were prescribed within a period of three weeks from Ms B being admitted as a patient. She considers these fast changes must have caused side effects and are the reason the perinatal team decided not to change medication after discharge. There had been too many changes with no noticeable improvement. Mrs Y is also concerned that the clinical team did not take into consideration a previous observation made by one of the teams who treated Ms B, that she was ‘treatment resistant’ to medication.
77. The Trust’s RCA report details that medication was changed following transfer as the consultant psychiatrist felt there had been no significant improvements, so a different approach was needed. It also acknowledged that whilst each team acted to treat Ms B in the way they thought would best help her, this had an impact on the continuity of care, which may have caused her some confusion and had a detrimental impact on her recovery.
78. On 23 January 2018, whilst on Mother and Baby Unit 2, lithium treatment (used for mood stabilisation) was stopped and was planned to be reintroduced on 24 January if safe to do so. Olanzapine (an anti-psychotic used as an antidepressant for individuals with difficult to treat depression) and mirtazapine (an antidepressant) were also stopped at this time.
79. Following transfer to Acute Psychiatric Ward B, on 26 January 2018, Ms B’s medication plan was noted as:
• Mirtazapine 30 mg at night • Lorazepam 1 - 2mg as required (PRN) – max. of four times daily (a benzodiazepine used to manage acute agitation or anxiety) • Zopiclone 7.5 mg PRN at night (used to manage insomnia) • Promethazine 25 mg PRN (an anti-histaminergic medication used to manage acute agitation and insomnia)
80. The recommendation to recommence lithium medication was discussed, but did not materialise. On 29 January, 50mg of sertraline once daily was prescribed.
81. During the handover on 30 January, it was noted that the team on Mother and Baby Unit 2 felt Ms B was stuck and not responding to medication.
82. Ms B was then transferred to Acute Psychiatric Ward C on 31 January, and her medication was changed again. It was noted as:
• Sertraline stopped • Mirtazapine reduced from 30mg to 15mg at night and to stop on 6 February • Escitalopram 10mg once daily (antidepressant) • Promethazine 50mg • Pregabalin 25mg (used to treat anxiety) • Zopiclone 3.75mg
83. During a review on 12 February, medication was changed again as follows:
• Escitalopram increased to 20mg once daily • Promethazine reduced to 25mg • Pregabalin 75mg • Zopiclone unchanged at 3.75mg
84. On 19 February during an MDT review meeting, medication remained the same as the list above, with two changes in dosage, promethazine was increased to 50mg, and pregabalin was increased to 150mg.
• Change of antidepressant
85. During the review on 31 January the consultant psychiatrist recommended Ms B tried an alternative antidepressant, escitalopram, and began pregabalin to help reduce her anxiety. Zopiclone and promethazine were prescribed to help Ms B sleep.
86. With regards to changing antidepressants, our psychiatry adviser explained that where the patient is tolerating the antidepressant, it would be appropriate to consider increasing the dose of the original antidepressant if there is a lack of treatment response to lower doses of the antidepressant. Whereas switching from one antidepressant to another would be clinically indicated and justified if a patient was not tolerating, or was poorly tolerant of, the original antidepressant.
87. It appears the decision to change antidepressant was made during this review as Ms B had reported weight gain from mirtazapine. This is listed as a “common or very common” side effect of mirtazapine in the BNF.
88. The Maudsley Prescribing Guidelines provide general guidance on how to switch antidepressants safely and appropriately and recommend cross-tapering cautiously. Notably there is no guidance on over how many weeks this should be done.
89. Our adviser explained that the combination of mirtazapine and escitalopram is a safe combination, frequently used in patients with “difficult to treat” depression. Ms B was taking the two medications together between 1 February to 6 February, when mirtazapine was stopped.
90. The BNF recommends a starting dose of 10mg for escitalopram, which we can see was prescribed in line with this recommendation, from 1 February.
91. We have not identified a service failure relating to the change in medication on this occasion.
• Concurrent changes in medication
92. With regards to the number of changes in medication, our psychiatry adviser explained that good and safe clinical practice would be to make changes to only one medication at a time, wherever possible. The rationale for this, and the benefit of this approach, is that if the patient experiences unpleasant or intolerable side effects, or an adverse reaction, it is evident and obvious which medication is responsible for this.
93. The GMC’s Good Medical Practice guidance says when providing clinical care, you must provide effective treatments based on the best available evidence (16b), it also says clinical records should include decisions made and actions agreed in relation to any prescribed medication (point 21). This supports the practice of changing one medication at a time, to accurately evaluate its effects.
94. It is not clear from the medical records why the antidepressant medication was changed and pregabalin was started for anxiety at the same time.
95. There are situations where it may be necessary to start a patient on two new medications depending on their presentation and clinical need, but we cannot see these applied in Ms B’s case.
96. Our psychiatry adviser explained that if there was a perception Ms B was ‘treatment resistant’, it may have driven decisions to change medication prescribed for her mental health. Especially at the point of transfer, and following transfer, from Mother and Baby Unit 2 to Acute Psychiatric Ward C. We understand this would increase the risk of changes being made prior to an adequate trial of treatment with a specific medication.
97. If there were concerns that Ms B was treatment resistant, there should have been a thorough formal review of what medication had been previously prescribed and why any medication was stopped or changed. This should have also prompted the inpatient team to consider changing the medication and considering any non-pharmacological treatments such as electroconvulsive therapy or repetitive transcranial magnetic stimulation as alternatives, or adjunct to any existing medication.
98. Whilst the RCA report explains that Ms B’s medication was changed as the consultant psychiatrist felt there had been no significant improvements, there is no rationale documented within the medical records to explain these changes or to explain any other considerations that had been made.
99. We consider changing both medications at once was not in line with GMC guidelines. We understand it would have been more suitable to only make one medication change at a time, and to monitor Ms B for evidence of a response to the initial/first medication change before considering a second change. We also consider the rationale for such changes should have been documented. We will address the impact of this later in our report.
• Increase of dosage
100. We can see the dosage of escitalopram was increased from 10mg on 31 January, to 20mg by 16 February. 20mg is the maximum permitted dose, as outlined in the BNF.
101. Our psychiatry adviser explained that whilst it was not unsafe to only wait two weeks before increasing the dose of a prescribed antidepressant for a patient, it would be usual practice to increase from 10 to 15mg, and then from 15 to 20mg, if a further dose increase was required to achieve better treatment response (NICE CKS GAD). We understand that a more cautious increase reduces the risk of the patient experiencing intolerable side effects and also ensures the patient is treated with the minimum effective dose of the antidepressant prescribed.
102. We can also see the dosage of pregabalin was increased rapidly. It was first prescribed on 31 January at a dosage of 25mg twice daily. On 12 February this increased to 75mg twice daily, and on 16 February it increased to 100mg twice daily. By the time of the discharge meeting on 19 February, the dosage had been increased again to 150mg twice daily.
103. The BNF recommends a starting dose of 150mg daily (in 2-3 divided doses) and increased in steps of 150mg daily if required at seven-day intervals. If necessary, it can be increased to a daily dosage of 600mg (2-3 divided doses).
104. The starting dose prescribed on 1 February and the subsequent increases on 12, 16, and 19 February were not in line with the recommendations provided by the BNF. There has been no rationale documented as to why the consultant deviated from the BNF recommendations with regards to initiation and dose increases.
105. This is not in line with the GMC’s Good Medical Practice guidance, which says clinical records should include decisions made and actions agreed in relation to any prescribed medication (point 21).
106. We consider it was not in line with GMC, NICE, and BNF guidance for so many changes in Ms B’s prescribed medications to be made in a very short period.
107. In our view, there was insufficient time allowed for the medication that had been prescribed to take effect before increases in the dosage to escitalopram were made by the consultant psychiatrist, and the prescription of pregabalin was not managed in line with BNF guidance.
Diagnosis
108. Mrs Y is concerned that the Trust diagnosed Ms B with EUPD without a proper assessment and without consulting family or other professionals involved in her care. She says the first time this was mentioned in the medical records was 12 February 2018, and it was not recorded as a diagnosis until the point of discharge. Mrs Y says there is no evidence in the medical records of an assessment being carried out to support a diagnosis of EUPD.
109. In the Trust’s RCA report, it has acknowledged there is no documented evidence that a change in diagnosis was made in consultation with the agreement of the perinatal team. It said despite this, once discharged, there was no evidence the perinatal team changed their treatment plan or their attitude to Ms B’s risk based on this opinion.
110. NICE CG78 provides guidance on assessing those with possible EUPD. It instructs clinicians to fully assess:
• psychosocial and occupational functioning, coping strategies, strengths and vulnerabilities • comorbid mental disorders and social problems (1.3.1.2)
111. GMC’s Good Medical Practice guidance states the importance of working collaboratively with those involved in an individual’s care, as well as their family (points 16d, 31, 33, and 35).
112. Our psychiatry adviser also explained that to be confident in making a diagnosis of EUPD, it would be necessary to refer to the diagnostic criteria contained in the International Classification of Diseases 10th edition (ICD-10).
113. We understand that good and safe clinical practice would involve speaking with the patient’s family to provide collateral history. This is particularly important in individuals with a suspected personality disorder, as many difficulties and traits start in childhood or early adolescence and continue into adolescence and adulthood.
114. In reviewing Ms B’s medical records, we cannot see any evidence that she ever underwent any formal assessment for a diagnosis of EUPD. There is no evidence of the consultant or any other member of the inpatient multidisciplinary team discussing this diagnosis with Ms B, her family members, her perinatal psychiatrist, or her care co-ordinator during the admission, or at the point of discharge.
115. The only documentation of, and reference to, a diagnosis is within the inpatient discharge summary dated 7 March 2018, for the admission from 24 January to 19 February 2018. The discharge summary does not include any explanation of why the diagnosis was felt to be appropriate and applicable for Ms B.
116. There is no reference to the ICD-10 criteria for EUPD, and no explanation of how she met any of the diagnostic criteria.
117. For these reasons, we consider there were failings in the diagnostic process, and in communicating the diagnosis. There is no evidence that the Trust followed the appropriate guidance or standards when diagnosing Ms B with EUPD. The diagnosis has been made and documented in Ms B’s inpatient discharge summary without any clinical justification or rationalisation. This change in diagnosis was not communicated to any relevant health care professionals, Ms B, or her family.
Discharge
118. Mrs Y believes Ms B was only discharged because she was “institutionalised”. They could not understand why it was thought the outcome of discharge would be different than the last, as Ms B’s symptoms remained unchanged. The family feel the medical team had not read the prior medical records and based the opinion of institutionalisation on ward observations alone.
119. The Trust’s RCA report explains that the decision to discharge was reached due to the opinion that the acute phase of Ms B’s illness was over, and that she needed to return home to continue with her recovery. There was concern she was becoming “institutionalised”. It was recorded that Ms B had been compliant with her medication, without any reported or observed side effects, and that objectively she appeared less anxious and more stable in her mood.
120. NICE CG136 explains that the ending of treatment or services can evoke strong emotions and reactions in those using mental health services. For this reason, it advises healthcare professionals to ensure discharge is discussed, planned, and agreed carefully with the patient, and to ensure it is structured and phased. When plans for discharge are initiated by the service, patients should be given at least 48 hours’ notice of the date of their discharge from a ward.
121. It goes on to explain that a care plan should be put into place which supports effective collaboration with care providers during endings and transitions and includes details of how to access services in times of crisis, as well as details of all possible support options available to them.
122. NICE CG136 also advises discussing discharge arrangements with any involved family or carers, and assessing the patient’s home situation, including housing, before they are discharged from inpatient care.
123. GMC’s Good Medical Practice guidance says doctors must listen to patients and take account of their views and they must be considerate to those close to the patient and be sensitive and responsive in giving them information and support. It also states doctors must work collaboratively with colleagues and contribute to the safe transfer of patients between healthcare providers.
124. In our review of the medical records, we can see the consultant psychiatrist began to discuss discharge with Ms B on 12 February. As we have addressed earlier in our report, the team did not include the family and the perinatal team in this initial discussion. This was followed by a period of day leave, which Ms B spent with Mrs Y.
125. The consultant psychiatrist reviewed Ms B again on 16 February with a view to arranging weekend leave, and subsequent discharge. In this assessment there is a review of her mental state, her risk profile, and of the clinical rationale for considering discharge from the ward. It was evident in this review Ms B was not happy with the plan for discharge or weekend leave, reporting that she would be suicidal if this went ahead.
126. On the same day, the plan for Ms B to use a crisis bed over the weekend, was discussed with Mrs Y. Mrs Y had significant concerns about this plan. The crisis team assessed Ms B and accepted her into the bed until Monday 19 February. The records say Ms B was happy to give this a go, but was hesitant about how she may feel. The possible risks of suicide and self-neglect were noted.
127. Whilst in the crisis bed, Ms B was reviewed by a mental health practitioner each day. No significant concerns were raised regarding her presentation during any of those reviews.
128. On 19 February, a discharge review meeting took place. Present were Ms B, Mrs Y, the perinatal care co-ordinator, the consultant psychiatrist and consultant perinatal psychiatrist, the charge nurse, and the mental health practitioner from the crisis resolution and home treatment team. The records of this meeting show all parties actively contributed to the meeting, and again it is noted no significant concerns were raised by those present, including Mrs Y. The discharge plan appeared to be agreed by all parties present.
129. Ms B returned to the crisis bed for the following 72 hours, before being discharged home. Staff visited Ms B daily whilst in the crisis bed to establish her plans and review her progress, and the crisis resolution and home treatment team continued with visits once Ms B returned home.
130. In our view, there is evidence that the discharge process was carried out in line with the guidance quoted above. There is evidence of collaborative decision making with the patient, as the discharge was discussed and planned carefully with Ms B and was carried out in a structured and phased way. The plan for discharge was also discussed with Mrs Y, as she was involved in the discharge planning meeting on 19 February.
131. There is also evidence that there was an assessment of Ms B’s mental state, and a review of her risk profile. We can see the team listened to Ms B’s concerns and provided reassurance and encouragement where appropriate.
132. We also consider there is evidence of planned appropriate and timely follow-up review and care being put into place. We can see Ms B was given information about the support available in the community and was discharged under the care of the crisis resolution and home treatment team. Following discharge, Ms B was visited at home regularly by the perinatal team and her care co-ordinator, as well as the CRHT. Mrs Y was present for these reviews and had documented input. There were no changes in presentation or risk reported, meaning there was no increase or decrease in the perceived level of risk, and Ms B spoke positively about future plans. We also understand Ms B was attending private therapy. We have not seen any evidence of deterioration following discharge in the evidence reviewed.
133. For these reasons, we do not uphold this part of the complaint.
Impact
134. Understandably, Ms B’s death has had a considerable impact on Mrs Y and her family and continues to do so.
135. With regards to the failure in communication with the family, we consider there were missed opportunities throughout the admission to involve Ms B’s family in the care planning, risk assessment, weekly reviews, and discharge planning.
136. We consider this meant there were missed opportunities to obtain valuable information about her level of progress, her mental health history and presentation, and any concerns regarding her risk profile. We recognise this contributed to Mrs Y’s frustration and concerns both at the time of the admission and discharge, and following Ms B’s death.
137. We recognise that more effective communication with, and involvement of, the family would have provided reassurance to Ms B’s family that all reported concerns about her presentation and risk had been duly considered.
138. With regards to the failure in developing adequate care plans, we recognise that by Ms B not being involved in developing the care plans, they were not personalised to her specific circumstances. This would likely mean they did not empower her, promote her independence and recovery, help her to be more involved in decisions about her care, and in finding out what mattered to her, and what further support she needed.
139. We consider a more collaborative approach with detailed care planning and goals to work towards may have helped to focus any interventions on the areas of most immediate need and would have helped to monitor progress through any goals set. This would have allowed for any necessary changes to the care plan and goals as time went on.
140. With regards to not considering the views of the family in the risk assessments, we consider it evident the family had a different perception of Ms B’s presentation. If this had been drawn into the risk assessment, it may have given the clinical teams more insight into Ms B’s presentation and level of risk. We consider this missed opportunity increases the likelihood of the risk assessment not being as holistic as it could have been. The Trust itself has acknowledged the risk assessments do not fully represent the complexities of Ms B’s presentation.
141. For this reason, we consider it is likely there were missed opportunities to increase engagement with services and provide reassurance to both Ms B and Mrs Y about the care she was receiving by not involving them fully in the care planning and risk assessment processes. A more holistic risk assessment may have led to a more rounded approach to care planning and communication.
142. We consider it is unlikely this would have changed the decision to discharge Ms B. Although the risk assessments do not capture the family’s concerns and viewpoint, they do record Ms B’s thoughts, feelings, and suicidal ideation. When Ms B went on weekend leave to the crisis bed, she was reviewed each day by a mental health practitioner from a different clinical team. No concerns were raised regarding Ms B’s presentation during any of these reviews. Similarly, there were several mental health professionals present at the discharge meeting on 19 February, along with the peri-natal care co-ordinator, Ms B, and Mrs Y, and no concerns about an increased level of risk were raised.
143. With regards to changing more than one medication at the same time and increasing medication dosages too rapidly, we understand it is possible this may have had a negative impact on Ms B’s mental health. Our psychiatric adviser commented that it is not possible to say if this was more probable than not, but the risk of experiencing a negative impact on Ms B’s mental health as well as unpleasant side effects was increased by taking those actions. We also consider that by not reviewing any available non-pharmacological treatments, there was a missed opportunity to give Ms B the best possible chance of improvement.
144. With regards to not communicating the change in diagnosis, we can see this did not change the way the perinatal team or CRHTT treated Ms B following her discharge. However, we recognise this caused confusion and distress for Ms B and Mrs Y.
145. We also understand this likely contributed to Mrs Y’s feelings of not being listened to and not being included in Ms B’s care, as well as her concerns about the treating team not discussing Ms B’s care with the perinatal psychiatrist or care co-ordinator.
146. Overall, we recognise that Ms B’s inpatient journey could have looked different, had these failings not occurred. We consider it is possible these failings had a negative impact on Ms B’s mental health.
147. We are unable to say, with certainty, if the failings had not occurred, Ms B’s death would have been prevented. This is because it is possible that even if the failings had not occurred, Ms B may not have felt able to engage fully. We cannot be certain that it would have made a difference to the sad outcome of this case.
148. We recognise these failings have caused significant uncertainty for the family as they are left not knowing if the outcome could have been different, had these failings not occurred. We recognise this is likely to compound the family’s grief and distress further.
149. We will now review the actions already taken by the Trust and provide our view on whether it has done enough to address the failings and impact we have identified in this report and to put things right for the family.
Recommendations developed from the Trust’s RCA report
150. As we have detailed through this report, the Trust’s RCA identified several areas where the care provided fell below the expected standards. It developed recommendations to address these areas of concern.
151. It recommended the following areas of discussion for representatives from the Clinical Cabinet, Lead Clinicians, and Commissioners:
• To discuss what changes could be made regarding the continuity of care for patients who have the involvement of a specialist team when they are admitted to other inpatient areas, to consider:
• Formalising clinical collaboration between teams, • Shared clinical responsibility between the specialist community team and inpatient team, • The specialist team retaining clinical responsibility, oversight, and collaboratively guide treatment and management decisions, • The impact of sudden ward moves triggered by geographical factors, • A need for more clinically driven oversight and planning, • Provide feedback and assurances to Safety Managers of the CCGs (now ICBs) that clinical care will not be compromised by geographical moves, • Outcomes and actions to be reported back to the Patient Safety Team,
152. It also recommended the following action for the Operational Manager and Matron for the clinical area of Acute Ward (C), supported by the Recovery and Participation team:
• To use the principles of the Triangle of Care and a validated quality improvement methodology to:
• Examine routine ward practices, • Identify any training needs, • Work to ensure staff accurately record concerns from family members, patients, and other staff in the notes, • Guidance to be given for recording clinical debates and disputes regarding treatment and risk, • Obtain feedback from patients and carers with current or recent experience of an episode of care on the ward, and co-design actions to improve carer inclusion and the experience of care, • Identify how findings can be measured and used as a baseline, • Implement actions and evaluate effectiveness, • Outcome and actions to be reported back to the patient safety team and shared with other acute units.
153. We understand these steps are intended to ensure families/carers are fully supported and included in any decisions about relatives as inpatients or in the community, and in developing treatment plans.
154. We consider the Trust’s recommendations address the failings we have identified with regards to the level of communication between the clinical teams, the involvement of family in care planning and decisions, as well as responding to familial concerns about presentation and risk, and improved record keeping with regards to this type of communication.
155. For this reason, we will not be making recommendations for service improvements in this area as we consider the Trust has taken proportionate steps to remedy these aspects of the complaint.
156. Whilst we are not making recommendations in this area, we will be asking the Trust for evidence to show it has taken these actions.
157. Aside from this, we have identified several failings which have not yet been addressed through service improvements, in relation to poor care planning, multiple concurrent changes in medication and increases in dosages, and the failure to carry out a formal assessment before making a diagnosis.
158. We also cannot see the Trust has provided Mrs Y with a sincere and meaningful written apology for the events that have happened, the way in which this impacted Ms B, and the way this continues to impact Mrs Y and her family.
159. In the next section of our report, we will explain what actions we will be asking the Trust to take to put things right for the family.