February 2024 discharge
19. Mrs E states in February 2024, she told the ward manager and doctor she would take an overdose if discharged. They discharged her, then she took an overdose which required a hospital stay.
20. In its response, the Trust explained a discharge meeting took place before reaching this decision.
21. The Mental Health Act Code of Practice sets out Guiding Principles including:
• ‘Least restrictive option and maximising independence: Where it is possible to treat a patient safely and lawfully without detaining them under the Act, the patient should not be detained. Wherever possible a patient’s independence should be encouraged and supported with a focus on promoting recovery wherever possible.
• Empowerment and involvement: Patients should be fully involved in decisions about care, support and treatment. The views of families, carers and others, if appropriate, should be fully considered when taking decisions. Where decisions are taken which are contradictory to views expressed, professionals should explain the reasons for this’
22. Our adviser explained mental health care focuses on supporting and enabling independence with the least restrictive approach to care and empowering and involving the patient. Mrs E had been detained under Section 2 of the Mental Health Act, so the principles were fundamental to her care management.
23. The Trust’s management of Mrs E’ care and subsequent discharge evidence this approach, and this was in line with the Mental Health Act.
24. To support Mrs E’s discharge, comprehensive discharge planning was implemented by the Trust. Mrs E’s medical records show risk management was clearly considered in the discharge planning process, the records show the Trust considered prolonged admission would not reduce risk, and would likely increase emotional dysregulation and increase risk, it set out that risks would be best managed in the community with care co-coordination. When assessing risk, the Trust acted in line with NICE guidelines on borderline personality disorder, which states:
‘1.3.3 Risk assessment and management 1.3.3.1 Risk assessment in people with borderline personality disorder should: • take place as part of a full assessment of the person's needs • differentiate between long-term and more immediate risks
1.3.3.2 Agree explicitly the risks being assessed with the person with borderline personality disorder and develop collaboratively risk management plans that: • address both the long-term and more immediate risks • relate to the overall long-term treatment strategy • take account of changes in personal relationships, including the therapeutic relationship.’
25. Our adviser explained is important that mental health teams collaborate with the patient when planning discharge and ongoing care management, as discharge from hospital may evoke strong emotions and reactions.
26. NICE guidance on borderline personality disorder goes on to state:
‘1.1.6 Managing endings and supporting transitions 1.1.6.1 Anticipate that withdrawal and ending of treatments or services, and transition from one service to another, may evoke strong emotions and reactions in people with borderline personality disorder. Ensure that: • such changes are discussed carefully beforehand with the person (and their family or carers if appropriate) and are structured and phased • the care plan supports effective collaboration with other care providers during endings and transitions, and includes the opportunity to access services in times of crisis’
27. Mrs E’s medical records show on 10 February discharge planning took place in preparation for her discharge. The medical records set out a comprehensive, detailed discharge plan and arrangements in collaboration with Mrs E. This was a ‘criteria-led’ discharge plan (a process used in healthcare to ensure that patients are safely and efficiently discharged from the hospital based on specific criteria) involving the multidisciplinary team and psychiatrist, and Mrs E. It covered mental state examination, risk formulation, observation level, safeguarding, medication, and action plans for the next seven days.
28. Risk formulation showed short term risk of suicide appeared low, the medical records show Mrs E was assertive, forward planning and looking to improve her social situation.
29. Mrs E was actively involved in developing and implementing her discharge plan, which was inclusive and thorough. Our adviser explained this approach to discharging a patient with personality disorder from hospital is in line with NICE guidance on borderline personality disorder for good clinical practice, as set out above.
30. In considering the above, we consider the Trust’s decision to discharge Mrs E in February 2024 was appropriate and in line with guidance. We consider the Trust appropriately considered the risk of suicide during discharge planning. We are very sorry to hear that Mrs E took an overdose following her discharge, we appreciate this must have been an extremely difficult and distressing time for her.
The Trust refused to change Mrs E’s medication in May 2024
31. Mrs E states the Trust refused to change her medication in May 2024. She wanted levopromazine (an antipsychotic medicine) increasing.
32. In its response, the Trust explained it discharged Mrs E on both Amitriptyline 20mg and Levomepromazine 50mg, both to be taken at night. Mrs E’s medical records show advice from the sleep clinic was that ‘if Levomepromazine is not effective then a referral for CBT is to be considered’. Mrs E’s psychiatrist informed her they would not be making any changes to her medication, as an increase in Levomepromazine can be addictive.
33. Good medical practice states:
‘In providing clinical care you must:
• d propose, provide or prescribe drugs or treatment (including repeat prescriptions) only when you have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment will meet their needs • e propose, provide or prescribe effective treatment based on the best available evidence’
34. Our adviser explained the rationale from the psychiatrist and the explanation by the Trust are reasonable and coherent in terms of advice from the sleep clinic and the addictive nature of the medicine. This is in line with the above GMC guidance, as is rational and in the patient’s best interests in terms of clinical care and treatment. For this reasoning, we have seen no indication of failing in the Trust decision to not change Mrs E’s medication in May 2024.
The Trust did not refer Mrs E to the sleep clinic in May 2024
35. Mrs E states the Trust did not refer her to the correct sleep clinic in May 2024. In its response, the Trust explained it referred Mrs E to the sleep clinic at Manchester University NHS Foundation Trust. The sleep clinic issued a response, and information was relayed to her care coordinator to further support on discharge.
36. The medical records show the sleep clinic’s explanation for declining the referral to the Clinic was because it is not a commissioned insomnia service.
37. NICE guidance on borderline personality disorder state:
‘1.3.8 The management of insomnia 1.3.8.1 Provide people with borderline personality disorder who have sleep problems with general advice about sleep hygiene, including having a bedtime routine, avoiding caffeine, reducing activities likely to defer sleep (such as watching violent or exciting television programmes or films), and employing activities that may encourage sleep.
1.3.8.2 For the further short-term management of insomnia follow the recommendations in the NICE technology appraisal guidance on the use of zaleplon, zolpidem and zopiclone for the short-term management of insomnia. However, be aware of the potential for misuse of many of the drugs used for insomnia and consider other drugs such as sedative antihistamines.’
38. Our adviser explained Mrs E’s sleep difficulties were primarily linked to her mental health, rather than physical health issues that the sleep clinic would typically treat. The sleep clinic advised her care should be managed by the mental health team, who could prescribe suitable medication and refer her for cognitive behavioural therapy (CBT). The Trust followed this advice, which was appropriate and consistent with both the sleep clinic’s recommendations and the above NICE clinical guidelines for borderline personality disorder.
39. In considering the above, the Trust did refer Mrs E to the sleep clinic, the sleep clinic rejected the referral, then followed the advice the sleep clinic had provided. There are no indications of failings for this complaint component, Mrs E was experiencing problems with sleep, the Trust correctly sought advice from the sleep clinic and then followed this.
Staff did not re-refer Mrs E to the Urology team
40. Mrs E complains staff did not re-refer her to the Urology team in May 2024.
41. The medical records show on 5 March 2024, the Trust contacted the Urology team at Mrs E’s request as she stated she had not received a response about sacral neuro modulation (a minimally invasive procedure that uses electrical stimulation to improve bladder and bowel function). The Urology consultant responded, and explained it had discharged Mrs E back to her GP in 2022 as she had not attended a twelve-monthly review. It explained she would need to be re-referred if she needed to be seen again, and advised this could be done through her GP.
42. On 30 May, the Trust wrote to the Urology department (at another Trust) and requested a re-referral.
43. In considering the above, we have seen no indication of failing for this complaint component. The medical records show the Trust did re-refer Mrs E to the Urology team in May 2024.
Ward staff did not answer Mrs E’s phone calls
44. Mrs E says on 8 July 2024 she spoke over the phone with the ward manager to report that she was being harassed and bullied by another patient. She states the ward manager told her to come back to the ward early the next day to discuss the situation, but when she arrived was informed the ward manager was too busy to speak to her and would contact her the following day. She made five calls the following day and each time she was told that the ward manager was busy or in a meeting.
45. In its response, the Trust apologised that staff did not speak with Mrs E to give her the opportunity to express how she was feeling. It explained following Mrs E reporting the incident, staff addressed the issues with the other patient in an informal manner. It apologised it had not provided Mrs E with feedback following this conversation. It also said it reminded staff of their role in feeding back to patients when they have completed an intervention to ensure adequate communication between staff and patient.
46. Our Principles for Remedy say remedial action can be an apology, explanation, and acknowledgement of responsibility. Our principles also say revising procedures to prevent the same thing happening again, giving learning and training to staff are appropriate remedies when things have gone wrong.
47. We appreciate Mrs E felt upset, and the Trust should have kept her informed about the actions it had taken. We consider the Trust has acted in line with our Principles for Remedy by apologising to Mrs E and making service improvements in terms of giving reminders to staff.
48. We consider these actions are proportionate to remedy the distress caused to Mrs E especially (distress and frustration of around two days when she could not speak with the ward manager). Therefore, we will take no further action.
Complaint handling
49. Mrs E complains the Trust took too long to investigate her complaint.
50. Mrs E initially complained to the Trust on 5 June 2024, she then sent emails to the Trust with further complaint points on 19 and 20 June. The Trust sent her a letter on 18 July, setting out the concerns she had raised and explained it aimed to provide her with a response by 7 August. On 8 August it emailed Mrs E to explain unfortunately it would need to extend this deadline. It provided the first complaint response on 17 October. Mrs E was unhappy with the response, and raised further points on 18 October. The Trust provided a second response on 16 December.
51. Our NHS Complaint Handling Standards state public bodies should do the following:
• ‘Deal with complaints promptly, avoiding unnecessary delay, and in line with published service standards where appropriate. Resolving problems and complaints as soon as possible is best for both complainants and public bodies’.
52. The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 (the 2009 Regulations), Regulation 13(7) says the body responsible for dealing with a complaint must offer to discuss with the person making the complaint how their complaint will be handled and the relevant timescales. Regulation 14 says it must keep the complainant informed on the progress of the investigation, as far as reasonably practicable. It says the responsible body should respond to the complaint within six months of receipt and, if it does not do so, it must notify the complaint of the reason for this in writing and send a response as soon as is reasonably practicable.
53. We consider the Trust acted in line with NHS complaint handling standards. It provided Mrs E with a response to her complaint within six months of the date the complaint was raised and kept her updated when the deadline changed. For this reason, we will take no further action on this complaint point.
54. We hope Mrs E can be reassured that we have taken her concerns seriously.