Miss B’s discharge from the Trust in February 2023
19. Miss A complains that Miss B was discharged from the Trust too soon in February 2023. Miss A says Miss B needed to be kept in a more controlled and secure environment, and she was not ready to be discharged back to the community due to the condition of her mental health at that time.
20. In its response, the Trust stated the decision to discharge Miss B was based on several factors. It considered Miss B’s mental state had made significant improvements throughout her hospital admission, and she had been stabilised to the point where discharge from hospital was appropriate. The Trust considered Miss B had insight into her mental health condition, and she understood the importance of being involved in decisions about her medication and engaging with community services.
21. The Trust stated it was felt that an inpatient unit was not helpful to Miss B’s recover at that time. It said the chaotic and loud environment was unsettling for Miss B, and it was a trigger for her distress. The Trust stated it considered that by keeping Miss B at an inpatient unit environment would have led to a deterioration in her mental state.
22. Section 4.4.6 of the Trust’s Admission, Discharge, and Transfer of care policy outlines that the patient will be identified as ready for discharge when: Deemed medically optimised and ready for discharge by the multi-disciplinary team, and management of their psychiatric /physical health condition and risks to self or others that could occur in the community are controlled, and support and resources are identified and available within an alternative setting to meet their care needs effectively.
23. Section 4.4.10 states once a decision to discharge is agreed, the multidisciplinary or SPOA (Single point of access) teams will ensure that adequate preparation for discharge is made. It states the discharge care plan updated to ensure any necessary support in place or other appropriate care is arranged, and the discharge address will be confirmed, and all professionals involved in ongoing care will be informed of the estimated discharge date. This guidance was ratified in January 2023 and issued in February 2023; it is therefore appropriate for us to refer to this guidance for the purposes of the investigation.
24. The Trust stated that the inpatient ward was a chaotic and distressing place for Miss B, and this is one of the reasons she was discharged when she was. We have reviewed Miss B’s records that outline her daily interactions when she was an inpatient at the Trust in January and February 2023.
25. On 15 February 2023, it was noted that a patient was verbally abusive towards Miss B, and they placed their hands around Miss B’s neck. This must have been very scary and distressing for Miss B.
26. The records note on 16 February 2023; Miss B shouted at staff and other patients. The records state that Miss B was an informal resident (not sectioned) on the ward and she was able to spend time off the ward, if she did not find the ward environment helpful to her recovery.
27. Another incident on 17 February 2023 is recorded in the records, stating a patient was abusive towards Miss B. This again must have been very upsetting for Miss B.
28. This shows the ward was a chaotic environment, and it could be unsettling for Miss B, as the Trust stated in its response.
29. The records dated 17 February 2023 also show Miss B was engaging with the Trust for her needs to be met. She was having longer periods of being calm and she was able to engage in general conversation. Miss B stated on this date she was worried about staying on the ward as she always gets irritated due to other patients.
30. We can see that the Trust had a Care programme approach (CPA) meeting on 23 February 2023. Care Programme Approach (CPA) is a package of care that may be used to plan a patient’s mental health care.
31. At the meeting Miss B’s consultant psychiatrist discussed Miss B’s discharge with several other clinicians without Miss B and her family being present. The Trust noted Miss B came into hospital in a manic state, and she became a victim of several unwell people on the ward.
32. We can see the care coordinator raised the question of Miss B’s home environment being suitable, and the psychiatrist said he was happy for Miss B to be discharged on the understanding Miss B’s flat was sorted out. Our understanding of this if any fire risks were removed from the flat.
33. We can also see the Trust considered if Miss B should be discharged to ‘Hollybank’ which is a mental health rehabilitation service, but the psychiatrist stated Miss B was mentally well, and she had been treated.
34. The psychiatrist stated the risks of Miss B’s mental health deteriorating would increase if she stayed on the ward, and she would be likely to be detained again. The psychiatrist stated he was worried about the behaviour from other patients, and that this was not helping Miss B’s recovery.
35. We can see Miss B; Miss A and her sister then joined the meeting. The psychiatrist explained to the family that the meeting was taking place because Miss B was being discharged.
36. The psychiatrist explained to Miss B and her family that the medication Miss B would need when she was discharged had been discussed, and they asked for Miss B thoughts on her accommodation in the community.
37. Miss B said she did not want to live in her flat, and she wanted to live somewhere else. The psychiatrist also asked Miss B for her thoughts on her mental health. Miss B said she believed she was getting better, but she did not want to go home, because she was worried about becoming ill again and ending up back in hospital. Miss B said she did not want to remain in hospital any longer than a few more days.
38. The meeting notes show the psychiatrist explained to Miss B that whilst she stayed in hospital, the main concern was her interactions with very unwell people. They explained it would be best for Miss B if she spent more time away from the ward.
39. The meeting notes show Miss B’s sister questioned why Miss B should need to be discharged if other service users are causing issues. Miss B outlined to her sister it was her choice to leave. The psychiatrist stated that Miss B staying on the ward was more detrimental to her than her being discharged and living in the community.
40. The psychiatrist outlined Miss B was suitable to be discharged as an inpatient from the Trust. The plan was for a social worker to arrange a home visit to see Miss B upon her being discharged. Miss B’s medication was to be reviewed. Miss B was to have a blood test, and she was going to be discharged on 27 February 2023.
41. The meeting notes also show the Trust was going to arrange for a fire safety check at Miss B’s flat. Miss B was to be assessed by the social worker, and the crisis team would see Miss B daily and support her with her medication. The community mental health team (CMHT) would take over Miss B’s CPA from the Trust and this needed to be in place when Miss B was discharged.
42. Miss B’s progress notes dated 27 February 2023 outline a mental health nurse met with Miss B to discuss the concern raised by her sister regarding Miss B’s perceived early discharge from the Trust. The mental health nurse requested Miss B’s consent to discuss the discharge planning with Miss B’s sister. Miss B did not provide consent for the Trust to discuss these details with her sister.
43. The notes outline Miss B said the ongoing inpatient care was not helpful to her, she found the loud and chaotic environment very stressful, and she responds poorly therefore. Miss B said she was a bit anxious about being discharged, but her ongoing recovery should be in the community and remaining in hospital was not the best option for her. Miss B said she was happy to engage with community services.
44. The Trust discharged Miss B from the ward on 27 February 2023. We have reviewed the discharge liaison form, and we can see The Trust identified there was a low to medium risk of Miss B not following her prescription plan when she was in the community. Miss B was a low to medium risk to others as there was a risk she would react to stimulus (such as provocation from others) and there was a low risk of her being vulnerable.
45. We can see from the progress notes that after Miss B was discharged, she returned to the hospital later that night demanding to be let back on to the ward.
46. We can see that on 28 February 2023, a mental health nurse telephoned Miss B. Miss B was calmer during the call and the Trust advised Miss B to telephone if she was struggling, or to go to the SafeHaven service if it was after 6pm. (SafeHaven is a multi-disciplinary team of mental health professionals specialising in early-intervention critical incident support, crisis mental health care, and the treatment of psychological trauma).
47. Section 1.6 of the NICE guidance on Self-harm: assessment, management and preventing recurrence, outlines that risk assessment tools and scales should not be used to predict future self-harm and should not be used to determine if a patient is to be discharged.
48. The guidance outlines that an assessment of a person's needs, vulnerabilities, and safety should be a part of every assessment and that risk should not be used to determine care management in isolation of other factors.
49. Whilst the Trust did complete a risk assessment, we can see this was not done in isolation to determine if Miss B should be discharged, and Miss B’s needs were discussed at the CPA meeting.
50. We have found the Trust adhered to its own guidance here as the psychiatrist identified that Miss B’s condition would not improve further, it identified her risks in the community, and the support that Miss B needed within the community.
51. Guidance from Refocusing the Care Programme Approach says that Trusts should assess the mental and physical health of the patient, the social care needs and the risk and safety issues of the service user. We can see that the Trust reviewed Miss B’s mental health at the CPA meeting, and it arranged for Miss B to have blood tests. It arranged for a social worker to assess her and there was a risk assessment on the discharge form.
52. The Care Programme Approach also states a care coordinator should be appointed to keep in close contact with the service user. We can see from the meeting notes that the care coordinator was present at the meeting, and they were going to arrange for a social care assessment for Miss B and a fire safety check of her accommodation.
53. The Care Programme Approach outlines a written care plan should be written up that identifies the mental and physical health needs, and the social care support required to meet those needs. Ideally this should be agreed with members of the multidisciplinary team, the GP, the service user and any other relevant agencies.
54. The meeting notes show that Miss B’s needs were identified, the Trust outlined it was not helpful for Miss B’s mental health to remain on the ward at that time. A plan was written up for Miss B to be seen by the crisis team daily, and then the community mental health team would be managing Miss B’s care. The plan stated the Trust were going to contact the social worker to arrange for them to visit Miss B the next day. Miss B’s medication was going to be discussed after the meeting, and she was going to have a blood test the following morning.
55. We obtained clinical advice on this from our mental health nursing adviser (the adviser). The adviser stated there are detailed notes that explain what happened in the care programme approach review and the plan for when Miss B was to be discharged from hospital.
56. Our adviser stated this indicates that the Trust followed the CPA guidelines when Miss B was discharged from hospital. The CPA recommends that a review meeting should take place, and this is what happened.
57. The adviser also stated that Miss B was not discharged prematurely, Miss B was ready to be discharged because there are entries in the records to say that staying on the ward would have a detrimental effect on her mental health. The clinical impression from the CPA meeting was that Miss B was ready to be discharged home, and there are continuous risk assessments done during Miss B’s admission from when she was discharged that show her risk was continuously assessed. These show she was a low risk to the staff and the public when Miss B was discharged. We have referred to the risk assessment that the Trust did when Miss B was discharged at paragraph 44.
58. Based on the evidence and guidance we have referred to, and the clinical advice we have received, we have seen no indication to show Miss B was discharged too soon. We understand Miss A considers that Miss B would have benefited from staying longer in hospital, however, after careful consideration, we have not identified a failing here.
59. We understand this was a very difficult time for Miss A, Miss B and her sister. We in no way mean for our finding here to take away from their experience, and we understand this was a very upsetting and stressful time.
Miss B’s medication when she was discharged on 27 February 2023
60. Miss B says Miss A was discharged from hospital with inadequate medication.
61. We have reviewed the Trust’s response, however, this only addressed Miss B’s discharge from hospital. Due to the time that has passed, we consider it proportionate for us to investigate and address this as opposed to referring it back to the Trust.
62. To determine if the Trust discharged Miss B with appropriate medication on 27 February 2023, we have referred to the Trust’s Admission, Discharge and Transfer of Care Policy. We have also referred to Miss B’s discharge liaison form.
63. Section 4.4.10 of the Admission, Discharge and Transfer of care policy states that patients should have a 14-day supply of medicine as a minimum, but a 28-day supply is recommended.
64. We can see from the CPA meeting notes that Miss A asked about Miss B’s medication for when she was discharged. The Trust explained to Miss A that the crisis team were going to see Miss B daily and support her with her medication and then the community mental health team would be taking over this. We can see from the notes that this would need to be in place for when Miss B was discharged. We can also see that the plan was for Miss B’s medication to be discussed after the meeting.
65. We can see from the discharge liaison form that Miss B was prescribed quetiapine XL (anti-psychotic medication used to treat mental health conditions). The XL means the quetiapine is released more slowly into the body than plain quetiapine. Miss B was also prescribed lithium carbonate (mood stabilising medication), furosemide (to treat fluid retention and high blood pressure) lansoprazole (reduces the amount of acid produced in the stomach) clonazepam (to treat agitation and aggression) lorazepam (to treat anxiety) paracetamol (pain relief and fever relief). The discharge form outlined that the quantity of supply was 14 days. We can see this is in line with the Trust’s own Admission, Discharge and Transfer of care policy.
66. We can also see on the discharge liaison form that the Trust wrote to Miss B’s GP to explain she had been started on a lithium titration (titration is finding the perfect balance of a drug dosage to get the maximum benefit and the minimum side effects) but her levels had not reached an optimum level yet. The Trust asked if Miss B’s GP could titrate the therapy for Miss B’s mood stabilisation. It also stated Miss B’s metal health was managed well with quetiapine XL, but she would benefit from lithium.
67. This shows Miss B was prescribed a number of medications when she was discharged, and the Trust had written to Miss B’s GP to explain the situation regarding her lithium titration.
68. We also received clinical advice on this from our adviser. Our adviser stated Miss B was discharged with adequate medication on 27 February 2023. Miss B was discharged with a 14 day supply of medication which is in keeping with the Trust’s policy. Our adviser stated Miss B was not given her medication on discharge because the plan was for the crisis team to visit her at home and administer her medication. The Trust explained this at the CPA meeting before Miss B was discharged, and a member of the crisis team was present at this meeting.
69. Based on the evidence and guidance we have reviewed, and the clinical advice we have received, we have not identified a failing with the medication Miss B was prescribed when she was discharged from hospital on 27 February 2023.
The risk assessments following Miss B’s discharge from the Trust
70. Miss A says the Trust failed to adequately update Miss B’s risk assessments when she was in the community from 27 February 2023 to when she was sectioned by the Trust on 20 May 2023.
71. We have reviewed the Trust’s response to Miss A, and we cannot see the Trust has provided a response to this. Due to the time that has now passed, and how long our office has had this case, we consider it proportionate for us to investigate this point.
72. We can see that the Trust updated risk assessment form on 1 March 2023 after Miss B had been discharged from hospital. This stated Miss B was seen by the crisis team on 1 March 2023 for her 48 hour follow up. With regards the risk to herself, it stated there was no obvious risk that Miss B was going to harm herself, and she had not voiced any suicidal ideations. With regards Miss B’s risk to others, the risk assessment stated Miss B had previously displayed threatening behaviour, but she had not displayed any aggression at her 48 hour follow up. The Trust also assessed Miss B’s risk of vulnerability and stated she can become easily distressed or confused, and Miss B has voiced concerns about who is supporting her. It stated Miss B displays some vulnerability due to her poor understanding and intimidating manner.
73. The progress notes dated 3 March 2023 outlined Miss B had her seven-day review with the mental health team following discharge from the Trust. The Trust reviewed Miss B’s risk, and it stated she is not a risk to herself, but she does become easily angry with other people due to her frustration and anxiety.
74. Miss B was reviewed face to face by a psychiatrist on 9 March 2023, and her risk to herself and other was noted to be low.
75. The Trust updated Miss B’s risk assessment on 17 March 2023. The Trust stated Miss B was observed to be walking towards a building shouting, and it stated she was emotionally dysregulated (unable to manage and control emotional responses). The Trust outlined that throughout the shared care review, Miss B was volatile and abusive, and she demonstrated threatening and abusive behaviour towards the team leader. The risk assessment also stated Miss B was to be always seen by two members of staff due to her escalating threatening behaviour when she became emotionally dysregulated. Shared care refers to a patient’s care being managed between the Trust and community services, such as GP.
76. Miss B attended the emergency department of the Trust on 3 April 2023 after reporting she had punched a wall, and she needed medical care for her hand. The Trust assessed Miss B’s risk to herself and to and from others was low, and she was advised to contact the community mental health team.
77. The Trust updated the risk assessment on 12 April 2023 to state the housing officer had raised a safeguarding concern for Miss B’s partner, as Miss B had been heard physically assaulting him. The Trust did not add anything further to the risk assessment at that time.
78. The progress notes on 10 May 2023 shows Miss B’s GP had contacted the Trust based on information provided to the GP by Miss A. Miss A telephoned the GP to express concern about the deterioration of Miss B’s mental health. The GP stated Miss B has been aggressive when she had attended the Practice, and that she would no longer engage with the GP. The GP stated they suspected Miss B may be psychotic (losing contact with reality) and had recently been in possession of a knife. There is no evidence to show that the Trust assessed Miss B’s risk to herself or others at this point.
79. On 15 May 2023 the Trust noted there was a risk of violence from Miss B as she had assaulted her sister that resulted in her sister getting a black eye. It is noted the staff were now to visit Miss B in pairs.
80. The Trust completed a further risk assessment on 16 May 2023 when Miss B had a review. This stated Miss B had reported domestic violence from her partner, and it stated he had been sexually inappropriate. It stated Miss B had said the police were aware, but they were not believing her claim. The Trust stated it was going to raise a safeguarding referral regarding her partner.
81. The risk assessment stated Miss B appeared to lack insight into her needs, and there was clear evidence that she was emotionally dysregulated. The Trust described Miss B as being aggressive and confrontational, and she would not respond to requests to calm down.
82. The risk assessment outlined Miss B had said she was taking her medication, but this could not be confirmed. The Trust stated it was going to refer Miss B to the Crisis Resolution and Home Treatment Team so that her mental state and medication compliance could be monitored. It added Miss B was a high risk of harm to others when she was emotionally dysregulated, and she was at a high risk of harm to herself.
83. The Trust carried out a review with Miss B on 17 May 2023 and it identified there was a strong chance she was not taking her medication as she should have been as she had medication in her dossete box (a box to help people track their medication) that was not taken.
84. The Trust determined it was appropriate to assess Miss B under the MHA due to her recent aggressive and unpredictable behaviour, and because there was a strong chance she had not been taking her medication correctly.
85. On 19 May 2023, Miss B was arrested by the police after she became aggressive and threatening whilst on the Trust premises. Miss B was sectioned under section 136 of the MHA.
86. Miss B was later sectioned under section 2 of the MHA on 20 May 2023.
87. It is clear this was a very distressing and worrying time for both Miss B, her partner and her family.
88. The Best Practice on Managing Risk guidance states that whilst remaining flexible, risk management plans should include scheduled dates for reassessment, so that they are not simply amended as a reaction to crisis or other events. These review requirements should be part of the risk management plan and not separate from it, and the service user and all those involved in their care should be involved in this review. Risk management plans should also include a clear statement of responsibility for carrying out specified tasks in the plan and for reviewing these tasks.
89. Section 1.6.1 of the NICE guidance NG225, outlines that clinicians should not use risk assessment tools and scales to predict future suicide or repetition of self-harm. Section 1.6.2 of the NICE guidance outlines that clinicians should not use risk assessment tools and scales to determine who should and should not be offered treatment or who should be discharged.
90. Section 1.6.5 of the NICE guidance says clinicians should focus the assessment on the person's needs and how to support their immediate and long-term psychological and physical safety.
91. We can see that Miss B’s discharge assessment on her discharge liaison form used a risk assessment tool to determine the risk to herself and others when she was discharged. Following this, the Trust complete three further risk assessments when Miss B was in the community.
92. From the evidence we have seen so far, we have not seen evidence that Miss B’s family were involved with the risk assessments, or that specified tasks were outlined in the risk assessments with how to mitigate the risks identified. We can see the 16 May 2023 risk assessment outlined Miss B was going to be referred to the crisis team for medication monitoring because it was unable to confirm she was taking her medication, but there is no structure outlined in there of how and when Miss B would specifically be monitored to ensure she was taking her medication. This is not in line with the Best Practice on Managing Risk Guidance, that does outline that risk assessment should be more specific to the service users’ needs.
93. We also obtained clinical advice on this from our adviser. Our adviser stated a discharge risk assessment is a vital component of patient care that helps ensure safe transitions from hospital to home and involving patients and families in the process, clinical staff can significantly reduce the risk of readmission and improve overall patient outcomes.
94. Our adviser stated the risk assessments completed by the Trust between February and May 2023 were not adequately updated to constitute a valid and updated risk assessment because they are brief, and the Trust did not include a management plan to address the risks that it identified. Our adviser stated the Trust should have outlined the risks posed to Miss B when she was living in the community, and it did not do this.
95. The Best Practice in Managing Risk Guidance outlines that risk formulation is a process in which the practitioner decides how the risk might become acute or be triggered. It identifies and describes predisposing, precipitating, perpetuating and protective factors, and how these interact to produce an elevation in risk. This formulation should be agreed with the service user and others involved in their care in advance and should lead to an individualised risk management plan. Every risk formulation should have attached to it a plan for what to do when the warning signs become apparent. The plan should also include more general aspects of management, such as monitoring arrangements, therapeutic interventions, appropriate placements and employment needs.
96. Best Practice point 14 of the Best Practice Guidance says risk management should be developed by multidisciplinary and multiagency teams operating in an open, democratic and transparent culture that embraces reflective practice. We have not seen evidence that the Trust did this as the risk assessments do not explain the specific actions needed to be taken to mitigate the risks identified. There is also no evidence that there was a specific structure to when the risk assessments would take place. The risk assessments to be reactive as opposed to proactive. We therefore do not consider this to be in line with the Best Practice Guidance.
97. We can clearly see this was an extremely difficult time for Miss A, Miss B and her sister. Based on the evidence we have considered, and the guidance and advice we have referred to, we have identified a failing with the Trust’s management of the risk assessments it completed from 27 February to May 2023 when Miss B was readmitted to the Trust. We will discuss the impact of this in the impact section of the report.
The flat Miss B was discharged to
98. Miss A complains that when Miss B was discharged from the Trust on 27 February 2023, she was discharged back to live in the flat she had previously been living in prior to being sectioned. Miss A says this flat was not suitable for Miss B due to the condition the flat was in.
99. Miss A has sent us a video of the flat that was taken before Miss B was discharged back to the flat. This showed the state of the flat at the time.
100. Section 4.4.6.3 of The Trust’s Admission, Discharge and Transfer of Care Policy states that the patient will be identified as ready for discharge when support and resources are identified and available within an alternative setting to meet their care needs effectively, and once a decision to discharge is agreed, the multidisciplinary team will ensure that adequate preparation for discharge is made.
101. We can see that the Trust discussed where Miss B would be living once she was discharged at the CPA meeting on 23 February 2023. Miss B’s care coordinator asked if her home environment was suitable for her. She explained Miss B’s partner has learning disabilities and autism and he had been sleeping on the floor of the flat due to hoarding. A hoarding disorder is where someone acquires an excessive number of items and stores them in a chaotic manner, usually resulting in unmanageable amounts of clutter.
102. At the CPA meeting the psychiatrist explained Miss B had been living like that for several years, and she could not be kept in hospital because of reasons discussed. The psychiatrist stated they would like the social worker to help sort Miss B’s flat as it was a fire risk, although habitable.
103. The psychiatrist stated that the issue with the hoarding of items could first be addressed by removing some of the items from Miss B’s flat. The psychiatrist outlined that the priority was to remove the fire risk, but her partner, mother and sister could help with clearing Miss B’s flat to make it safe for Miss B to return to. The psychiatrist also acknowledged that a video of the flat had been sent to Miss B’s social worker, but they had not attended the meeting.
104. Miss B said she did not want to live in her flat, or with her partner, and she wanted to live somewhere else. The psychiatrist asked Miss B what needs to happen at home for her to be ok to move back there. She said that her partner needs to get rid of the hoarding, and the council need to help. Miss B said she was not saying she should stay in hospital until the flat is cleared, but it makes her anxious and angry if she is rushed.
105. It was noted at the meeting that Miss B’s partner had started to get rid of some of the hoarding. The psychiatrist stated that Miss B’s flat needed to be sorted for her so she was able to move back to it. There was a plan for the social worker to speak to Miss B the next day to find out how they can get things sorted.
106. Miss B’s progress notes dated 28 February 2023 stated Miss B’s allocated mental health social worker reported they had viewed Miss B’s flat and were able to allocate a caseworker to help with the hoarding at the flat. The social worker was planning to speak to the housing officer at the council for support with a move.
107. This shows the Trust has acted on what it had said it would do at the CPA meeting.
We have found the Trust acted in line with its policy here as it discussed Miss B’s living arrangements at the CPA meeting, and it addressed the potential issues with her moving back to her flat.
108. We have reviewed the video that was sent Miss B’s social worker and that is referred to at the CPA meeting. We can see from the video that there was an issue with clutter and hoarding within the flat, however, we can see the Trust addressed this at the CPA meeting.
109. We have also received clinical advice on this from our adviser. Our adviser stated there are continuous notes in Miss B’s clinical records that state she was ready for discharge, and being on the ward was having a detrimental effect on her mental health. Miss B was discharged back to her own accommodation with a plan for the crisis team and the social worker to support her discharge, and for Miss B’s care to then be transferred to the community mental health team.
110. Based on the evidence we have reviewed, the guidance we have looked at and the clinical advice we have reviewed, our view is we have not identified a failing with the Trust’s decision to discharge Miss B back to her own flat. The flat was her previous place of residence, and the Trust was addressing the potential barriers to Miss B returning to live in the flat after she was discharged.
111. We completely understand this was an upsetting time for Miss A and Miss B, and we understand the concerns Miss A had about Miss B’s living arrangements once she was discharged.
Miss B declining consent for the Trust to share information about her with her family
112. Miss A says The Trust did not give her information regarding Miss B’s condition from 27 February to 20 May 2023, despite Miss B not being well enough to decline consent to share information with her family.
113. We can see Miss B’s sister emailed the Trust and outlined her concerns with the discharge meeting that took place on 23 February 2023. The Trust responded to Miss B’s sister on 6 April 2023 and stated that unfortunately it could not share any of the details regarding the clinical reasoning behind the discharge process as it did not have consent to share information with family member from Miss B.
114. The Trust also said it is aware Miss B’s sister had raised concerns about the support Miss B was getting from the community mental health team, but the Trust was not able to respond to Miss B’s sister in any detail about this without breaching Miss B’s right to confidentiality.
115. Section 8 of the GMC guidance on Confidentiality: good practice in handling patient information says that doctors should make sure any personal information they hold, or control is effectively protected at all times against improper access, disclosure or loss. It also states that doctors should ask for explicit consent to disclose identifiable information about patients for purposes other than their care or local clinical audit, unless the disclosure is required by law or can be justified in the public interest.
116. Section 1 of the Mental Capacity Act states a person must be assumed to have capacity unless it is established that they lack capacity. A person is not to be treated as unable to make a decision unless all practicable steps to help them to do so have been taken without success. A person is not to be treated as unable to make a decision merely because they make an unwise decision.
117. We have reviewed Miss B’s clinical records, and we can see that on 27 February 2023, Miss B informed the Trust that she did not want it to discuss the details of her discharge planning with her sister as it would likely inflame the situation and put a further strain on their relationship.
118. On 1 March 2023, Miss B contacted the Trust to state she did not want her mother or her sister to act as her advocate. We can see that on 2 March 2023; the Trust contacted Miss B’s sister and informed her that Miss B had said she wanted her and her mother to be present for a telephone call Miss B was going to have with the Trust on 3 March 2023.
119. We can see that on 3 March 2023, the Trust informed Miss A of the details of the call it had with Miss B, in line with her wishes.
120. We can see that on 6 March 2023, the Trust contacted Miss A to inform her that Miss B was going to have an outpatient appointment on 9 March 2023, and it advised her to write down a list of questions she wanted to ask for when she attended the meeting. Miss A was then present at the appointment on 9 March 2023. We can also see that Miss A attended a further appointment at the Trust with Miss B on 17 March 2023.
121. Miss B’s clinical notes dated 30 March 2023 stated Miss B removed consent for the Trust to share information about her mental health with her mother and her sister. Miss B attended an outpatient appointment at the Trust with her sister on 5 April 2023. The purpose of the appointment was for the psychiatrist to review Miss B’s mental health. The notes of that appointment state Miss B had capacity (was able to make her own decisions), and she was present at the meeting with her sister.
122. Miss B has not given permission to share information with her family, including her mum or sister, however she brought her sister to the appointment, implying consent for her to sit it on the appointment.
123. On 12 April 2023 it was noted on Miss B’s records that Miss A and Miss B’s sister were aware that Miss B had retracted permission to share information about her mental healthcare with her family. We can see Miss A telephoned the Trust on 24 April 2023 to raise concerns about Miss B’s mental health. The Trust advised Miss A that it did not have Miss B’s consent to share information with her, but if a patient is under its service, it will endeavour to engage and support them as best it can.
124. We can see that Miss A telephone the Trust again on 5 May 2023 to raise concerns about Miss B’s mental health, but she said she appreciates that the Trust does not have Miss B’s permission to share information about her mental health with her.
125. From the evidence we have reviewed so far, we are satisfied the Trust acted in line with the GMC guidance in respecting Miss B’s wishes for her confidentiality to be upheld. It provided information to Miss A when Miss B had given consent for this, and it explained to Miss A it was unable to provide information about Miss B’s mental health when she had withdrawn consent. We can also see the Trust outlined Miss B had capacity, and so she was able to decide whether she wanted information about her mental health shared with her family.
126. We also received clinical advice on this from our adviser. Our adviser stated that in mental health, sharing information guidelines generally prioritise patient confidentiality and consent, while also allowing for information sharing in emergencies or where there is a risk of harm to the individual or others.
127. The Trust recorded Miss B’s wishes as to whether she wanted Miss A and her sister to be informed of her mental health care and status. Our adviser outlined that the Trust did not suspect Miss B did not have capacity and so the Trust did not need to formally assess her capacity.
128. After carefully reviewing all the evidence we have seen so far, we have not identified a failing with what the Trust has done here. We can see from Miss B’s clinical records that the Trust considered Miss B to have capacity. It therefore acted in line with her wishes as regards her family being informed about her mental healthcare. The evidence shows the Trust acted in line with Miss B’s wishes and the GMC guidance.
129. We understand Miss A was very worried about Miss B, and we acknowledge she wanted what was best for her and wanted to help as much as she could. We understand this was a very upsetting time for Miss A and her other daughter, and we understand they were both very concerned for Miss B.
Section 117 aftercare
130. Miss A complains that Miss B did not receive section 117 aftercare when she was discharged from the Trust as an inpatient on 27 February 2023.
131. We have not seen any evidence to show this was directly raised with the Trust.
However, due to the time that has passed and the investigation we are carrying out into the other aspects of Miss A’s complaint, we do not consider it proportionate to ask Miss A to directly raise this with the Trust at this stage.
132. Section 117 of the MHA 1983 states this applied to people who: are detained under Section 3 of the MHA 1983, are sentenced by a criminal court to detention in a psychiatric hospital are transferred to psychiatric hospital from prison
133. We have reviewed Miss B’s clinical records from when she was admitted to the Trust on 26 January 2023. We can see Miss B was sectioned under section 2 of the MHA. Whilst Miss B was an inpatient, she was under section 2 and section 5, and her status was changed to an informal patient prior to her being discharged.
134. Miss B’S records show Miss B was not under Section 3 of the MHA whilst she was an inpatient at the Trust. Miss B was not sentenced by a criminal court, and she was not transferred from a prison, this means that if she had not been sectioned under Section 3 prior to being discharged on 27 February 2023, then she would not be entitled section 117 aftercare.
135. We contacted the Trust to confirm if Miss B had been detained under Section 3 of MHA prior to 27 February 2023. The Trust confirmed to us that Miss B has only been section under Section 3 once, and this was from 16 June to 31 August 2023. This means Miss B had not previously under Section 3 prior to her being discharged on 27 February 2023. This means she would not have been eligible for S117 aftercare in the community during the time she was in the community from February to May 2023.
136. We also obtained clinical advice on this from our adviser. Our adviser stated there was no requirement from the Trust to put S117 aftercare in place when she was discharged from the Trust’s inpatient service on 27 February 2023. This is because Miss B had not been sectioned under Section 3 of the MHA whilst she had been an inpatient at the Trust.
137. We understand that Miss B and her family were under a lot of stress when she was discharged and living in the community, and we understand they consider more should have been done for Miss B.
138. Based on the evidence we have considered so far, and the legislation and clinical advice we have referred to, we have not identified a failing with the Trust not providing Miss B with S117 aftercare after she was discharged on 27 February 2023.
Crisis plan
139. Miss A complains that Miss B was discharged to the community on 27 February 2023 without a crisis plan being put in place for Miss B.
140. We have not seen any evidence that this was raised directly with the Trust, However, due to the time that has now passed, and the other parts of Miss A’s complaint that we are investigating, we have determined it will be more proportionate for us to consider this part of Miss A’s complaint, as opposed to asking her to raise this directly with the Trust.
141. To determine if the Trust created a crisis plan for Miss B, we have robustly reviewed her clinical records from February to May 2023. Whilst we can see that the Trust created a crisis plan for Miss B in May 2023, we have not seen any evidence to show that the Trust formulated a crisis plan for Miss B when she was discharged from its inpatient service in February 2023.
142. To determine if the Trust should have formulated a crisis plan when Miss B was discharged from its inpatient service on 27 February 2023, we have reviewed the Care Programme Approach guidance.
143. The guidance outlines that all care plans must includer explicit crisis and contingency plans. This will include arrangements so that the service user or their carer can contact the right person if they need to at any time, with clear details of who is responsible for addressing elements of care and support. Copies of the plans should be offered to the service user and given to his or her GP and any other significant care provider, including carers if appropriate.
144. The guidance outlines that the Trust should have created a crisis plan when Miss B was discharged from its inpatient service.
145. Quality statement 3 of the NICE guidance on transition between inpatient mental health settings and community or care home settings outlines that people discharged from an inpatient mental health setting have their care plan sent within 24 hours to everyone identified in the plan as involved in their ongoing care.
146. Section 4.5 of the Trust’s Adult Mental Health Community Mental Health Team Standard Operating Procedure outlines that service users should have a risk assessment and My Crisis and Safety Plan, which is co-produced, updated regularly and shared where necessary with relevant agencies. The assessment considers risk to self, risk to others and risk from others.
147. Once an individual is accepted on a community mental health team caseload, a combined Crisis and My Safety Plan is required to be completed for all Service Users.
148. This shows that the Trust needed to formulate a crisis plan for Miss B when she was discharged from its inpatient service on 27 February 2023.
149. We have reviewed Miss B’s discharge liaison form that the Trust completed when it discharged Miss B on 27 February 2023. We can see that the Trust wrote to Miss B’s GP regarding her medication, but there is no evidence it created a crisis plan for Miss B, or that it communicated details regarding a crisis plan to Miss B or any of her other care providers.
150. As there is no evidence to show the Trust created a crisis plan for Miss B, we have found this was not in line with the guidance.
151. We also received clinical advice on this from our adviser. Our adviser stated that the care programme approach meeting for Miss B did take place on 23 February 2023, but where a patient is under the care programme approach, a written care plan specifying aftercare arrangements should be produced which incorporates crisis and contingency arrangements in accordance with the Care Programme Approach Policy. Our adviser added that patients should be offered a copy of their Care Programme Approach care plan and give consent as to whom else may have a copy of it.
152. Our adviser added that creating a crisis plan involves outlining a series of actions and decisions that a person or Trust will take in response to a crisis. This plan should include identifying potential crises, defining roles and responsibilities, developing communication strategies and updating the plan regularly to reflect any changes in circumstances.
153. We understand this was a very difficult and upsetting time for Miss B and her family, and we are very sorry to learn of the issues that have been raised in this complaint.
154. There is no evidence to show that the Trust formulated a crisis plan for Miss B when she was discharged from the Trust on 27 February 2023. We have therefore identified this to be a failing. We will discuss the impact of this in the impact section of our report.
Our findings in relation to impact
155. We have identified two failings with the issues we have investigated so far. We will address each of these individually.
156. We note that Miss A says that she and her other daughter had to incur significant costs in caring for Miss B when she was in the community from February to May 2023, and they say this is because Miss B should not have been discharged from the Trust’s inpatient service on 27 February 2023. As we have not identified a failing with how Miss B was discharged from the Trust, we will not be discussing the issue of claimed costs and reimbursements in this section.
Risk assessments
157. We identified that the Trust failed to maintain adequate risk assessments for Miss B when she was discharged from its inpatient service on 27 February 2023. To help us determine the impact this had on Miss B when she was in the community from 27 February to 20 May 2023, we have looked at what Miss A has informed us. We have also received clinical advice on this from our adviser, and we have reviewed her clinical records.
158. Miss A says Miss B’s mental health deteriorated when she was in the community, and this caused added stress to Miss A and her other daughter.
159. Our adviser stated that risk assessments in mental health are essential for identifying and managing potential risks to people including self-harm, harm to others, and ensuring safe and effective clinical practice. They help clinicians to understand the individuals’ circumstances and formulate appropriate interventions.
160. We have carefully reviewed Miss B’s clinical records with regards to her mental health when she was in the community, and how the Trust managed the risk around this. We have found that whilst the Trust did complete risk assessments, the risk assessments that the Trust did do were not comprehensive enough to meet the standards outlined in the guidance we have referred to.
161. The risk assessments were not adequately updated to constitute a valid and updated risk assessment because they are brief, and the Trust did not include a management plan to address the risks that it identified. The Trust should have outlined the risks posed to Miss B when she was living in the community, and it did not do this.
162. Whilst this is the case, we are unable to say that the Trusts’ failure to complete adequate risk assessments directly led to a deterioration in Miss B’s mental health between February and May 2023. The Trust remained in contact with Miss B throughout this period and it did review her mental health during this time.
163. After careful consideration, we have found the impact of this to Miss A and Miss B is the distress at knowing the risk assessments were not completed in line with the guidance we have referred to, and there were missed opportunities for the risk assessments to be more comprehensive and robust than what they were. We consider this is likely to reduce Miss A and Miss B’s confidence in the Trust’s ability to risk assess patients to ensure their needs are met and that they are kept safe when they are discharged to the community.
Crisis plan
164. We have found the Trust failed to complete a crisis plan for Miss B when she was discharged from its inpatient service on 27 February 2023. To help us determine the impact of this, we have looked at the impact Miss A has claimed, we have looked at Miss B’s clinical records and we have received clinical advice on this from our adviser.
165. Miss A says Miss B’s mental health deteriorated when she was in the community, and this led to significant stress for Miss A, Miss B, and her other daughter.
166. Our adviser stated a well-structured crisis plan would be a vital tool for Miss B to prepare for and respond to unexpected events that could potentially harm her or others. Our adviser stated the impact of Miss B not having a crisis or safety plan could have significant negative impacts to cope with mental health challenges.
167. Without a plan, Miss B may have struggled to recognise early warning signs, leading to a potential escalation of her condition. This could result in increased distress, difficulty in managing daily activities, and a lack of access to necessary support services. Our adviser also said that not having a crisis plan can make it more challenging to access professional help when needed.
168. We have reviewed Miss B’s clinical records, and we can see there were several occasions where Miss B was unsure of what the next steps were with her treatment, what would happen if her mental health declined. For example, Miss B’s progress notes show that on 1 March 2023, Miss A telephoned the Trust to ask what the plan is for Miss B, as she has been discharged and it is not going well.
169. On 2 March 2023, Miss B telephoned the Trust to say she was worried, and she was seeking assurance and confirmation over when she would next be seen by the Trust. Miss B’s sister also telephoned the Trust on the same day to say she was worried about Miss B, and the alleged lack of planning for her on her discharge home.
170. Miss B had a face-to-face review with a psychiatrist on 9 March 2023. This was requested by Miss A and Miss B’s sister because they were concerned about Miss B’s mental health. We can see that throughout the notes, the Trust advised Miss B to contact it if she felt she needed to speak to someone, and it did advise her of a SafeHaven service she could contact if her mental health was declining and she needed to see someone when the Trust’s outpatient service was not available. Whilst this is the case, if a crisis plan would have been in place for Miss B, this would likely have helped her recognise when her mental health was deteriorating, the coping mechanisms she could take when she was entering a crisis.
171. We can see that the Trust did create a Crisis and Safety Plan for Miss B on 23 May 2023. after she was readmitted to the Trust. This shows us what the Plan would have looked like for Miss B, had it been formulated for her when she was discharged on 27 February 2023. It outlines what Miss B is like when she is feeling well, indicators that things are breaking down for her, what safety looks like to her, what makes her feel unsafe, and what people can do to help her when she is experiencing a mental health crisis.
172. Whilst we cannot say the absence of a Crisis and Safety Plan led to Miss B’s mental health declining when she was in the community, or that it led to her being readmitted to the Trust in May 2023, it is clear from her clinical records that Miss B was worried about what was going to happen to her, and at time she was unsure of who she should be contacting if she was experiencing a mental health crisis.
173. A Crisis and Safety Plan would have given Miss B and her family a level of reassurance when she was discharged from the Trust, as there would have been a plan in place of what they could and should be doing if Miss B’s mental health was breaking down or she was experiencing a mental health crisis. The absence of a Crisis and Safety Plan would have led to further distress to Miss B and Miss A at what was already a very difficult time.
174. Additionally, there was a loss of opportunity for a Crisis and Safety plan to be put in place when Miss B was discharged from the Trust, and so Miss B will now not know if she would have been able to cope better when she became emotionally dysregulated had a plan been in place. There was also a loss of opportunity for the plan to have been reviewed during this period.