Mr A went nine days without medication, and the family were not informed nor involved in discussions of his presentation during this time
15. Based on the available evidence, including the independent clinical advice we obtained, our view is Mr A’s refusal to accept oral antipsychotic medication between 30 January 2021 and 8 February 2021, and the recommendation that he be commenced on Depixol depot, was handled appropriately by the Trust and in line with applicable guidance. The inpatient team appears to have worked with Mr A to try to persuade him to accept Aripiprazole as an alternative to the Olanzapine he was prescribed and wished to stop.
16. The inpatient team provided Mr A with written information about Aripiprazole and assured him this would not cause a raised prolactin level, something Mr A was concerned about. The records show that Mr A was able to speak with both nursing and medical staff about the option of Aripiprazole. There was collaborative working with the ward pharmacist about suitable alternative antipsychotic options for Mr A and this included a medication history being completed for him, which determined that Aripiprazole had previously been tried but had been discontinued due to it being ineffective in treating his paranoid schizophrenia.
17. The actions of the Trust were in keeping with the General Medical Council’s (GMC’s) “Good Medical Practice” document - Good medical practice-english- Archived 30 January 2024, which states:
“Good doctors work in partnership with patients”
and
“In providing clinical care you must: a 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 serve the patient’s needs
b provide effective treatments based on the best available evidence
d consult colleagues where appropriate”
and
“You must make good use of the resources available to you.”
and
“You must listen to patients, take account of their views, and respond honestly to their questions.
You must give patients the information they want or need to know in a way they can understand.”
and
“You must work collaboratively with colleagues, respecting their skills and contributions”
18. In February 2021, the Trust replied to Mrs B’s complaint about this issue. It explained that Mr B had been prescribed Olanzapine during the relevant 9-day period but declined to accept it. It is also said this:
‘During the initial 9-day period of [Mr A’s] admission there were reviews of his mental health state and discussions within the Multi-disciplinary Team Meeting regards his current presentation and treatment plan. The notes reviewed do not reflect that family were asked to be part of these discussions or to gain their viewpoint or perspective on [Mr A’s] presentation. We apologise for this and the undue distress caused in relation to the lack of communication. We do recognise the importance of carer involvement in patients care and the need to actively listen to carers views and share information where consent is given to do so. Work with carers is an ongoing development that we are working on within the Rehabilitation Service.’
19. From that, we can see the Trust, in February 2021, acknowledged it did not communicate with the family as well as it should have done and apologised for that. It also said it intended to learn from what happened to try to improve its service. Our decision is that the Trust did enough at the time to try to put this right and we are therefore not upholding this part of the complaint.
After requesting a Second Opinion Appointed Doctor (SOAD) to address his concerns about being forcibly medicated he was offered a five-minute telephone conversation on 14 February 2021, which he was not comfortable with as he was unable to ascertain with whom he was speaking
20. Mr A and Mrs B were concerned that the Trust considered him able to have sufficient capacity to engage in a five-minute telephone conversation with a Second Opinion Appointed Doctor (SOAD) that was unknown to him, despite continuously assessing him to have no capacity whatsoever. They also thought a brief ‘phone call was insufficient and that Mr A should instead have been seen face-to-face.
21. A SOAD is an independent clinician appointed by the Care Quality Commission (CQC), and their job is to assess if the care and treatment proposed by the Trust is appropriate for the patient’s presentation.
22. In its response to Mrs B’s complaint, the Trust explained that this consultation happened remotely because of the restrictions in force due to the Covid-19 pandemic. It assured her that the SOAD had access to relevant records and consulted with a staff nurse and occupational therapist.
23. We saw in the clinical records that the CQC contacted the Trust after it referred Mr A for a SOAD and set out what is required. This confirmed that the SOAD appointment would be conducted remotely because of the pandemic, asked the Trust to provide a summary of the patient’s current issues, and/or any relevant documents that would include this information. The records show that Mr A’s RC comprehensively set out this information in an entry on 8 February 2021.
24. We say more about Mr A’s capacity in paragraphs 88 to 97 below. In the context of this part of the complaint, however, we would expect a SOAD to talk directly to the patient to hear their views on their treatment, which we can see is what happened here. In terms of how that conversation should take place, we agreed with Mr A’s view that it is generally better if that happens face-to-face rather than over the ‘phone. We understood Mr A’s, and Mrs B’s, concern about this.
25. We also needed to bear in mind that this happened during the pandemic, when special arrangements were in place across multiple clinical settings. Our view, therefore, is that while the ‘phone call was not ideal, it was not an unreasonable way to proceed in the circumstances which applied at the time. The Trust’s explanation to Mrs B was consistent with the contemporaneous evidence, and it facilitated Mr A’s SOAD request in line with our Principles of ‘being open and accountable’. We decided not to uphold this part of the complaint.
A ward round meeting on 26 November 2020 was brought forward at short notice without his family being informed, leading to Mr A being there alone and leaving him feeling forced to accept being administered Risperidone via depot rather than orally during this meeting
26. We understand that Mrs B was highly frustrated at how the Trust handled discussions about Mr A’s medication in ward rounds. Mrs B complained specifically about a ward round meeting on 26 November 2020. Mrs A, Mr A’s mother, and an advocate were booked in to attend this meeting. Mrs B said the Trust moved it forward without telling anyone. She said the Trust’s actions ‘broke him’ and it led to Mr A agreeing to start risperidone medication. We understand that this would be concerning.
27. The Trust explained that its records evidenced that this meeting took place in the presence of Mrs A and her advocate, and their concerns about risperidone were discussed in detail. As agreement was not reached, a further meeting was held the following week which was also attended by Mrs A.
28. We reviewed the clinical records, which evidence that Mrs A and her advocate attended both meetings outlined in p27 above. This means Mr A had family and carers available to advocate for him in relation to his concerns about receiving a depot. This is in line with GMC guidelines, which says clinicians, ‘must be considerate to those close to the patient and be sensitive and responsive in giving them information and support’.
29. Based on the available information, we found the Trust acted in line GMC guidance, and we saw no evidence that Mr A’s mother and her advocate were excluded from this meeting. We do not uphold this part of the complaint.
While being forcibly medicated on 19 February 2021 he was surrounded by a number of staff and felt violated and disrespected, and a welfare check that Mrs B requested after hearing this incident via his mobile phone was completed without speaking to him
30. Mr A and Mrs B were extremely concerned about a forcible administration of depot medication on 19 February 2021. Mrs B explained to us that she was on the telephone with Mr A beforehand and remained on the line during this event. She has told us that this was ‘horrific’ and kept her up at night for two weeks after. We can understand how unpleasant and distressing this must have been.
31. When Mrs B complained, the Trust acknowledged this understandable distress. It explained that it had reviewed CCTV footage of the incident and noted that Mr A was approached by a total of seven staff immediately prior to administering the medication in the courtyard of the Ward. It acknowledged this was disproportionate given Mr A’s relaxed, non-hostile presentation at that time.
32. We understand this to be contrary to the Code of Practice, which says that an act of restraint can only be used if ‘[…] the amount or type of restraint used and the amount of time it lasts is a proportionate response to the likelihood and seriousness of that harm.’ We consider that the disproportionate use of restraint was a failing.
33. Nothing can change what happened, but it was appropriate that the Trust acknowledged this in its response and apologised to Mr A and Mrs B. We considered the impact of this incident carefully and whether the Trust’s recognition and apology was sufficient.
34. We saw in the clinical records that the Trust did make efforts on the day of this incident to obtain Mr A’s compliance, unfortunately without success. Its staff therefore considered that it had no alternative but to medicate Mr A forcibly. We consider that this decision was reasonable.
35. We do agree with Mrs B, and the Trust, that the level of restraint was excessive. We understand that this likely caused distress to Mr A, and to Mrs B who heard the incident playing out over the phone.
36. We understood and share Mr A’s, and Mrs B’s, concern about what happened. We do not underestimate the impact this must have had on them. We consider that the Trust’s recognition of the impact on them in its response, and its apology for what it did wrong, is enough to put things right. We therefore are not upholding this part of the complaint.
37. Mrs B further complains that after the above incident, she contacted the Chief Executive about her concerns who arranged for a welfare check to be done. She understands that this was conducted without speaking to Mr A but instead by checking his records and speaking with staff. We understand that this would be frustrating, and why it was so important to Mrs B that somebody ensured that her brother was okay.
38. The Trust explained that the member of staff who was delegated to undertake this check was attending a scheduled visit to the ward, and he was asked to focus his concerns around specific questions Mrs B had raised. The Chief Executive later followed up with a request that he checks in with Mr A, which unfortunately the member of staff did not see until after his visit. The Trust apologised for this miscommunication and recognised the distress that Mr A’s family were experiencing at this time.
39. We believe that was a reasonable explanation, in line with the NHS Complaint Standards by offering ‘meaningful and sincere apologies and explanations that openly reflect the impact on the people concerned’. We therefore consider that the Trust had already done enough to put this right before this complaint reached us.
The Trust did not complete a ‘DATIX’ entry for the first occasion that Mr A was forcibly medicated on 11 February 2021
40. In its response to Mrs B on 30 November 2021, the Trust confirmed that it did not initially complete a DATIX entry for the forced medication of Mr A that occurred on 11 February 2021.
41. The Trust acknowledged after speaking with the relevant team that a DATIX entry should have been completed as passive holds were used during this incident, and it apologised for not doing so. It confirmed that the necessity of completing DATIX entries would be added to its staff training manual.
42. It was appropriate that the Trust recognised that it had made an error and took steps to put that right. This was in line with our ‘NHS Complaint Standards’ which says that organisations should be ‘giving fair and accountable responses by being ‘open and honest when things have gone wrong’ and being ‘clear about how the learning will be used to improve services and support staff.’
43. We have considered this carefully, and we think what the Trust has done was enough to put this right. We therefore are not upholding this part of the complaint.
Mr A was medicated with Risperidone despite concerns about his previous experiences with this mediation, and he and his family were told that he had a sensitivity to Quetiapine despite him being well taking this in the community
&
Mr A repeatedly asked for blood tests to check his prolactin levels during December 2020 and eventually it was found that these were much higher than normal
44. Mr A and Mrs B were unhappy about him being medicated with risperidone, because of concerns about this having excessively elevating his prolactin levels in the past. Prolactin is a hormone with the primary function of enabling the production of milk for post-birth baby feeding. Mrs B also told us that the Trust wrongly told her and Mr A that he had an allergy to their preferred medication, quetiapine, and this is why it instead prescribed him with risperidone.
45. The Trust explained that prior to his transfer to the Ward Y, it had been noted on Mr A’s record to ‘avoid Quetiapine immediate release – preference’. The Trust asked a pharmacist to look at this as part of its investigation, and it was deemed likely that this had been wrongly interpreted as a marker of an allergy or adverse reaction.
46. The Trust explained that after discussing medication with Mr A in October 2020, he clarified that the immediate release variation of quetiapine, which quickly works its way into the bloodstream to take effect, causes him drowsiness. He was therefore started on slow-release tablets, which have a more gradual effect.
47. The clinical records show that in a conversation in October 2020, Mr A expressed his concerns about risperidone, and it was agreed that he would be taken off it and would be started on quetiapine instead.
48. Our Adviser referred us to the NICE clinical guideline, ‘Psychosis and schizophrenia in adults: prevention and management’, which sets out how clinicians should make decisions about antipsychotic medications with the service user. It says: -
‘The choice of antipsychotic medication should be made by the service user and healthcare professional together, taking into account the views of the carer if the service user agrees. Provide information and discuss the likely benefits and possible side effects of each drug, including:
• metabolic (including weight gain and diabetes) • extrapyramidal (including akathisia, dyskinesia and dystonia) • cardiovascular (including prolonging the QT interval) • hormonal (including increasing plasma prolactin) • other (including unpleasant subjective experiences)’
49. In engaging with Mr A about his concerns and allowing him to have a say in his medication, we consider that the Trust was acting in line with the above guidance.
50. However, several days later his treating consultant referred to the above-referenced note about quetiapine and planned to stop this medication. Mr A’s presentation deteriorated, and Mrs B expressed concern about this plan. She told the Trust that Mr A had not experienced any problems with quetiapine in the past.
51. After this, the Trust made enquiries with the pharmacy and confirmed there was no allergy recorded. We saw that it discussed this with Mr A, who advised that he had no allergy but preferred the slow-release tablets, as per the Trust’s response.
52. In listening to Mr A and his family members, and making enquiries with the pharmacy, the Trust acted in line with the NICE guideline reference above, and the NICE guideline on ‘Drug allergy: diagnosis and management’. This says that treatment providers should ‘check a person's drug allergy status and confirm it with them (or their family members or carers as appropriate) before prescribing, dispensing or administering any drug’.
53. Having made these enquiries, we noted the Trust agreed to prescribe a therapeutic dosage of quetiapine. This was in line with GMC’s ‘Good medical practice which says that clinicians ‘must listen to patients [and] take account of their views’. For that reason, we do not uphold this part of the complaint.
54. We understand that this was frustrating for both Mr A and Mrs B. We hope that they are reassured that the Trust appears to us to have had Mr A’s wellbeing appropriately in mind when taking a cautious approach to administering quetiapine, due to what was recorded in his medical records.
55. Thereafter, we can see that the Trust was of the view that quetiapine was having minimal clinical effect, and risperidone was restarted. It also planned to prescribe him with a monthly by a depot, which is an injected dose of anti-psychotic medication. We understand that Mr A and his family had concerns about these decisions because of the concern about prolactin levels and his needle phobia.
56. We saw that Mr A’s prolactin levels were taken into consideration. It was noted that he was experiencing no symptoms associated with enhanced levels, nor did Mr A report any to Trust staff. We noted that when Mr A raised this concern in early December, the Trust agreed to retake his bloods to check this. We understand that this did find elevated levels of prolactin.
57. Mrs B told us that she understood that Mr A had been asking for blood tests to check his prolactin levels, but this was refused. She says the family was told that Mr A was refusing blood tests because he was scared of needles.
58. The Trust explained in its response that it made several attempts to undertake blood tests to check Mr A’s prolactin levels in October. It said Mr A refused to consent.
59. The clinical records document that the Trust first attempted to take bloods from Mr A soon after his arrival on Ward Y in September, and Mr A refused. We saw that the Trust tried to explain the importance of undertaking a blood test for the purpose of checking his prolactin levels, but Mr A refused to comply. At this stage that the Trust was taking the concerns Mr A had expressed, and the possible side effects of risperidone on him as referred to above, seriously. This was in line with the GMC guidance referred to above.
60. Furthermore, after the Trust later was able to test Mr A’s prolactin levels and found that they were elevated after starting him on the depot, it discussed his options with him. It explained that he was not displaying any of the adverse symptoms associated with raised prolactin levels and there had been an improvement in his clinical state. Mr A decided that, despite this, he wanted to discontinue the depot, and this was respected by the Trust. We therefore saw further evidence of the Trust continuing to engage with Mr A about his treatment options, in line with the NICE guidelines referenced above.
In Mr A’s third week on the ward, his mother attempted to contact him, and staff were repeatedly rude and advised her that contact with her was not in his care plan
61. Mrs B and Mr A complained that Trust staff were rude to their mother, Mrs A, when she contacted Ward Z during the third week of his admission there. Mrs B told us that staff would say that they could not talk to her and would put the phone down.
62. In its response to the complaint, the Trust said that it had set out a communication plan to update Mr A’s family after the weekly ward round. It acknowledged that there was no evidence that this plan had been discussed or agreed with the family. Its response recognised the importance of open communication from clinical teams with family and carers, and it explained that it had set up new initiatives to improve this.
63. The clinical records set out the communication plan as set out above after Mr A was transferred to the Ward Z. We saw evidence of telephone calls on 8 February and 9 February in which this was explained to Mrs A on occasions where she tried to speak to staff prior to the ward round, and the records document that she was unhappy about this.
64. We see there was a detailed conversation with Mrs A on 11 February. In this conversation, Trust staff reflected on how it had handled communication and apologised. It decided that its plan was not beneficial to Mr A or his family, and it assured that it wanted to involve the family in his care. The records document that Mrs A was satisfied with this.
65. We decided that we do not have sufficient evidence to be able to conclude that Trust staff spoke rudely to Mrs A, but we are sorry that was her experience and was how she felt about the communication.
66. The records do show that the Trust was aware that communication was an issue. It accepted it had not done everything it could to ensure communication was as good as it could be, and we can see it was actively working with the family in real time to try to improve communication. This was in line with our Principles which say that organisations ‘should treat people with sensitivity, bearing in mind their individual needs, and respond flexibly to the circumstances of the case.’
67. We are unable to say whether the Trust’s staff were ‘rude’ or not.
Mr A’s ‘Responsible Clinician’ (RC) made decisions about his care without meeting him
68. Mr A and Mrs B were concerned that decisions made while Mr A was on Ward Z were made without his Responsible Clinician (RC) meeting him in person.
69. Mrs B considered that it was the other staff on the ward making the decisions about Mr A’s care, and not the RC. She believed decisions about revoking his entitlement to leave were made as a ‘punishment’ if he did not ‘toe the line’.
70. The Trust explained that, because of the impact of the Covid-19 pandemic, RCs sometimes had to oversee patient care remotely. It said the RC worked collaboratively with staff on the ward and received regular updates, especially before making any significant decisions about care and treatment.
71. We saw from our review of the clinical records that Mr A was reviewed regularly by staff on the ward. This included, where possible, review from the RC, one-to-one sessions with nursing staff, input from the ward pharmacist, and access to therapeutic activities such as Occupational Therapy. We also found evidence of regular collaboration with the community mental health team and social services and housing services, where appropriate.
72. This was in line with the NICE clinical guideline 136, ‘Service user experience in adult mental health: improving the experience of care for people using adult NHS mental health services’, by ‘[ensuring] that the overall coordination and management of care takes place at a regular multidisciplinary meeting led by the consultant and team manager with full access to the service user's paper and/or electronic record’.
73. We concluded that despite not meeting Mr A in person, his RC had sufficient knowledge of his condition and was appropriately involved in his care. We hope that this is reassuring. We do not uphold this part of the complaint.
Mr A’s unescorted leave that he was entitled to under Section 17 of the Mental Health Act was revoked at short notice on 10 March 2021
74. Mrs B told us that she understood that the Trust was ‘constantly’ revoking his right to leave without reason, and as outlined above, it almost seemed as a ‘punishment’. We understand why it would be alarming to feel like Mr A was losing his right to leave without good reason.
75. The Trust explained that while the RC had agreed Mr A could take this leave, he had not signed the necessary paperwork to make this legal. The Trust staff could therefore not allow Mr A to take the leave as planned, although it quickly resolved this issue.
76. The relevant paperwork requiring signature related to Section 17 of the Mental Health Act, which allows patients under section the opportunity to have leave from the ward, if granted by the RC.
77. The clinical records show that Mr A’s RC discussed his unescorted leave with him on 9 March 2021, and explained to him that he awaited an updated Section 17 form for him to sign.
78. On 10 March 2021, Mr A raised concerns with staff about not being granted unescorted daily leave, and Trust staff explained to Mr A that his RC had not signed the necessary paperwork to grant this. The available evidence indicated that this was solely because the RC was unavailable to do so. We have seen nothing to support Mrs B’s view that it was an act of punishment by any Trust staff.
79. After the Section 17 paperwork was signed, Mr A was allowed to take unescorted leave that same day. The records show that on this occasion, Mr A returned from his leave quickly due to rain. There is no evidence that Trust staff interfered with his entitlement to take this leave. We hope this helps to alleviate the family’s concerns.
80. We were satisfied that the Trust met its statutory obligations by not granting the enhanced Section 17 leave that Mr A sought, at least not until his RC had approved the necessary paperwork. We do not uphold this part of the complaint.
Mr A’s family requested a change of consultant, but this did not happen
81. In early November 2020, during Mr A’s stay on the Ward Y, Mrs B requested that the consultant with overall responsibility for his care and treatment be changed. This was because she was not happy with the consultant’s approach and was concerned that a good therapeutic relationship had not been established with Mr A. Mrs B is unhappy that the consultant was not changed immediately despite her request.
82. In its response to Mrs B, the Trust referred to its ‘Protocol for Service Users requesting a change of Consultant Psychiatrist or a second opinion’. This says that if a patient lacks capacity to make decisions about their treatment, a representative can make an application to change consultant on their behalf in writing.
83. The Trust acknowledged that it did not strictly follow the guidance in this case, nor did it refer Mrs B to the policy. The Trust said that it will remind its staff that service users and their relatives should be made aware of the correct process to follow. This is in line with our Principles of ‘seeking continuous improvement’ by ‘us[ing] feedback to improve their public service delivery’.
84. Mr A’s medical records show the Trust accepted Mrs B’s request as a valid ‘application’ and it was carefully considered. Thirteen days after Mrs B’s request, staff acknowledged that Mr A did not have a strong opinion about his consultant and there was no clinical reason for a change. The Trust still decided to agree to a change in the hope that this would build a good therapeutic relationship with his family.
85. This is in line with our Principles of Good Administration which state:
‘In some cases a novel approach will bring a better result or service, and public bodies should be alert to this possibility. When they decide to depart from their own guidance, recognised quality standards or established good practice, they should record why.’
86. The Trust also explained that patients are required to remain with their existing consultant while a change is considered. We noted that the policy referred to above says that ‘the existing Consultant is obliged to continue to offer care until he/she has received written notice from the new Consultant that they accept the transfer of care.’ This means that it was right for the Trust to keep Mr A with his existing consultant while it considered Mrs Bs request.
87. We therefore do not find any service failure in how the Trust handled the request for a change of consultant, and this part of the complaint is not upheld.
Staff made decisions about Mr A’s care and treatment without adequately assessing his capacity
88. We have considered the capacity assessments that were conducted during Mr A’s admission. We can see that capacity assessments were conducted on the following dates:
• 6 November 2020 – regarding involvement of Mrs B in his care • 26 November 2020 – regarding information sharing with Mr A’s family • 20 December 2020 – regarding medication • 22 December 2020 – regarding managing finances, information sharing with family and make accommodation decisions
89. The Trust explained to Mrs B that formal capacity assessments are to be completed upon admission, and for any significant decisions around their care and treatment, such as above.
90. The ‘Mental Health Act 1983: Code of Practice’ sets out the following guidance for the completion of formal capacity assessments:
Decision-makers should ensure that where a capacity assessment is undertaken, this is recorded in the individual’s care and treatment record. As well as the outcome of the test, the following should be recorded:
• the specific decision for which capacity was assessed • the salient points that the individual needs to understand and comprehend and the information that was presented to the individual in relation to the decision • the steps taken to promote the individual’s ability to decide themselves. How the information was given in the most effective way to communicate with the individual • how the diagnostic test was assessed, and how the assessor reached their conclusions, and • how the functional test was undertaken, and how the assessor reached their conclusions
91. We must be clear that it is not our role to substitute the Trust’s decisions on capacity with our own, and we can only consider if the assessments were completed in line with the above. We will not detail each assessment and set out how we considered each one against each of the points laid out above, however we confirm that we have done so.
92. We noted that on each occasion, the assessor referred to the points above in setting out its thinking. For example, each assessment documents the specific decision being considered and sets out how the assessor reached their decision. We found no evidence that any of the capacity assessments carried out were completed contrary to the above.
93. We were surprised to see that there were not more formal capacity assessments. However, based on the available evidence we agree with our adviser’s view that the care and treatment provided to Mr A by the Trust was based on adequate assessment and interaction with him. There is evidence of him being regularly reviewed on the ward by his inpatient Consultant Psychiatrist, of him being offered one-to-one time with nursing staff on the ward, input from the ward pharmacist to discuss medication, and of him being able to access therapeutic activities, e.g. with the Occupational Therapist, whilst on the ward.
94. There was evidence of regular engagement with and communication with Mr A’s family and listening to and taking account of their concerns and queries. There was evidence of regular engagement and communication with and working collaboratively with his community team (the Early Intervention in Psychosis Team). There was also evidence of appropriate collaborative working between the inpatient team and social services and housing services, e.g. when planning and facilitating Mr A’s discharge from Ward Z in April 2021.
95. We believe the care and treatment provided to Mr A was in line with the GMC’s “Good Medical Practice” document - which states:
“Good doctors work in partnership with patients”
and
“You must make good use of the resources available to you”
and
“You must listen to patients, take account of their views”
and
“You must give patients the information they want or need to know in a way they can understand”
and
“You must be considerate to those close to the patient and be sensitive and responsive in giving them information and support”
and
“You must work collaboratively with colleagues”
and
“You must contribute to the safe transfer of patients between healthcare providers and between health and social care providers.”
96. In our view the actions of the Trust were also in keeping with the NICE Clinical Guidelines on “Service user experience in adult mental health: improving the experience of care for people using adult NHS mental health services” (CG136; published 14 December 2011) - Service user experience in adult mental health: improving the experience of care for people using adult NHS mental health services, which states:
“Undertake shared decision-making routinely with service users in hospital, including, whenever possible, service users who are subject to the Mental Health Act (1983; amended 1995 and 2007).”
and “Ensure that the overall coordination and management of care takes place at a regular multidisciplinary meeting led by the consultant and team manager with full access to the service user's paper and / or electronic record.”
and “Ensure that service users in hospital have access to a wide range of meaningful and culturally appropriate occupations and activities 7 days per week, and not restricted to 9am to 5pm. These should include creative and leisure activities, exercise, self-care and community access activities (where appropriate). Activities should be facilitated by appropriately trained health or social care professionals.”
and “Service users receiving community care before hospital admission should be routinely visited while in hospital by the health and social care professionals responsible for their community care.”
and “Ensure that all service users in hospital have access to advocates who can regularly feed back to ward professionals any problems experienced by current service users on that ward. Advocates may be formal Independent Mental Health Advocate (IMHAs), or former inpatients who have been trained to be advocates for other service users not detained under the Mental Health Act (1983; amended 1995 and 2007).”
97. Our decision is therefore that the Trust’s clinicians did not make decisions about Mr A’s care without proper knowledge of his needs or condition, so we do not uphold this part of the complaint.
The Trust made a referral to Safeguarding about Mrs B as it said she had made him unlawfully homeless while he was in hospital
98. We reviewed the Trust’s Safeguarding policy that was in effect at the time of event. This sets out that if it has concerns that a vulnerable adult ‘is experiencing, or is at risk of, abuse or neglect’, it should undertake a capacity assessment and assess their understanding of the risk to them.
99. At the time, Mr A was admitted to a psychiatric hospital setting and detained under the Mental Health Act 1983. The records show that Mr A had been inconsistent about whether or not he consented to terminate his tenancy and had been inconsistent with what information could be shared with who and when. It was felt he did not understand the implications of giving up his tenancy and intentionally making himself homeless in the eyes of housing providers. At times, Mr A had reportedly informed the inpatient team that he wanted to keep his accommodation and did not wish to give it up.
100. At a multi-disciplinary team (MDT) meeting, it was felt that Mr A lacked capacity to make a decision around his accommodation. As a result, a referral to the safeguarding team was made to support with oversight and multi-agency management of the complex issues.
101. The actions of the Trust in managing Mr A’s tenancy and making a referral to the safeguarding team were appropriate and in line with good and expected clinical practice, given that Mr A was assessed to lack capacity to decide whether to terminate his existing tenancy.
102. Mrs B terminated Mr A’s tenancy on his behalf whilst he remained an inpatient. It was deemed by the Trust and by Mr A’s Social Worker that Mrs B’s action in terminating his tenancy was undertaken without Mr A’s consent and that, at that time, he had been assessed as lacking capacity to decide to end his tenancy. Mr A had stated that he had no knowledge that his tenancy had been terminated, and it was reported by staff on Ward Y that he was upset by the tenancy being terminated.
103. In those circumstances, we believe the actions of the Trust in completing a referral to the adult safeguarding team following Mrs B giving up Mr A’s tenancy without his consent and without his prior knowledge that she was going to do this, were appropriate, proportionate and taken with the intention of protecting his best interests.
104. In its response to this part of the complaint, the Trust acknowledged how distressing this must have been for Mrs B when she considered that she was only acting in Mr A’s best interests. It also explained that the Trust was also acting in Mr A’s best interests, and the safeguarding referral helped to obtain an independent and objective view about what had happened. We think that was a reasonable response.
105. We understand that Mrs B was highly distressed by this decision, and this added to a very difficult period for their family. We do not dispute that Mrs B was acting in what she believed to be Mr A’s best interests at this time. We can see that she was highly concerned about his financial situation given he was no longer on full pay and his return to work was uncertain. We hope that she is assured that the Trust followed appropriate guidance and were also acting in Mr A’s best interests when taking this step.
106. We are therefore not upholding this part of Mr A and Mrs B’s complaint.
Mr A’s planned discharge at the end of his section on 7 April 2021 was blocked
107. Mr A and Mrs B were of the view that the Trust was working to keep him as an inpatient longer than necessary and did not give him the opportunity to refute or pursue a challenge of his section. We understand that this would be highly worrying.
108. Patients under section are entitled to challenge their detention at a Manager’s Hearing, where a panel of ‘hospital managers’ that are independent from the patient’s care and treatment hear the case from both sides and decide whether or not a section should continue.
109. Mr A’s discharge was not blocked. The records show that following the Hospital Managers’ Hearing on 31st of March 2021, his Section 3 detention was discharged, and Mr A became an informal patient at Ward Z. Mr A was then informed that he was free to discharge himself and that he would not be held under an emergency doctor’s holding power - i.e. Section 5(2) of the Mental Health Act 1983 or under an emergency nurse’s holding power – i.e. Section 5(4) of the Mental Health Act 1983 if he attempted to leave the unit.
110. We carefully reviewed the clinical records pertaining to these events. It is evident that Trust staff involved in Mr A’s care thought that it would benefit him to remain an inpatient. However, we found no evidence that the Trust prevented Mr A from pursuing a hearing or impeded its progress. It thereafter honoured the outcome and advised Mr A that he was free to be discharged.
111. The Trust was entitled to give a clinical view on his section, was in fact obligated to do so, and we found no evidence that it acted contrary to what it considered to be in Mr A’s best interests.
112. We were therefore satisfied that the Trust’s actions were in line with our Principles of ‘being customer focused’ by ensuring that service users ‘are clear about their own entitlements’. We therefore decided not to uphold this part of the complaint.
An unknown individual joined a ward round meeting via Microsoft Teams on 27 October 2020, which Mrs B was informed of by a nurse, but no record was made of this conversation
113. Mrs B explained that she attended one of Mr A’s ward rounds in October, which was conducted via Microsoft Teams, and she could see that Mr A appeared distracted by something on the computer screen. She then heard a voice which did not appear to belong to anybody in the meeting and queried this, at which point ‘all hell broke loose’.
114. Mrs B told us that she was contacted by a member of Trust staff who explained that relatives of the next planned ward round had already joined the Teams meeting. She told us she was assured that this would be investigated, but she does not believe that anything happened. We understood why Mr A and Mrs B would be concerned that information about his condition and treatment might have been shared with strangers.
115. In its response, the Trust acknowledged that Mr A’s ward round overran and Trust staff who were familiar with him joined the call to be present for the next ward round. The family of the next patient also joined, so the call was immediately terminated.
116. We reviewed the relevant records and noted that these reflect the Trust’s explanation as set out above. We saw that Trust staff joined early, and the discussion was put to a stop once the next patient’s relative joined the call. The discussion about Mr A’s care continued later that same day.
117. Our Principles of ‘being open and accountable’ says that organisations should ‘respect the privacy of personal and confidential information.’ We were satisfied that the Trust met this responsibility by terminating the meeting as soon as there was a risk of information about Mr A’s care and treatment being wrongly shared. We therefore found no evidence of a failing on this part of the complaint.
The Trust did not comply with requests for information from Mr A’s employer, who was ready to support his release and return to work
118. We learned that during this time and leading up to his discharge from Ward Z, Mr A had a supportive employer who wanted to help facilitate his return to work in any way possible.
119. Mrs B told us that during Mr A’s inpatient stays, his employer wanted guidance from the Trust on how to best handle getting him back to work. She understood that Trust staff seemed enthusiastic about this, but his employer was then met with ‘hostility’ when contacting the Trust. She also told us that his manager asked if the Trust could help with a return-to-work care plan, and they said that was nothing to do with them.
120. The Trust explained that it works within information governance guidance and the Caldicott Principles when considering sharing patient information with third parties. The Caldicott Principles are a set of good practice guidelines for using and keeping safe information about patient care, which were first introduced in 1997.
121. It said that when applying the Caldicott Principles and guidance, it considered that it was not proportionate or relevant to share information with Mr A’s employer. This was because it was not deemed that his return to work would be imminent. However, it did refer Mr A to a service within the Trust that offers support in gaining employment or returning to work after periods of ill health in March 2021.
122. The clinical records showed that the Trust and Mr A discussed his employer’s request for information on 16 March 2021, and he declined consent for the Trust to share information with them. The Trust therefore confirmed it would not do so and later that day set out its view that it is not at liberty to discuss care plans, and it was not its place to advice his employer on facilitating his return to work.
123. We were satisfied that the Trust acted in line with Caldicott Principle 4 that ‘access to confidential information should be on a strict need-to-know basis’, and Principle 5 which says that Trust staff should ‘understand their responsibilities and obligations to respect the confidentiality of patient and service users’. It also acted in line with Mr A’s wishes.
124. We found no evidence of service failure in how the Trust considered and responded to requests for information from Mr A’s employer. We hope that Mr A and his family are assured that the Trust respected his right to confidentiality in refusing to share information about his condition unnecessarily with his employer.
125. This concludes our investigation on the concerns that Mr A and Mrs B asked us to consider, and our final decision is that we do not uphold this complaint. We know that this was a very difficult time for the family, and we hope our explanations will be helpful to them.