Care plans
15. Mrs S complains the Trust did not put in place a care plan between May 2022 and when Mrs R moved into a care home in December 2022.
16. Care plans set out how healthcare providers like the Trust will meet the needs of patients like Mrs R who suffer from mental health issues. They should include an agreement between those involved in the patients care such as family, carers and health professionals.
17. Mrs R’s mental health initially declined in early 2022 and she suffered from hallucinations. The Trust became involved in her care in May. It first created a care plan for her in November.
18. NICE’s, ‘Dementia: assessment, management and support for people living with dementia and their carers,’ sets out the standards for creating care plans. It says named professionals should:
‘develop a care and support plan, and: • agree and review it with the involvement of the person, their family members or carers (as appropriate) and relevant professionals • specify in the plan when and how often it will be reviewed • evaluate and record progress towards the objectives at each review • ensure it covers the management of any comorbidities • provide a copy of the plan to the person and their family members or carers (as appropriate).’
19. Our adviser helped us to understand the Trust should have held a care plan meeting in May, when it first became involved. At this point, it should have created a care plan in line with the above NICE guidelines. It did not do this until November. We consider not creating a care plan at this time to be a failing.
20. The Trust created its first care plan in November. The care plan was very limited in detail, containing very little information about Mrs R or her needs. It did not include the information as listed in the above NICE guidelines.
21. Once it made the care plan, our adviser explained, the Trust should have reviewed it throughout the period complained about. Specifically, it should have reviewed the care plan when there were changes in Mrs R’s presentation, changes in interventions such as medications, changes in her risks, and changes in the environment she received care.
22. Mrs R’s medical notes show she met the criteria for a care plan review on multiple occasions whilst she was under the care of the Trust. Mrs R’s health changed throughout this period, including frequent changes to her presentation which resulted in changes to her medication, changes to her risk factors due to her declining mental health, and when she moved into a care home.
23. The Trust did not review Mrs R’s care plan after each of these changes. As such it did not follow the above NICE guidelines and we have found this to be a further failing.
24. We go on to consider what the impact of not completing a care plan or reviewing her care plan was on Mrs S and her mother later in our report.
Medical assessments during medication changes
25.Mrs S complains the Trust did not carry out medical assessments of Mrs R when it changed her medication. During the period Mrs S has complained about the Trust changed Mrs R’s antipsychotic medication several times including in May, August and November.
26.Nationally, NICE’s, ‘Dementia: assessment, management and support for people living with dementia and their carers’ provides guidance on prescribing antipsychotics to patients with dementia.
27.Additionally, the Trusts: ‘Physical Health Monitoring of Patients Prescribed Antipsychotics and Other Psychotropic Medicines’ provides the Trusts’ internal policy on prescribing antipsychotics. Specifically, it says:
‘The relevant baseline physical health monitoring should be undertaken by the clinical team before the initial prescription of a drug. If this is not possible this must be completed within the first 14 days of treatment.’
28.And, regarding ongoing monitoring it says:
‘A clear plan for the monitoring required for a patient’s medication must be documented in the patient’s electronic care record. This should detail what monitoring is required and how this monitoring will be undertaken. This plan must be communicated to the patient’s GP.’
29.Our adviser helped us to understand, the Trust did not complete medical assessments consistently and in full when it started new medication or ended medication as it should have. This included blood tests and bedside physical health measures (such as blood pressure tests etc).
30.Additionally, Mrs R’s medical records show the Trust did not consistently monitor Mrs R following changes to her medication through medical assessments as it should have or in line with its own internal policy.
31.We note that in its complaints response the Trust explained that at the time of the events nurses would fill in medication change forms rather than doctors. The Trust acknowledged this did not always include information on how to monitor the patient (for example, blood pressure and repeat blood tests). This method of working meant Mrs R and potentially other patients missed out on medical assessments.
32.We have found the actions of the Trust were not in line with the above NICE guidelines or the Trust’s own internal policy. We do not consider it consistently carried out medical assessments of Mrs R when it changed her medication or that it monitored her new medication as it should have. Therefore, we have found failings in this part of the complaint.
33.We go on to consider the impact of the Trust not carrying out medical assessments or reviews on Mrs S and her mother later in our report.
Mental capacity assessments during medication changes and management of POA
34.Mrs S says the Trust did not fully understand the role of a POA when asking her and her sister to make decisions. She says the Trust did not assess Mrs R’s mental capacity to make her own decisions before involving her POAs.
35.The UK Government’s ‘Mental capacity act code of practice’ states clinicians should start by presuming someone has capacity to make their own decisions. It goes on to says:
‘A person’s capacity must be assessed specifically in terms of their capacity to make a particular decision at the time it needs to be made.’
36.We consider the Trust should have considered Mrs R’s mental capacity regarding each decision to change her medication. We have not seen evidence it did this in line with the above guidelines.
37.Despite this, it liaised with both POAs when making decisions about her care. This is evidence it did not fully understand the role of the POA and that it needed to assess Mrs R’s capacity before involving her POAs.
38.If the Trust considered Mrs R to lack the capacity to make decisions, it should then have involved both POAs in its decision making as they shared the same legal right to make decisions around their mother’s care.
39.Specifically, the above UK Government guidance says it should have consulted with:
‘any attorney appointed under a Lasting Power of Attorney or Enduring Power of Attorney made by the person’.
40.Mrs R’s medical notes show the Trust was aware of conflict between the POAs as early as August 2022. Between August and January 2023 there is evidence it sometimes consulted with one POA more than the other and did not always share information with both parties about the management of Mrs R’s care and medication. We consider this was not in line with the above UK Government guidance.
41.We have found failings in the Trust not completing mental capacity assessments and in its understanding of the role of a POA.
42.Additionally, we have found that the Trust did not consistently consult with both POAs when it made decisions around Mrs R’s ongoing care. We go on to discuss the impact of these failings later in our report.
43.Our adviser explained if the Trust deemed Mrs R did not have capacity and that her POAs had conflicting views, it should then have followed the above UK Government guidelines and made a ‘best interests’ decision on Mrs R’s behalf. This process involves a meeting of professionals and the POAs to decide on what is in the best interests of Mrs R. Specifically, the UK government sets out the following options for settling disputes about best interests:
‘• involve an advocate to act on behalf of the person who lacks capacity to make the decision • get a second opinion • hold a formal or informal ‘best interests’ case conference.’
44.The same guidelines also set out the role of the Independent Mental Capacity Act Advocates (IMCA). The role of the IMCA is to act as a representative for a service user who lacks capacity. Our adviser helped us to understand, this role would have been particularly pertinent given the disagreements between POAs regarding Mrs R’s care. The Trust did not request an IMCA to represent Mrs R following the initial conflict between her POAs.
45.Therefore, we have found, the Trust did not request an IMCA as it should have. It did not hold a meeting to determine a ‘best interests’ decision until January 2023. This was over four months after it first recorded disagreements between the POAs. We have found the Trust did not follow the above UK Government guidelines and that this is a failing.
46.We go on to discuss the impact of this failing later in our report.
Overall impact
47.Mrs S says the actions of the Trust contributed to her mother’s confusion and anxiety in the lead up to her death. Mrs S also says her mum died feeling anguish, despair and sadness unnecessarily.
48.Mrs S also told us the Trust’s actions caused her distress and anxiety at a very difficult time, when her mother was very unwell.
49.Our adviser explained the Trust provided timely and appropriate treatment. They explained there is no evidence of a direct clinical impact on Mrs R. We agree with our adviser and we consider it provided appropriate care and medication in line with the above NICE guidelines on treating patients with dementia.
50.We next considered whether the Trust’s actions negatively affected Mrs S’ mental health in the lead up to her death. We can see there was potentially a missed opportunity for the Trust to involve Mrs R in decisions about her own care. This might have provided her with more reassurance about her own care and reduced her confusion.
51.We cannot say with certainty the Trust would have assessed her as mentally capable had it carried out mental capacity assessments. Therefore, we cannot be sure the Trust missed opportunities to provide reassurance or reduce Mrs R’s confusion. We appreciate this leaves Mrs S not knowing whether different actions from the Trust could have reduced her mother’s confusion and anxiety.
53.We go on to consider the impact of the failings on Mrs S. We can see, the Trust’s actions caused her unnecessary distress at a very difficult time, when she was caring for her mother and later when she was grieving her death.
54.The failings we have found happened between May 2022 and January 2023, when it arranged a ‘best interests’ meeting. This period of time was around eight months. It is clear from Mrs S’ complaint that she had concerns in May 2022 and that her concerns escalated following medication changes in November 2022.
55.We have also found, the mismanagement of her joint POA status led Mrs S to feel unheard and to such a degree that she felt she needed to raise a safeguarding issue in December 2022. We cannot comment on the handling of this request as this does not fall within our legal remit. However, we can say it serves as evidence of how much she felt the Trust was not listening to her and not sharing information with her as joint POA. This clearly caused her a lot of distress as her mother’s illness progressed.
56.We have found the impact of the Trust’s failings was an exacerbation of the emotional distress Mrs S was already experiencing due to her mother’s declining health.
57.We next considered what has the Trust has already done to put right the impact of the failings we have found. Our ‘Principles for Remedy’ state organisations should:
‘ensure that the complainant receives:
• an assurance that lessons have been learnt • an explanation of changes made to prevent maladministration or poor service being Repeated.’
58.We have found the failings in the Trust not completing care plans or reviewing them in line with NICE guidance. In its complaint response the Trust said:
‘A discussion has been held with the care coordinator involved in Mrs R’s care at that time and she has been advised that a comprehensive care plan should have been documented. This has also been discussed with the team lead of the service and will be monitored in ongoing supervisions.’
59.We acknowledge the Trust has addressed this failing with a specific staff member which we consider to be appropriate and in line with our ‘Principles for Remedy’. Despite this, we consider there is further work the Trust can do in the form of an action plan, to ensure the failings are not Trust wide.
60.We have also found the failings in the Trust not carrying out medical assessments of Mrs R when it changed her medication or monitoring her new medication.
61.In its complaint response, the Trust explained it had reflected on how to completes medication change forms and all forms that are about antipsychotics will now originate from a doctor rather than a nurse or member of the clinical team. It said this should ensure that sufficient information about monitoring and risks associated with medication is shared with GPs when requests for medication changes are made on an urgent basis. We can see this action would have a positive impact on all future care following changes in medication.
62.We note the remedy the Trust has provided specifically says it will share information about monitoring and risks associated with medication. This leaves us with concerns that the Trust has not fully addressed the lack of medical assessments prior to changing a patient’s medication. The Trust has only addressed medical assessments following medication changes.
63.As such we consider there is more the Trust can do to ensure that it carries out appropriate investigations prior to changing medication. We go on to make recommendations regarding this later in our report.
64.Additionally, we have found failings in the Trust not completing mental capacity assessments. We have found this meant it did not fully understand the role of a POA or involve an IMCA to make a ‘best interests’ decision, as soon as it should have when there were disagreements between the POAs.
65.In its complaint response the Trust said:
‘A discussion has been held with the care coordination regarding a formal capacity assessment not being undertaken of Mrs R’s ability to make decisions in relation to her treatment, specifically around medication at the time of these changes being made.’
66.The Trust also said staff were fully aware of the roles and responsibilities of a designated POA. It states one staff member was unaware of how to escalate concerns to the Office of the Public Guardian but has now been trained in this.
67.We do not consider this action by the Trust recognises the lack of understanding of the role of a POA. Specifically, it does not recognise that the Trust did not carry out mental capacity assessments to determine whether Mrs R had capacity to make her own decisions before involving POAs in decision making. We do not consider the Trust has recognised or done anything to address this lack of understanding of when to invoke a POA.
68.Whilst it has addressed the lack of mental capacity assessments with one staff member, we cannot be sure this issue was solely down to one staff member. Therefore, we go on to recommend an action plan to address the lack of mental capacity assessments. This will also ensure an to ensure the failings are not Trust wide. Alternatively, the Trust can provide us with evidence this is not a systemic issue and solely down to the actions of one employee which we will consider before making our decision final.
69.Additionally, we cannot see the Trust has understood that it should have involved an IMCA sooner when there was a conflict of opinions between the joint POAs. Therefore, we recommend it addresses this failing in an action plan later in our report.
70.Given the seriousness of the above failings we consider there is more work the Trust can do to address these failings to prevent them from recurring. We go on to make recommendations in the next part of our report.