Support between January and October 2019
24. NICE guideline CG178 (psychosis and schizophrenia) states that EIP services should be available to all people with a first episode or presentation of psychosis.
25. EIP services should undertake a comprehensive, multidisciplinary assessment of people with psychotic symptoms. This should include an assessment by a psychiatrist or psychologist with expertise in treating people with psychosis. This assessment should address the following:
• psychiatric needs, including mental health problems, risk of harm to self and others, drug and alcohol use • full medical history to assess any physical health issues or medications that might be causing symptoms of psychosis • assessment of physical health and wellbeing • psychosocial factors, such as relationships or a history of trauma • social factors, including accommodation and caring responsibilities • quality of life and economic status.
26. A care plan should be formulated in partnership with the patient, which accounts for the factors outlined in the assessment. Clinicians should also routinely monitor for coexisting conditions such as substance misuse, depression and anxiety, particularly early on in treatment.
27. Mr N was referred to the EIP from the Crisis Team after his discharge from hospital in February 2019. We currently think this was in line with NICE guideline CG178.
28. On 5 March the EIP team assessed Mr N at home. It documented an assessment of his mental state, noting no evidence of psychosis. The team also documented that he appeared very anxious.
29. The assessment also considered his use of cannabis, provided information and education around his prescribed medication, and noted physical health checks would be completed on the next visit. The team also documented a care plan was discussed and a copy of this would be given to Mr N at the next visit. We currently think this was in line with NICE guideline CG178.
30. Between 15 March and 18 July, the EIP team visited Mr N regularly. Its view was that he was not experiencing a first episode of psychosis; rather, he was experiencing generalised anxiety disorder and a substance misuse disorder.
31. The EIP team developed a care plan with Mr N and gave him and his mother a copy of this. It also reduced and stopped his antipsychotic medication and prescribed an anti-anxiety medication instead.
32. The team consistently visited Mr N once per fortnight, assessing his mental state, risk, and activities of daily living. It offered to refer Mr N to primary care talking therapies and substance use services on multiple occasions, which he declined.
33. The Trust planned his discharge between 3 May and 18 July. On 18 July a full CPA review took place which reviewed whether he had any unmet needs. It documented Mr N and his mother were happy with the support provided by the EIP team and agreed with the discharge plan. He was discharged from the EIP service on 18 July, back to the care of his GP.
34. We have found that between January and July 2019 the Trust provided care which aligned with NICE guideline CG178. His care was documented to a good standard, with a full assessment of his needs and a care plan developed in partnership with Mr N and his mother.
35. Mr N’s care was managed by his GP from 18 July to 5 October 2019.
Support provided between October 2019 and March 2020 36. NICE guideline CG136 outlines the essential components of good service user experience in NHS adult mental health services. In line with these guidelines, the Trust should have taken care to understand and emotionally support Mr N and considered his level of distress.
37. This guidance also states that the Trust should have aimed to avoid admission to hospital and support him in his home environment. It should have considered what social support he had and provided contact details for 24-hour crisis support.
38. In October 2019, Mr N began experiencing a relapse of his mental health symptoms. On 5 October the Crisis Team assessed him at home. The notes of this assessment reflect the team were considering a Mental Health Act assessment. The notes also show that his mother was advised to call the police if he left the house.
39. During the assessment on 5 October, the Crisis Team conducted a brief risk assessment and agreed to support Mr N. It outlined a plan to support Mr N in his own home twice per day and provided contact details for local crisis services. We currently think this aligned the Department of Health’s guidelines and NICE guideline CG136.
40. The notes made by the Crisis Team also reflect that it took the time to understand his level of distress. This was comprehensively documented, noting that Mr N was ‘crying with his head in his hands’ and that he was ‘distressed and anxious’ throughout the assessment.
41. The Crisis Team also documented a discussion around social support, noting his mother was his social support.
42. We have found the Trust appropriately assessed Mr N whilst in crisis on 5 October and documented a plan to support him. This aligned with NICE guideline CG136. We recognise that Mr N feels strongly that the Trust should have done more and does not agree with the Trust’s account of the support provided.
43. Sadly, following the Crisis Team’s assessment on 5 October, Mr N was arrested later that evening for alleged criminal damage. He was detained under the Mental Health Act and admitted to hospital. He was discharged from hospital on 14 October.
44. Whilst in hospital, Mr N was prescribed antipsychotic medication and was discharged to the care of the CMHT under the Care Program Approach (the CPA). The CPA was a framework that outlined how people with severe mental health needs should be supported in the community. This framework included allocating a healthcare professional to take responsibility for managing a person’s care in the community (known as a ‘care co-ordinator’).
45. The Trust had a CPA policy that outlined the responsibilities of the care co-ordinator, which included undertaking a comprehensive assessment of Mr N’s health and social care needs in partnership with him. This also included co-ordinating a care plan with him.
46. The Trust’s CPA policy also outlined a statutory requirement to assess these needs, as outlined in the Care Act 2014. This should have included helping Mr N to understand his needs and reduce any onset of greater needs. It should also have helped him to access help when he needed it.
47. On 25 October Mr N began experiencing extrapyramidal side effects, which were causing him significant pain and discomfort. Extrapyramidal side effects are a common side effect of taking antipsychotic medications, and they can affect motor control, posture, and cause involuntary movements.
48. The main approach to managing these side effects is to reduce or switch the medication or add a different medication to help counter the effects. Both of these would need to be considered by the person who prescribed the medication.
49. A mental health nurse documented that Mr N was experiencing these side effects during a home visit on 25 October. The nurse noted ‘today he was unable to remain seated, complaining of pain and aching in his quadriceps, knees and hips. He has reduced aripiprazole [an antipsychotic medication] to 5mg since some time last week as a consequence of these side effects. He stated if the pain continues, he will be unable to continue with aripiprazole’.
50. The nurse also noted that Mr N had made contact with a drug service for his cannabis use but said ‘he cannot attend while he is in pain caused by aripiprazole’. The nurse also noted ‘mild signs of relapse’ related to psychosis and that Mr N lacked insight into his psychosis. The nurse spoke to the team’s psychiatrist who advised he should attend A&E if symptoms got worse.
51. There is no evidence the Trust formulated a care plan for Mr N regarding his medication. This care plan should have included education around medication and medication compliance, monitoring his mental state, and monitoring his response to prescribed medications. This was not in line with the Trust’s CPA policy, and amounts to service failure.
52. We cannot know whether, if Mr N had a care plan, the approach to managing his side effects would have been different. These side effects are common for people taking antipsychotic medications. What we can say, however, is that it is understandable that Mr N felt unsupported when he experienced these side effects and that this more likely than not caused him avoidable distress during this time.
53. With regards to the Trust dismissing Mr N’s feedback on his care, we can see that on 5 October the Trust documented that Ms N wanted her son to be admitted to hospital and was unhappy that he was not detained under the Mental Health Act during the assessment at home. The Trust also documented a telephone call from Mr N’s aunt, who raised the same concerns.
54. 17 January 2020, his mother raised concerns that the Trust did not help her when Mr N was unwell, and she wanted support if ‘things got out of control’.
55. We can see Mr N’s mother raised concerns about the lack of support offered by the Trust. We cannot know exactly what the staff said to them, but we can see there was nothing documented to indicate that Trust had taken this feedback seriously or that it had advised Mr and Ms N how to raise these concerns via its complaints process.
56. NICE guideline CG136 recommends that NHS services take feedback from service users to improve mental health services. It also recommends that services should explain how to make complaints and how to do this safely without fear of retribution. The Trust missed an opportunity to obtain valuable feedback on Mr N’s experience of the Trust’s support, and failed to advise him how to make a complaint. This was not in line with NICE guideline CG136 and amounts to service failure.
57. From October 2019 Mr N struggled to attend his appointments. His mother was his carer and was a positive source of support for him during this time. In line with NICE guideline CG136 the Trust should have:
• promoted active participation in treatment decisions and support self-management of his mental health needs • discussed sharing information with his mother on an ongoing basis to support engagement • used diverse media to contact Mr N, including letters, phone calls, emails or text messages in line with his preference.
58. NICE Quality Standard QS188 (severe mental illness and substance misuse) also says that patients should be followed up ‘promptly and actively’ if they miss any appointment.
59. There is a joint responsibility between NHS services and service users with regards to engagement. Service users should engage as much as possible to get the most out of their treatment, including attending appointments. NHS Service providers should be working to ensure services are accessible and they are actively supporting and engaging people to attend appointments.
60. Mr N missed his appointment with the CMHT following his discharge from hospital. On 16 October the CMHT could not make contact with him by telephone and so contacted his mother. Ms N expressed surprise at the missed appointment as she had not been made aware of this and it was not communicated in the discharge meeting. The Trust agreed to arrange another appointment for him.
61. Later that day, a member of the administrative team contacted her to arrange an appointment and documented that they offered a choice. An appointment was agreed for 25 October and a letter was sent out confirming this. This was in line with NICE guideline CG136 and QS188.
62. During the appointment on 25 October, the Trust did not explore whether it could share information with Mr N’s mother to support his engagement with attending appointments. It also documented, on 29 October, that he had an appointment on 31 October but there is no record of how or when this was communicated. It is unclear whether this was a failure in communication or record keeping.
63. Mr N missed his appointment on 31 October, and the Trust did not attempt to contact him for over a month. The Trust should have done more to engage Mr N, explore information sharing, and the best way to communicate after he missed this appointment. This fell short of NICE guideline CG136 and QS188.
64. The Trust next spoke with Mr N on 5 December, agreeing an appointment for 10 December. It did not document sending any confirmation of this appointment and did not explore whether Mr N wanted this sharing with his mother. This was another missed opportunity to explore information sharing and how the Trust could support Mr N’s engagement with his care, especially as he had missed previous appointments. This fell short of NICE guideline CG136.
65. Mr N missed his appointment on 10 December, and the Trust could not reach him by telephone. The Trust attempted to contact Mr N’s mother on 20 December, as it had previously done when it could not contact him by telephone. Ms N did not answer the telephone, and so the Trust sent a letter with another appointment, for 14 January 2020, via post. The Trust had not checked whether this was an effective way to communicate with him and had not attempted to contact his carer to share this appointment date with them after it issued the letter. This fell short of NICE guideline CG136.
66. Mr N missed his appointment on 14 January 2020 and the Trust contacted him promptly by telephone to arrange another appointment. It also checked with him whether he needed reminding of the appointment. This was in line with NICE guideline CG136 and QS188.
67. Mr N attended an appointment on 17 January. During this appointment the Trust documented his next appointment would be on 27 February. At this stage he had missed several appointments, and the Trust should have explored information sharing and the best way to communicate appointments to him. This did not happen and this was not in line with NICE guideline CG136.
68. In summary, whilst there were some examples of the Trust supporting Mr N to attend appointments, this was inconsistent. The Trust should have done much more to explore sharing information with his carer and how it should communicate with him regarding appointments.
69. There were also times when following up with Mr N after a missed appointment was delayed. This was important because NICE Quality Standard QS188 outlines that patients with severe mental health conditions should be followed up ‘promptly and actively’ if they miss any appointment. This fell so far short of national guidelines that it amounts to service failure.
Support between April and October 2020 70. The Trust’s CPA policy is clear that risk assessment and risk management is a fundamental aspect of care for individuals being supported under CPA. The policy also says that patients under the CPA should have a crisis and contingency plan, and that staff should provide positive responses to carers’ requests for help.
71. In April 2020, Mr N began experiencing a relapse of his symptoms of psychosis. His mother contacted the CMHT on 29 April to raise concerns about his wellbeing. During this call Ms N reported feeling very afraid of her son and that his behaviour was unusual. The CMHT asked her to get Mr N to call its team, and she said this would be difficult due to his paranoia.
72. On 6 May Ms N contacted the CMHT several times and reported she was scared of her son and was hiding in a car park. She reported that Mr N had been smoking cannabis and smearing pasta sauce all over the walls. She was advised to call the police if she felt afraid. The CMHT documented a plan for Mr N’s care co-ordinator to contact him the following day.
73. Mr N’s care co-ordinator rang Ms N on 7 May and attended their home at 6pm that evening. His care co-ordinator documented no concerns; however, Ms N says her son was behaving bizarrely and his care co-ordinator was not taking his signs of relapse seriously.
74. The CMHT updated Ms N later that evening and advised her to call the police if she felt afraid. Ms N told the CMHT that the police had been unable to help when she had called them previously. The CMHT continued to advise her to call the police, twice on 7 May and once again on 8 May. On 8 May Mr N was arrested and detained under the Mental Health Act 1983 following an instance of alleged criminal damage.
75. From 29 April the Trust knew Mr N might be experiencing a mental health crisis, and that his mother was not coping with this. Our Psychiatrist Adviser also said that in the days leading up to 8 May, it was clear from the Trust’s notes that Mr N was experiencing psychosis and required an urgent medical review.
76. From 7 May the Trust also knew that the advice to call the police might not be helpful as Ms N had told the team the police had repeatedly declined to intervene. The Trust offered no other advice as to how to manage her son’s mental health crisis.
77. The Trust had not developed any care plan or crisis plan for Mr N, and it had not provided any information or support to Ms N regarding her role as his carer. This meant there was no plan for how to manage his behaviour, and his mother was given no support options other than to call the police. This fell far short of the Trust’s CPA policy.
78. On 8 May, Mr N was detained under the Mental Health Act 1983 and admitted to hospital. A psychiatrist prescribed aripiprazole again and his presentation began to improve significantly. From 19 May the Trust began documenting a plan for his discharge, and Mr N was discharged from hospital on 1 June.
79. The Department of Health’s Best Practice in Managing Risk guidelines say that patients with a history of self-harm in the last three months should receive medication covering no more than two weeks.
80. Mr N had no documented instances of self-harm in the three months prior to his discharge. Although there are no national guidelines on the amount of medication patients should be discharged with, our Mental Health Nurse Adviser explained that discharging a patient with 28 days’ medication is standard practice in the absence of a clear risk of self-harm or suicide.
81. We can understand why this was so concerning for Mr N. That said, doing so was in line with the Department of Health’s guidelines on managing risk and was standard practice.
82. Whilst in hospital, Mr N was assessed as being homeless. This is because the Trust documented that his mother was struggling to cope with him at home. The Trust referred Mr N to the local authority on 15 May and documented he was ‘happy to engage with [the] housing department when needed’.
83. Mr N completed a homelessness assessment with the local authority on 27 May. The local authority found a property for Mr N and, on 1 June, he was discharged into this accommodation. His final ward round documented that he was ‘happy with the accommodation offered to him’.
84. The accommodation was provided by the local authority, not the Trust. The Trust had no control over where the local authority would place Mr N. It documented Mr N was happy with the information communicated to him about the accommodation. The Trust could not have known any of the concerns Mr N later raised about the standard of the accommodation. The Trust had a duty to plan for his discharge, which it did via the local authority, but it was the local authority’s role to ensure the accommodation provided was adequate.
85. We understand why Mr N was so concerned about the quality of his accommodation and the lack of essentials at the property. Managing his housing needs was the responsibility of the local authority, not the Trust. Therefore, we cannot reasonably conclude that any of the problems with this accommodation were due to service failure by the Trust.
86. Mr N remained under the CPA following his discharge from hospital. In October 2020, the Trust decided to discharge him from its CMHT and the CPA. The Trust’s CPA Policy states that a CPA meeting must be held before discharging a patient from the CPA.
87. NICE guideline CG136 says that any discharge should be discussed and carefully planned with the service user beforehand. This should include agreeing a discharge plan and a contingency plan in case problems arise after discharge. This discussion should also involve family and/or carers who are supporting the service user.
88. Whilst the Trust documented it had told Mr N about his discharge over the telephone, it did not hold a CPA meeting or make any attempt to communicate with him to agree a discharge plan. There was also no attempt to contact his carer. This fell so far short of NICE guideline CG136 and the Trust’s CPA policy that it amounts to service failure.
89. With regards to the Trust sending Mr N’s discharge letter to his GP, the Trust has acknowledged that this happened. The Trust’s Data Protection policy says that its staff should take reasonable steps to ensure personal data is accurate and kept up to date. This would include making sure the information it held for Mr N was accurate and up to date, and taking steps promptly to make any changes required.
90. In its complaint response dated 11 August 2023, the Trust explained that it did not have access to changing a patient’s GP Practice on its system. It explained it had since changed its processes to include additional checks before discharge letters are sent out.
91. Whilst the explanation offered by the Trust is understandable, it should have already had systems in place that enabled it to check it held the correct details before sharing this sensitive information.
92. Furthermore, had the Trust planned Mr N’s discharge and met with him face-to-face, it would have been a simple task to verbally check with him whether his details had changed. This would more likely than not have avoided his discharge letter being sent to the wrong GP Practice.
93. We have found that whilst the Trust documented communication with Mr N over the telephone, it failed to meet with him face-to-face and plan his discharge in line with its CPA policy. This amounts to service failure.
94. The Trust has explained that during this period it was experiencing significant staff sickness and radical changes to its ways of working due to the COVID-19 pandemic. We acknowledge the impact the pandemic had on frontline services; however, this does not reasonably explain such significant departures from both its own policies and national guidelines.
Serious incident investigation
95. NHS England has a published framework for investigating serious incidents in NHS services. This framework states that when undertaking a Serious Incident Investigation, the needs of those affected should be of primary concern to investigators. It adds that patients and their families should be supported and included throughout the investigation process.
96. In line with NHS England’s framework, the Trust should have:
• given Mr N the opportunity to inform the terms of reference (the scope, objectives and structure) for the investigation • explained how he could contribute to the report, for example giving evidence, and offer the opportunity to comment on it before closing the investigation and submitting the report to the commissioner • described how the victim(s) and their family/families had been involved in the process.
97. So far, we have seen no evidence the Trust engaged Mr N or his carer in explaining/agreeing timescales for the investigation. We have also seen no evidence it gave them the opportunity to inform the terms of reference; instead, these were set by the Trust’s serious incident and mortality review panel.
98. The Trust’s serious incident investigation report documents that it contacted Mr N early in the process to invite him to be part of the investigation. It did not document when this call took place. It documented that Mr N requested that the Trust contact his mother instead.
99. The Trust documented that it attempted to make contact with Ms N on several occasions between 17 December 2020 and 19 January 2021. This included attempts via letter and telephone. It was able to speak with her on 19 January and documented she was happy for the investigation to go ahead with the terms of reference the Trust had decided. It did not offer her the opportunity to engage in the process, however, and documented it offered her the chance to ask questions after the review was completed.
100. We have found the Trust failed to engage Mr N and his carer in discussing the timeframe for the investigation and the terms of reference for the investigation. It also failed to engage them in the investigation or provide the opportunity to comment before the investigation was completed. This lack of engagement was not in line with the NHS Framework and amounts to service failure.
101. Because of the lack of engagement with Mr N and his mother, the Trust was only able to consider the Trust’s records and its staff’s account of the events. This meant the completed investigation was not adequately balanced between the Trust’s perspectives and Mr N’s, and we can understand why the completed report appeared one-sided.
102. With regards to whether Mr N’s care co-ordinator was honest during the investigation, this is difficult to reach a decision on, even on the balance of probabilities. This is because it is difficult to find evidence that can tell us whether any discrepancies in the report were due to the care co-ordinator genuinely not remembering the events, or whether this was deliberate. There was also a concerning lack of documentation around Mr N’s care at that time, meaning many of the events outlined in the report could not be corroborated against the records made at the time.
103. There was nothing outlined in the Serious Incident Investigation report that we can robustly say was an incorrect account of what happened from the Trust’s staff. That said, the lack of engagement and communication led to a lack of balance in the report when analysing the series of events that took place. It is possible, for example, the two parties had different subjective experiences of what happened, rather than one party being dishonest. The lack of consideration of the subjective nature of the experience of these events and the failure to ensure both sides were reflected in the report are more likely than not what caused the family to feel like the care co-ordinator had not been candid in their account of what happened.
104. In summary, we have found the Trust failed to sufficiently engage Mr N’s mother, as he requested, throughout the process of the investigation. This caused Mr N to feel that the scope of the investigation was too narrow and did not include a review of the full series of events leading to his arrest.
105. We have also found the Trust also failed to engage Ms N and sufficiently to enable Mr N to provide his account of what happened via his mother. This led to the report containing a one-sided account of what happened.
106. Whilst we cannot robustly conclude there was a lack of candour in the report, we can understand why this appears to be the case to Mr N. The report failed to include the family’s perspective, which at times differed significantly from the staff’s perspective. Because the Trust failed to balance both perspectives, this led to Mr N perceiving a degree of dishonesty within the report.
107. We have found the Trust’s serious incident investigation fell so far short of the NHS England Framework that it amounts to service failure.
Communication with the criminal justice system 108. NHS Trusts have a duty of confidentiality and must not disclose sensitive information unless there is a lawful reason to do so. The Trust’s Sharing Personal Information Policy says that information is only shared outside the Trust when there is a lawful request from the patient or a third party.
109. In criminal cases, when healthcare information is required as part of a person’s defence, there is a standardised form the solicitor must use to request this information. This form is one which both the Law Society and the British Medical Association have approved for making these requests, and is available on the Law Society’s website. The first step is to obtain the person’s consent to request the information. The solicitor then completes the standardised form and sends this to the service which holds these records.
110. Once an NHS body receives this form, it then decides whether it should release the requested records. In cases where this is declined, the solicitor can apply for a court order to release these records.
111. In Mr N’s case, it was his solicitor who needed to communicate with the Trust and request the Serious Incident Investigation. The Trust could not lawfully disclose this to anyone without the standardised form being submitted to its information governance team. The Trust has confirmed Mr N’s solicitor did not request this evidence and we have seen no evidence this happened.
112. We cannot reasonably conclude the Trust communicated poorly with the criminal justice system or failed to share the Serious Incident Investigation report with it. This is because the Trust could not lawfully share this without a formal request from Mr N’s solicitor. This did not happen, and so the Trust could not share any information. Think this was in line with the Trust’s Sharing Personal Information policy.
Impact 113. We have found the provisional failings identified in this report caused Mr N avoidable and significant distress over a period of 12 months. Whilst experiencing psychosis and the side effects of his medication would more likely than not have caused distress in and of itself, we currently think the repeated failures to appropriately monitor and manage his care significantly compounded his distress.
114. There is insufficient evidence to robustly conclude the violent incident in November 2020 and Mr N’s subsequent arrest, more likely than not could have been avoided. Our Psychiatrist Adviser explained that this lack of evidence is due to the Trust’s failure to appropriately monitor and document his mental state during this time.
115. What we can say, however, is that, while Mr N will never know for sure, there is a tangible possibility these events could have been avoided. This is a serious injustice to him.
116. In addition, the Trust caused Mr N further distress when it sent his discharge correspondence to the wrong GP.