22. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by looking at clinical guidelines and comparing what should have happened with what did happen.
23. Mr M says Ms M was inappropriately discharged three times between July and September 2021. He also says the Trust did not provide adequate follow-up care and support in the community after discharge.
First admission
24. From Ms M’s medical records, we can see she first presented to ED in July after taking an overdose of paracetamol.
25. NICE CG16 ‘Self-harm in over 8s: short-term management and prevention of recurrence’ was the guidance on the assessment and management of patients who have self-harmed at the time of Ms M’s admissions. Section 1.5.2 recommends the use of acetylcysteine to treat paracetamol overdose.
26. From Ms M’s records, we can see she was given Parvolex. The British National Formulary (BNF) provides guidelines on prescribing and administering medicine. It describes Parvolex as an acetylcysteine medication used to treat paracetamol overdose.
27. From Ms M’s records, we can see the course of Parvolex successfully reversed the effects of paracetamol overdose.
28. NICE CG16 recommended patients who present with self-harm should have a mental health assessment with a mental health professional prior to discharge. This should include assessment of current mental state, history, suicidality, and risk.
29. From Ms M’s records, we can see on she had a full mental health and risk assessment with a mental health liaison nurse. This assessment covered Ms M’s current mental state, her history, suicidality, and risk factors.
30. The Mental Health Act (MHA) is the main piece of legislation which covers the assessment, treatment, and rights of people with a mental health disorder. In certain situations, people with a mental health disorder who are a danger to themselves, and others can be detained for compulsory treatment under the MHA.
31. Our adviser explained Ms M did not meet the criteria for compulsory detainment under the MHA. From Ms M’s records, we can see she was discharged three days after her admission.
32. NICE CG16 provided guidance on discharge and initial follow-up care after an episode of self-harm.
33. It says a care plan should be agreed with the patient for initial aftercare. It says this should be shared with primary care and community teams. From M’s records, we can see she had an agreed care plan prior to discharge.
34. In her care plan, Ms M was signposted to Swindon Intensive Services (SIS). SIS is a mental health team which provides at-home care and treatment in times of mental health crisis.
35. Ms M was given the telephone number for SIS, which is a 24-hour service and was told to contact it, if her mental health deteriorated. It was also agreed SIS would contact Ms M on 17 July and arrange a home visit if required.
36. Our adviser said Ms M had a safe route home from hospital, through collection by her mother and had a suitable supply of her prescribed medication.
37. We can also see a copy of Ms M’s discharge plan was shared with her GP and with the Community Mental Health Team (CMHT). We can see Ms M continued to remain under the care of CMHT and had a care co-ordinator.
38. Our adviser also said a referral to the Multi-Agency Safeguarding HUB (MASH) was completed for Ms M’s 17-year-old daughter.
39. The MASH team is the front door for all referrals in relation to young people in the Wiltshire area. The team is co-located with police and health colleagues to ensure timely decision-making occurs in response to safeguarding referrals.
40. We therefore cannot see any indications the Trust has not followed clinical guidelines in relation to her discharge and follow-up care.
Second admission
41. From Ms M’s medical records, we can see she very sadly presented to ED again in August 2021, after an taking overdose of paracetamol with alcohol. We understand this must have been extremely traumatic and difficult time for Mr M and the rest of the family.
42. From Ms M’s records, we can see she again received treatment in ED to reverse the effects of overdose in line with NICE CG16.
43. From Ms M’s records, we can see she had another full mental health and risk assessment with a mental health liaison nurse. This identified a risk factor around alcohol dependency.
44. We can see during her assessment, Ms M expressed a desire to return home. The Mental Health Capacity Act (MCA) sets out the principles and legislation around capacity and decision making.
45. Principle 1 of the MCA says every adult has the right to make their own decisions and must be assumed to have capacity to do so unless it is proved otherwise. Our adviser said there were no indications Ms M lacked any capacity to make decisions regarding her mental health care.
46. The MHA ‘Code of Practice’ provides guidance to professionals on the MHA and on the rights and responsibilities of people with mental health problems.
47. Alcohol dependence is an exclusion for treatment under the MHA, and our adviser said Ms M would not have met the criteria for compulsory treatment under the MHA.
48. The MHA ‘Code of Practice’ says patients should be treated with the least restrictive option, maximising independence, and where possible a patient should be treated without detainment under the MHA.
49. From Ms M’s records, we can see said she was willing to engage with community care as a less restrictive option to hospital. Ms M was discharged the following day.
50. We consider Ms M had capacity, was medically fit, wished to return home and did not meet the criteria for compulsory detainment under the MHA.
51. We therefore cannot say the Trust should not have discharged her or see indications it did not follow clinical guidelines.
52. From Ms M’s records, we can see another care plan was agreed prior to her discharge.
In her care plan, Ms M was again signposted to SIS for out-of-hours support. She also had a safe route home through collection by her mother.
53. We can see Ms M had an appointment scheduled the following day with her care co-ordinator which she had agreed to attend.
54. We can also see Ms M was signposted to Turning Point. Turning Point is a service which offers help to individuals with problems with alcohol misuse. We can also see a copy of Ms M’s discharge plan was shared with her GP and with the CMHT.
55. We therefore cannot see any indications the Trust did not follow clinical guidelines in relation to Ms M’s initial follow-up care.
56. From Ms M’s records, we can see she attended the appointment with her care co-coordinator, and it was agreed she would enter Herbert House respite facility for a two-week stay.
57. We can see Ms M had a consultation with her psychiatrist in early September 2021, which reported an improvement in her mental health following her stay at Herbert House.
Third admission
58. From Ms M’s records, we can see she was sadly admitted to ED for a third time in mid-September 2021, after taking another overdose of medication along with alcohol. She also had cuts to her forearms.
59. We cannot begin it imagine how immensely shocking and traumatic it must have been for Mr M and the rest of the family to learn Ms M had been admitted to hospital again.
60. From Ms M’s records, we can see she again received treatment in ED to reverse the effects of overdose in line with NICE CG16.
61. From Ms M’s records, we can see she had another full mental health and risk assessment with a mental health liaison nurse.
62. From Ms M’s records, we can see she also had a gatekeeping assessment. A gatekeeping assessment is used to determine whether a patient requires inpatient mental health care or can be supported through alternative community-based services.
63. Following Ms M’s gatekeeping assessment, she was offered an informal voluntary admission which she accepted. An informal admission is a situation where a patient is admitted to a psychiatric bed voluntarily, meaning they have consented to treatment for their mental health issues.
64. This indicated Ms M had mental capacity to consent to her admission and mental health care. Our adviser said the offering of an informal bed at this point was appropriate given the increased risk from multiple presentations and suicidality.
65. Unfortunately, a hospital bed was not immediately available to Ms M. Our adviser said this is not unusual in many hospitals due to pressure on psychiatric beds and patients may unfortunately wait day(s) on general wards or in ED while awaiting a psychiatric bed.
66. We understand this would have been very concerning for Mr M. Our adviser said patients that are more unwell or require compulsory detention or are not in a safe place (such as a community setting) would often get priority over an informal patient who is already in a safe hospital setting.
67. From Ms M’s records, we can see she had an assessment with a Trust psychiatrist around one week later. The Trust psychiatrist decided Ms M was suitable for discharge and was offered an admission to Herbert House for a four-week stay.
68. We appreciate Mr and Ms M felt the best option was for Ms M to remain in hospital.
69. Our adviser said at this point, there was no specific need for acute treatment to be delivered which required a hospital admission and Ms M was medically fit for discharge. We also consider Ms M again did not meet the criteria for compulsory treatment under the MHA.
70. We consider an admission to Herbert House offered a less restrictive option and offered more independence than remaining in hospital, which is in line with the MHA ‘Code of Practice’.
71. We therefore cannot say the Trust should not have discharged Ms M or see indications it did not follow clinical guidelines.
72. Our adviser said given the raised concerns from family members, increased risk from alcohol consumption, safeguarding concerns regarding Ms M’s daughter, and multiple overdoses over the past two months, Herbert House appeared to be a safe and balanced discharge route.
73. From Ms M’s medical records, we can see she has a diagnosis of cPTSD. Our adviser said a prominent symptom of cPTSD is emotional dysregulation.
74. Emotional dysregulation is the inability to control or modulate emotional responses, which can result in extreme or intense reactions and emotions to everyday situations.
75. Our adviser said following crisis, a stay in a reduced stress environment such as a respite facility, can help to moderate emotional dysregulation and aid recovery in the short term.
76. From Ms M’s records, we can see at Herbert House she remained engaged with SIS and CMHT, who continued to provide care and assess need for a hospital admission if required.
77. We have therefore identified no indications the Trust did not follow clinical guidelines in relation to Ms M’s initial follow-up care following her third discharge.
Conclusion
78. In summary, we have not identified any failings in the actions of the Trust regarding Ms M’s admissions or discharge.
79. However, our ‘Principles of Good Complaint Handling’ say organisations should use all feedback and the lessons learned from complaints to complaints to improve service, and where appropriate tell the complainant about the lessons learnt and changes made to services.
80. We are therefore pleased to see that in the Trust’s responses of 10 September 2022 and 2 December 2024, it identified several areas of learning and improvement following its investigation into Mr M’s complaints.
81. While we have not been able to identify failings in line with clinical guidelines, we hope this can reassure Mr M, the Trust has taken learning from his complaint and made improvements to its service, taking several actions in relation to the concerns he raised.
82. We appreciate that this has been an extremely upsetting and distressing time, and our decision is not intended to lessen the impact the issues in this complaint have had and continue to have on Mr M and the family.
83. We hope we have clearly explained the reasons for our decision regarding the concerns Mr M has raised and where possible reassure him with our explanation of the care provided by the Trust.
84. We would like to thank Mr M for giving us the opportunity to consider his complaint.