Summary
Ms C complained about the care and treatment provided to her late daughter (Miss A) by the board's Intensive Home Treatment Team (IHTT), and about the way in which Miss A was discharged from their care. Miss A, who had a history of low mood and self-harm, was referred to the IHTT following an attempted overdose. She was discharged from their care after around six weeks and died at home a week later, having completed suicide.
Ms C complained about a lack of continuity of care, noting in particular the absence of a key worker for Miss A. I took independent medical advice from a consultant psychiatrist, who noted that in a crisis service such as the IHTT, it is difficult to avoid patients being seen by a number of different staff. However, the adviser considered that much more could have been done to enhance the continuity of care provided to Miss A. The IHTT policy indicates that every service user will be allocated a named worker and that complex case discussions will take place, but neither appears to have happened in Miss A's case. Ms C also complained about a lack of clarity surrounding Miss A's diagnosis. I was advised that the sharing of Miss A's diagnosis was reasonably consistent throughout, although differing terminology was used. However, I noted that there was some ongoing uncertainty surrounding the extent of Miss A's unstable personality traits, which might have benefited from a psychological opinion. The IHTT policy indicates that a psychological opinion can be sought within the IHTT but I found no evidence of this having been considered. I was also advised that the IHTT policy might benefit from being updated to define clearly the role of medical staff in diagnosing patients. I upheld this complaint.
Ms C complained about the appropriateness of Miss A's discharge from the IHTT, noting that she had ongoing suicidal thoughts. I was advised that the decision to discharge Miss A was not in itself unreasonable, as the IHTT provide short-term input to patients in crisis and that chronic risk over the long-term is not managed in this setting. However, I was advised that the process followed in discharging Miss A was unreasonable. I found little evidence of discharge planning and no indication that plans were discussed with Miss A. I was particularly concerned that there was a lack of evidence of medical input into Miss A's discharge. Ms C also expressed unhappiness with the follow-up plan that was put in place and said that Miss A felt lost and abandoned. I agreed that the follow-up arrangements were not sufficiently robust. Miss A was discharged into the care of her GP, with the noted involvement of a private counsellor she was seeing and the provision of crisis service contacts. I concluded that Miss A should have been referred for psychiatric follow-up. I was concerned that Miss A was discharged entirely from the board's care on the basis of her private counselling, when no steps were taken to contact the private counsellor to find out what was being offered in terms of follow-up. I upheld this complaint.
Miss A attended A&E on three occasions while under the care of the IHTT, following further suicide attempts. Ms C complained that during these attendances, Miss A was not afforded sufficient privacy and dignity in her distressed states. She also complained that there was a four hour delay in Miss A receiving a mental health assessment and did not consider that enough had been done to ensure Miss A was supported following discharge from A&E.
I took independent medical advice from a consultant in emergency medicine. I was advised that Miss A had been treated in line with normal practice in a busy A&E department and I could not conclude that there was a failure to afford her adequate privacy or dignity. I was advised that a four hour wait is not unreasonable where a patient has taken an overdose and a detailed medical assessment is required prior to mental health assessment. I was critical, however, that it was not documented who was accompanying Miss A and assuming responsibility for her when she was discharged following her third attendance. In addition, I was advised that a mental health assessment form was only completed for Miss A's first attendance. While I was assured that she was appropriately assessed, and that this omission made no material difference to the care she received, I concluded that it would be good practice for this form to be completed in every instance. On balance I did not uphold this complaint but I made some recommendations.
Redress and recommendations
The Ombudsman recommends that the board:
- support the IHTT to implement and adhere to the IHTT Operational Policy, specifically with regard to named workers and facilitating complex case discussions;
- consider revising the IHTT Operational Policy to include a description of the roles of medical staff (including different grades of medical staff) within the IHTT;
- apologise to Ms C for the failings identified in the care and treatment provided to Miss A;
- review the discharge planning process in the IHTT, taking account of the considerations highlighted in this report;
- review the IHTT Operational Policy, setting out clear guidance for when patients should be seen by medical staff;
- provide detailed evidence of all action taken to implement the AER (adverse event review) recommendations;
- apologise to Ms C for the identified failings in the process for discharging Miss A and planning her follow-up care;
- consider introducing a system whereby completion of the A&E mental health risk assessment form is mandatory for all mental health patients; and
- highlight to A&E staff that it is good practice for them to document who vulnerable patients are accompanied by on discharge, and whether the accompanying persons are happy to accept responsibility for patient safety.