Clinical advice
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The nursing advice
Discharge from section 117
- The Nurse Adviser confirmed that Mrs M was entitled to receive aftercare services under section 117 of the Act. She said that in keeping with the Code of Practice (which was first published in 1990, after Mrs M’s discharge), any discharge decision would usually only be made following a multidisciplinary review meeting. The Nurse Adviser found no evidence of any such meeting, or that the Trust or the Council ever appropriately agreed that Mrs M no longer required aftercare services.
Basis of admission to care home
- The Nurse Adviser said that before admission to the Care Home, Mrs M should, in line with the Care Programme Approach and the Care Programme Approach guidance, have had a robust assessment to formulate her needs. She said that as Mrs M was on the enhanced level of the Care Programme Approach, there should have been ongoing assessment of her health and social care before the admission to the Care Home. The Nurse Adviser referred to the ongoing monitoring of Mrs M’s mental health, but she found no evidence of any assessment of her physical needs before admission. Therefore, she concluded that there was no specific evidence that Mrs M was admitted to the Care Home primarily for her physical needs. The Nurse Adviser noted that Mrs M had been closely monitored by the community psychiatric nurse and the second consultant psychiatrist in the period immediately before her admission to the Care Home, and commented that the decision to admit her seemed reasonable.
Discharge from CMHT
- The Nurse Adviser said that, in line with the Care Programme Approach, Mrs M should not have been discharged from the CMHT without appropriate assessment of her health and social needs. As part of this, there should have been a medical review to assess whether she was medically fit for discharge. The Nurse Adviser said that there was no evidence of any such assessment and the clinical records suggested that the decision to discharge Mrs M was made in isolation by the social worker, who was acting as her care co-ordinator. She noted that, contrary to the requirements of the Care Programme Approach, there was no robust assessment of Mrs M’s health and social care needs and no multidisciplinary review meeting involving her family. The Nurse Adviser said that the social worker’s assessment of Mrs M was based on conversations with the proprietor of the Care Home, and that the social worker did not even speak to Mrs M.
The medical advice
Discharge from section 117
- The Medical Adviser said that there should be a ‘clear paper trail’ for patients entitled to receive aftercare services in line with section 117. This should have included documentary evidence confirming the agreement that a patient no longer needed aftercare services, and the reasons for that. He concluded that there is no evidence that the Trust or the Council appropriately decided that Mrs M no longer needed aftercare services under the provisions of section 117 in 1989, in 1996, or at all. He said that despite this, the Trust did not ‘neglect’ Mrs M’s mental health need for aftercare, and they provided ‘appropriate clinical treatment and care for her in the community until at least 2005’. He said that Mrs M’s symptoms and the risk to herself and others varied at times, but her ‘underlying condition persisted’. He concluded that at no point between 1989 and 2005 could it be said that she ‘no longer had a significant and serious mental disorder’. However, the Medical Adviser found no evidence that Mrs M experienced any ‘adverse clinical consequences’ as a result of any failure to meet section 117 obligations.
Basis of admission to the Care Home
- Mrs M was under the Care Programme Approach in the period leading to her admission to the Care Home. The Medical Adviser said that the Care Programme Approach was designed to ensure that people with enduring mental illness are robustly assessed and reviewed with transparency of process, and with the involvement of patients, their family, carers, and professionals. He said that there should be detailed documentation of assessments, reviews, and care plans. The decision to enter the Care Home should have been discussed with Mrs M and her family, and there should have been an assessment to ensure that the proposed placement was appropriate. The Medical Adviser found no evidence to demonstrate that Mrs M had been appropriately assessed in line with the requirements of the Care Programme Approach.
- The Medical Adviser noted that Mrs M was ‘seriously depressed … [and] her physical condition was very poor’ at the time of her admission. He said that the severity of her mental illness may have meant that Mrs M was unable to make a decision about her care and in these circumstances, the health professionals should have made a decision based on their assessment of her ‘best interests’. The Medical Adviser noted that the clinical records showed that Mrs M wanted to avoid admission to hospital.
- The Medical Adviser said that Mrs M’s clinical condition was closely monitored by the Trust in the time immediately before her admission to the Care Home. He said that Mrs M was facing a clinical emergency and immediate action was required. The placement enabled an assessment to be undertaken while Mrs M received appropriate observation and care, which would not have been possible had she remained in her home. The Medical Adviser said that she could have been admitted to hospital for assessment, but that this was not recommended by the medical staff nor desired by Mrs M. He said that the decision to admit Mrs M to the Care Home was in line with established good practice at the time.
- The Medical Adviser said that it was not evident that Mrs M’s mental condition had had no bearing on her need for care home admission. He said that if Mrs M’s needs were seen as primarily physical, she would have been admitted to hospital or transferred to the specialist care of physicians in the care of the elderly. He noted that her condition fluctuated and there were phases in which physical incapacity was present. He said that this supported the view that Mrs M’s physical and mental needs were intertwined.
- The Medical Adviser said that there is sufficient evidence in the clinical records to confirm that one of the stated purposes of Mrs M’s admission to the Care Home was to prevent hospital admission. He said that, if one were to take the view that the services provided by the Trust from June 1989 until October 2004 were part of section 117 aftercare, then Mrs M’s admission to the Care Home might be interpreted as forming part of that aftercare.
Discharge from the CMHT
- The Medical Adviser said that in line with the Care Programme Approach, Mrs M and her daughter should have been consulted on the discharge from the CMHT, which represented a ‘significant change in care provision’. He said that there was no evidence that the assessment of Mrs M prior to discharge was in accordance with the Care Programme Approach. He noted that there was no record of discussion nor consultation with the third consultant psychiatrist about the discharge. There was no evidence that Mrs M or her daughter were consulted about the discharge.
- Furthermore, the limited clinical records meant that it was not possible to say with certainty whether Mrs M was clinically fit for discharge from the CMHT. The Medical Adviser noted that the CMHT had confidence in the care provided at the Care Home, and in the skills of the senior staff there, to detect and ask for assistance with any significant change or deterioration in Mrs M’s mental health. However, although he could not conclude that the decision to discharge Mrs M from the CMHT was appropriate, the Medical Adviser found no evidence of any adverse consequences as a result of this decision.
Care and treatment
- The Medical Adviser commented that he could identify no failings in the care and treatment given to Mrs M by the CMHT.
