The investigation

Introduction

51. During this investigation our staff contacted Miss M on a number of occasions to confirm our understanding of the nature of her concerns.  Our staff have examined Mrs M’s medical records, and information from the Trust and the Council about their attempts to resolve the complaint at local level.  In addition, our staff interviewed Trust and Council staff who were involved in Mrs M’s care or in the handling of Miss M’s complaint.  Our staff also met Miss M on 13 June 2011.
52. We obtained specialist advice from two clinical advisers: a Consultant Psychiatrist (the Medical Adviser), and a Mental Health Nurse (the Nurse Adviser).  The clinical advisers are specialists in their field and, in their role as advisers, they are completely independent of any NHS organisation.
53. We have not included all the information found during the course of the investigation, but we are satisfied that we have not omitted anything of significance to the complaint and our findings.

Key events

54. Mrs M had a history of affective bipolar disorder dating back to 1955, and had had a number of admissions to psychiatric hospitals.  In 1989, after being admitted voluntarily to a psychiatric hospital, she was detained under section 3 of the Act.  On discharge from hospital in June 1989 she was discharged from the section 3 order, and arrangements were made for her to attend occupational therapy sessions at the hospital (which she did for some months before deciding she did not wish to attend any longer), along with regular appointments with a consultant psychiatrist, and attendance at a clinic to monitor lithium levels.  She saw the consultant regularly until 1996.  The records which the CMHT have been able to locate make no reference to any decisions about provision under section 117 of the Act, and there is no evidence of any assessment, review or social work involvement at that time.
55. In a letter dated 29 February 1996 to Mrs M’s GP, the consultant psychiatrist said Mrs M:  

    ‘appeared to be very well, asymptomatic and her medication [was] unchanged. … At present I am seeing her at 3 monthly intervals and although she has been well for many years she seems to appreciate the contact she has from time to time.’

56. Mrs M was admitted voluntarily to a psychiatric hospital in 1997 for over four weeks. Her husband was admitted to hospital in July 1998 and Mrs M went into hospital again on the day that he died. She remained there for four-and-a-half months and was readmitted a month later for a further three months. She was admitted to hospital again in 2001 for nine weeks, and again in 2003 for over two weeks. Mrs M lived alone following her husband’s death.
57. In 1999 Mrs M had been referred to a consultant neurosurgeon because of a marked deterioration in her physical health. She had a tendency to falling, her gait had changed, she had become incontinent of urine, and needed considerable help with day-to-day activities. Mrs M was admitted to a general hospital for treatment of hydrocephalus, and was fitted with a shunt that resulted in an improvement in her mobility.  She was referred to a neurosurgeon in 2002 because her mobility had deteriorated, but no evidence was found that the shunt was malfunctioning or that this had caused her physical decline.  At the time of her admission to the psychiatric hospital in 2003, no significant problems with her physical health were recorded.
58. From 2001 the CMHT operated under a partnership agreement between the NHS and the Council to provide an integrated health and social care team.  Social workers were seconded to the CMHT.  Social workers and health workers within the CMHT delivered services on behalf of both the Council and the Trust. Mrs M was supported by a community psychiatric nurse following her discharge from hospital in July 2000. The community psychiatric nurse commented in her care plan review of 6 October 2003 that Mrs M’s ‘mental health needs remain and are of enduring nature and will need ongoing CMHT input’. CMHT support was ongoing up to and including her admission to the Care Home.

Admission to the Care Home in October 2004

59. In April 2004 a consultant psychiatrist noted that Mrs M was free from depression, but he noted that she: ‘continues to be rather Parkinsonian and although has no tremor has a shuffling gait and marked bradykinesia ³ and mask- like faces’. The community psychiatric nurse who had been supporting Mrs M since the 1990s recorded that her problems differed from previous occasions, and that her decline had a physical and age-related origin. Mrs M was then 79 years old.
60. From June 2004 Mrs M was prescribed medication for Parkinsonian symptoms and was seen regularly by the community psychiatric nurse and the consultant psychiatrist. In August 2004 she was seen at home by the consultant psychiatrist, who undertook to review her antidepressant medication because she ‘remains in her low mood’. In September 2004 the consultant psychiatrist asked the GP to review Mrs M’s physical state because he was: ‘quite disturbed by the deterioration in her gait’ and by her increasingly frequent falls.
61. On 4 October 2004 the community psychiatric nurse recorded that Mrs M’s physical and mental health needs were so interconnected that it was impossible to assess which was the primary need.  She arranged a package of care for Mrs M at home with the Social Services Home Assessment Team (HAT) and her bed was moved downstairs; but this was not sufficient and Mrs M was unable to remain at home.  On 7 October the community psychiatric nurse noted that Mrs M was overwhelmed and wanted to go into a care home for respite.
62. The community psychiatric nurse arranged a placement for Mrs M at the Care Home (a residential care home, not a nursing home), and she moved there on 8 October 2004.  In a fax to the Care Home, the community psychiatric nurse requested ‘a respite, rehabilitation admission’.  She said that Mrs M had a long-standing depressive illness and had been known to the mental health team for many years, that she had been unwell physically and mentally since March 2004, and that her antidepressant medication was being reviewed.  She noted that Mrs M required: ‘care to give her “asylum” in the true sense of the word.  Peace from trying to orchestrate her life’, and that the plan was for her to return home.
63. The community psychiatric nurse noted that she had advised Miss M to investigate finances, but no request was made for consideration of the funding of the placement at the Care Home, and Mrs M paid the full fees from her own resources.
64. Miss M says that she was told that her mother was being placed at the Care Home because there were no psychiatric hospital beds available for her mother at that time.  (The community psychiatric nurse told our staff that this was not the case and that she had arranged the placement at Mrs M’s request because she needed help in looking after herself.)  The CMHT files do not contain any reference to the consideration of a hospital admission.
65. Following her move to the Care Home, the consultant psychiatrist and the community psychiatric nurse visited Mrs M and recorded that she appeared to be improving mentally but that her mobility had worsened.  The community psychiatric nurse requested the GP to make a referral to a consultant physician to determine if anything could be done to enable Mrs M to return home.  The consultant psychiatrist reviewed Mrs M in the Care Home on 12 October and asked the GP to let him have: ‘any report that yourself or the HAT team have regarding her physical health’.
66. On 5 November 2004 the community psychiatric nurse carried out a care plan review based on her recent contact with Mrs M, the consultant psychiatrist, and Miss M.  The Care Programme Approach review document (dated 6 December 2004) stated that Mrs M was on the enhanced level of the Care Programme Approach and that the placement at the care home was ‘a consequence of increased mental and physical health needs’.  The community psychiatric nurse noted that Mrs M had complex mental and physical needs, and was so handicapped by the latter that, at present, it was unsafe for her to return to her own home.  The care plan stated that Mrs M’s mental health had improved following a change in her medication, but that she would continue to be assessed, and the cause of her physical health and mobility problem was being investigated.
67. In January 2005 a consultant physician at Salisbury District Hospital concluded that there was no apparent neurological cause for her falls, and noted that Mrs M’s depression was clinically significant, that she was withdrawn, and that she lacked confidence.
68. Miss M believes that the community psychiatric nurse ‘abandoned’ her mother at the Care Home. The community psychiatric nurse has said that Mrs M was being appropriately looked after at the Care Home with 24-hour cover, so that it was not necessary for her to visit so often.

The discharge from the CMHT in July 2005

69. Mrs M’s case was transferred in February 2005 from the community psychiatric nurse to a CMHT social worker, who became her care co-ordinator.
70. Mrs M was reviewed in April 2005 by the consultant psychiatrist, who concluded that from a psychiatric point of view she was remarkably well, but noted that her mobility was a major issue.  He requested that she continue to receive her antidepressant medication from her GP, but did not arrange to see her again.  He noted that the social worker should remain involved in her care for a few months but that she could be discharged from the CMHT if she were to remain at the Care Home.
71. Also in April 2005 Mrs M was reviewed by the consultant physician who considered that her problems were more mental health related than physical, and that she might have ‘psychomotor retardation secondary to depression’.  She requested a psychiatric review and an assessment for Parkinson’s disease.
72. The social worker visited the Care Home on 9 May 2005 but the contemporaneous notes indicate that she did not speak to Mrs M, who was engaged in an activity session at the time.  She noted concerns raised by staff about Mrs M’s difficulties in day-to-day living, and concluded that her needs were being met at the Care Home.  She requested a reassessment of Mrs M’s mental health to determine whether this was the cause of her recent symptoms and deterioration.
73. A locum consultant psychiatrist reviewed Mrs M on 7 June 2005, and concluded that she was not currently depressed and that her affective illness was not the cause of her mobility problems.
74. The social worker visited again on 18 July 2005, but again did not speak to Mrs M, who was engaged in an activity session.  Following discussion with staff, the social worker noted that Mrs M was a permanent resident and was settling well. She concluded that Mrs M’s needs were being met at the Care Home and that there was no longer a role for the CMHT.  The social worker completed the paperwork to discharge Mrs M from the CMHT in July 2005.  The care plan she completed said that Mrs M was on the standard level of the Care Programme Approach, that Mrs M would continue to be offered appointments with a consultant psychiatrist so that her mental health could be assessed, and that the Care Home staff knew that although she was being discharged from the CMHT, a re-referral could be made.
75. The social worker has told our staff that she would not have made the decision to discharge Mrs M from the CMHT by herself.  She would have discussed the case with the consultant psychiatrist (who was part of the CMHT), and it would have been discussed at a weekly team meeting before the decision to discharge was made.  There is no record of such discussions.  The social worker said that she attempted to contact Miss M to discuss the proposed discharge, but again there is no record of this.

2005 to 2008

76. Following an assessment by a consultant physician in August 2005, it was confirmed that Mrs M did not have Parkinson’s disease. He noted that she had ‘the akinetic rigidity syndrome (Gegenhalten)⁴ associated with advanced Alzheimer’s disease’.  He said that there was little that drug treatment could do to help, but asked that physiotherapists visit to maximise her mobility.
77. The records from the Care Home indicate that Mrs M’s depression was managed with medication prescribed by her GP.  There were references to her mood being low for short periods of time, but generally she was well.  There is no record of any concern being expressed about her mental health by Mrs M, her family, the staff at the Care Home, or the healthcare professionals who came into contact with her during this time.
78. A care manager from the Care Home wrote a letter on 17 October 2006 stating that Mrs M had declined both physically and mentally in the previous six months. She noted that physically Mrs M was unable to carry out simple tasks and that her mobility was poor, requiring help from two carers at all times because she was unable to walk on her own. She also noted that she was unable to hold long conversations with anyone, and found it difficult to concentrate and understand what was said to her. She also wrote that ‘she suffers from severe depression which she has medication for’.
79. In January 2008 Mrs M was assessed by the occupational therapy and physiotherapy team at the Trust.  They confirmed that Mrs M had restricted movement at her elbow joints.  They noted that she had poor cognitive function and that she was unable to engage in activities of daily living, requiring assistance from staff to prompt all activities.  Mrs M was given a home exercise programme.
80. There is no recorded contact with the CMHT between 2005 and February 2008 when, at Miss M’s request, a consultant psychiatrist from the CMHT assessed Mrs M’s capacity in connection with an application to the Court of Protection.  The consultant psychiatrist stated that Mrs M had had chronic anxiety and depressive disorder since 1955, and established dementia since 2005.  He noted that Mrs M was no longer able to understand complex information about her financial affairs, that she was aware that she was no longer able to do this, and that Miss M currently managed her affairs.

The transfer to social services in 2008

81. In March 2008 Miss M complained to the CMHT about increased fees at the Care Home.  A senior practitioner at the CMHT arranged a meeting with Miss M, Mrs M, her care manager at the Care Home, and a duty community psychiatric nurse from the CMHT.  The community psychiatric nurse’s assessment indicated that Mrs M did not have high mental health needs but that she had a high level of general nursing needs.  She concluded that Mrs M had a high level of needs that could be managed in an ordinary residential care home, but that she might require nursing care if her mobility continued to deteriorate.  She also concluded that Mrs M did not meet the criteria for a full continuing healthcare assessment (for full NHS funding).
82. Miss M refused to pay the increased fees at the Care Home and Mrs M was served with a notice of eviction.  Miss M contacted the senior practitioner to request assistance in finding a new home for her mother because she wanted her mother to live nearer to her.  The senior practitioner arranged for Mrs M to remain at the Care Home and for the Council to fund the additional fees until a satisfactory resolution could be found.
83. By letter dated 26 June 2008, Miss M complained formally to the Trust that her mother’s needs were not being met, and about the lack of consultation and information she received about the Care Home and the fee structure.  She said her mother’s mental and physical health deteriorated significantly after her admission to the Care Home; and she complained about the decision to discharge her mother from the CMHT (which Miss M had not been informed about), given her long-term mental health problems and needs.  She said that in line with section 117 of the Act, her mother was entitled to receive aftercare services until the point of discharge from mental health services.  She said that following her compulsory detention in 1989, her mother was regularly assessed and reviewed and was not discharged until 2005 (albeit inappropriately) while she was in the Care Home.
84. The Trust responded on 1 August 2008 that they did not accept the basis of the complaints made.  The Trust said that following Mrs M’s discharge from hospital, she would have received aftercare under the provisions of section 117 until it was no longer needed, and they were liaising with the Council to establish when aftercare ended.
85. In an email dated 28 August 2008, the community service manager at the Trust who was investigating Miss M’s complaint said:  

    ‘I am sticking my neck out on this one as we do not have the paperwork to back up that discharge.  3.3 of the s117 policy clearly states that discharge should be joint decisions and should be discussed in detail at the ICPA [Integrated Care Programme Approach] review meeting, which it was not.  I am trying to keep this as simple as possible as there is too much evidence from our own procedure to hang us.’

86. On 2 September 2008 the Trust wrote that Mrs M was discharged from her entitlement to receive aftercare services on 8 December 1995, when she was discharged to her own GP on the grounds that she did not require continuing follow up by the CMHT.  On 20 October the Trust provided a copy of the psychiatrist’s letter of 29 February 1996 (paragraph 55).
87. The Trust said that aftercare services are triggered on discharge from a compulsory detention under the Act, and are aimed to ensure safe discharge and prevent readmission to hospital; the need for aftercare must come from an assessed need arising from the person’s mental health disorder.  The Trust acknowledged that Mrs M was entitled to aftercare services when she was discharged from the hospital on 12 June 1989; and said that she received services such as outpatient appointments, monitoring medication, and access to a community psychiatric nurse and occupational therapy, and that these constituted aftercare services for the purposes of section 117.  The Trust acknowledged that people can remain eligible to receive aftercare services in line with section 117 for some time after discharge, but said it does not follow that in the event that their condition deteriorates, any service needed in the future will automatically be aftercare under the provisions of section 117.  The Trust said that the decision to move Mrs M to residential accommodation did not arise as a result of her mental health disorder, and it was also not aimed at preventing admission to hospital for treatment of this mental health disorder.  They said that the provision of residential accommodation was not part of aftercare services within the meaning of section 117, and therefore did not qualify for funding.
88. During a local resolution meeting on 27 November 2008 Miss M said that, contrary to the Trust’s assertions, the 1996 letter was not a letter of discharge and that her mother had not been formally discharged from aftercare services until 2005.  The Trust provided notes of the resolution meeting that Miss M says were not an accurate nor comprehensive record of the meeting.
89. Miss M made several complaints about the care given to her mother at the Care Home. The senior practitioner agreed to arrange a meeting between her, the manager and Miss M to try to resolve these concerns.  It took some time to agree a date but it was eventually arranged for December 2008.  However, the meeting did not go ahead because it was decided that Mrs M’s needs could be managed more appropriately by the Council’s ASC team (paragraph 2) than by the CMHT, and the case was referred to the ASC team in December 2008.  The senior practitioner has explained that it was not considered appropriate to proceed with the meeting because the ASC team were now responsible for managing the case.  Miss M says that the referral of the case to the ASC team deprived her of an opportunity to pursue her concerns: about her mother’s discharge from the CMHT; that her mother’s mental health needs were not being met; about the home’s high fees and the inadequate care provided for her mother at the Care Home; and that the transfer to the ASC team was inappropriate because of her ongoing complaint to the Trust.

The assessment of Mrs M’s needs by the ASC team in 2009

90. A social worker was appointed care manager for Mrs M on 6 January 2009.  She visited the Care Home on 13 January to carry out an assessment of Mrs M’s needs.  Miss M was unable to attend but the social worker met Mrs M and the workers supporting her.  Her notes record that Mrs M was mostly happy at the Care Home and considered it to be her home; and that although she would have liked to live closer to her daughter, she hated moving and would therefore prefer to remain at the Care Home.  The social worker noted that Mrs M’s general health was good and she was generally content.  She noted Mrs M’s history of mental illness, which she had been told had been stable for approximately four years.  She did not identify any significant issues in Mrs M’s placement, and concluded that it was appropriate for her needs.  The manager of the Care Home, who was present, agreed that Mrs M’s needs were fully met, but said the issues in respect of the fee increases needed to be resolved.
91. On 21 January 2009 Miss M complained about the assessment by the social worker.  She said that it was based on inadequate information and that there was no assessment of her mother’s ability to walk or care for herself.  She insisted that no further assessments be conducted unless she and her mother’s advocate were present.  The Council responded on 30 January 2009 to explain the background to the referral to the ASC team and the purpose of the assessment carried out. The Council said that the transfer was in Mrs M’s best interests because her physical needs outweighed her mental health needs, that the assessment was appropriate and in line with good practice, and that as they were now aware of Mrs M’s advocate, they would ensure that she was involved in any visits.  The Council concluded that there had been some misunderstandings, and that to ensure clear communication they would in future communicate with Miss M in writing.
92. Miss M remained dissatisfied with the Council’s response and wrote again on 13 February 2009.  She complained that the transfer of her mother’s care arose from the local resolution meeting, and that there had been no assessment of her mother’s health needs, which was unacceptable, given that her mental health needs were in dispute.  She complained that the assessment was not independent and had failed to consider properly her mother’s physical capabilities.  In response, the Council said that the assessment carried out was not intended to include a full assessment of her mother’s mental health, and maintained that the assessment was appropriate; but offered to arrange another assessment by a different social worker.  Miss M did not respond to this offer and a reassessment was not undertaken.
93. Miss M informed the Council that her mother’s savings had fallen below the threshold level.  The Council undertook a financial assessment in March 2009, following which it assumed responsibility for payment of Mrs M’s fees at the Care Home.
94. Miss M had first raised the possibility of her mother moving to another care home in June 2008.  At that time the senior practitioner at the CMHT had offered to assist in arranging the move to a care home close to London.  Miss M complains that although the Council’s social worker said that she would help in finding accommodation for Mrs M nearer to Miss M’s home (in London), no assistance was provided.  She says that when she asked for assistance the Council said it could not find a placement outside Wiltshire.
95. Councils are required to review care plans at six-monthly intervals.  The social worker wrote to Miss M on 13 July 2009 to invite her to a review meeting.  Miss M responded in a letter dated 31 July that she was unable to attend on the proposed date.  She did not ask for the review to be postponed.  The file notes record that the social worker discussed this response with her manager, who advised her to proceed with the review that was already overdue.  The review proceeded as planned on 4 August.
96. The social worker said that she contacted Mrs M’s advocate (whom she knew from work on other cases) by telephone to invite her to the review meeting.  The advocate was unable to attend.  The review, completed on 4 August, concluded that Mrs M was suitably placed at the Care Home.
97. Miss M said that the advocate told her that she had not been invited to the review meeting.  In response to our enquiries, the advocate reviewed her records and found no note that she had been invited.  However, she said it was possible that she had been invited but did not record it.  She said that, generally, social workers could be relied on to invite her to such reviews.  The advocate said that even if she had attended the review, she did not think the outcome would have been any different.  She said that she last saw Mrs M on 2 July 2009 and closed her case on 10 September.
98. Mrs M was admitted to hospital in September 2009 and sadly died there on 12 October.