What Health Commission Wales had to say
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In its formal comments to the Public Services Ombudsman for Wales, HCW said that anorexia nervosa is a complex condition and is extremely difficult to treat. It said that specialist in-patient treatments should only be used when the patient requires an intensive care package, and only as a holistic pattern of care before and after admission. It said that in-patient admissions should generally be short-term and said, too, that it is vital that the patient has access to support and care within the community following discharge, otherwise the in-patient treatment will not have any positive impact beyond the short- or immediate-term.
HCW commented that the quality and availability of local services in Wales is variable and in many cases does not meet the needs of patients with eating disorders. HCW said it had experienced many cases where significant investment in in-patient packages of care (sometimes costing more than £500,000 per patient) gave no long-term benefit to patients on discharge, as the local services (that is, the relevant local health board and community mental health services) failed to put in place appropriate packages of care. It said it therefore did its utmost to ensure that any in-patient admission occurred with the full commitment of local services to engage with the patient and provide appropriate aftercare.
HCW said that due to where Miss S normally lived, she would fall, in the first instance, within the remit of the Welsh Consultant’s team. HCW noted that Miss S was away from home when her health deteriorated; however, it considered it was still the Welsh Consultant who would have been responsible in the first instance for her care and for clinical advice.
HCW said it first became aware of Miss S’s case following telephone calls, and then the English Consultant’s letter of 4 December 2006 (dated 1 December 2006) requesting funding for a period of in-patient care at the EDU. HCW said the English Consultant had enclosed copies of her earlier correspondence with the Welsh Consultant. HCW had noted that the English Consultant’s team had felt strongly that Miss S should be transferred to Wales. HCW said this correspondence showed that the English Consultant’s team recognised the role of Miss S’s local (that is, the Welsh Consultant’s) team in managing the total treatment plan, but it noted that it had appeared that the Welsh Consultant felt unable to facilitate this. HCW noted that it was not made aware of the case when discussions were first taking place between the English Consultant and the Welsh Consultant.
HCW said it was clear from the English Consultant’s letter that further information was required, and in particular that it would be important to establish the position of the local services. It therefore asked the English Consultant to confirm the Welsh Consultant’s response to her earlier letter to him of 31 October 2006. It said it understood the Staff Grade Doctor had written to the Welsh Consultant asking him to confirm his position to HCW. HCW said that the Welsh Consultant’s letter was then received on 20 December 2006. It said that the Welsh Consultant stated that he was unable to offer suitable care and that he supported the English Consultant’s team’s funding request. HCW commented:
‘For [HCW] this was a serious deficiency in the care the patient required. Effectively, [HCW] was being asked to consider funding a period of in-patient care without identification of a clear treatment pathway or any support on discharge. [HCW’s] view was that this was in contradiction to NICE guidelines and the [Mental Health Act 1983] Code of Practice, and could lead to risk for the patient’s continuing health.’
HCW said it therefore wrote to the Welsh Consultant on 2 January 2007 reminding him of the commissioning criteria and requesting details of plans to develop a package of care to meet Miss S’s needs on discharge. HCW said that on reflection this letter could have been sent sooner, and it apologised for that. HCW said the Welsh Consultant replied on 3 January 2007 and stated that Miss S had refused a transfer for assessment. HCW noted that the letter contained no proposals about how Miss S’s needs might be met after her discharge.
HCW said the case was considered by its individual patient commissioning panel, which concluded that the absence of input from local services would significantly compromise any benefit gained from in-patient treatment. It noted that Miss S was at that time in a ‘place of safety’ – that is, a psychiatric unit. It said, too, that there was no clinical suggestion that Miss S’s health was gravely compromised, was unstable, or that the matter should be treated as an emergency. HCW said that its staff had made repeated attempts to contact the Welsh Consultant by telephone (we have seen no written confirmation of this on HCW’s file).
HCW said that its decision was conveyed to the Welsh Consultant on 11 January 2007 suggesting that Miss S be transferred to Cardiff for assessment. HCW said that that letter could have been worded better, and could instead have suggested that Miss S be assessed in situ by a member of the Cardiff team. It apologised for this not being made clear.
HCW said that it was informed on 11 January 2007 that Mrs S had elected to admit her daughter to the private centre. It said it understood Mrs S was very anxious about her daughter; however, it had been given no clinical indication at that time that Miss S’s condition had become critical. It said that if that had been the case, it would have acted differently. HCW said it should have been informed of any change in condition that might have affected its decision, but the clinicians involved did not do this. HCW said that, but for Miss S’s discharge to the private centre, it would have continued to liaise with local services to achieve a satisfactory outcome, and was in the process of doing so when it learnt Miss S had been transferred.
HCW said it was regrettable that it was not involved at an earlier stage when a transfer to Wales could have taken place with its attendant benefits. It recognised, however, that more robust communication was required with local services to avoid a repetition of the incident. It said that at the time the panel considered this case, HCW was in the process of meeting local services and local health boards across Wales to establish local network groups to work with HCW to create a cohesive care pathway for eating disorder patients. It said that the aim was to create local referral units to act as the point of contact for clinicians working with patients with an eating disorder. It said it also, as part of this work, aimed to develop contingency plans for the repatriation of patients admitted to healthcare services outside Wales. HCW apologised for the anxiety caused to Mrs S, and said that its Acting Chief Executive would write to her and Miss S with its apologies.
Subsequently, asked why it would not be possible for a plan of follow-up care to be arranged once a patient had been admitted to an in-patient facility, HCW said it was important to ensure that a patient ‘would have access to a whole pathway of care’ and, in particular, that links were formed between in-patient and out-patient providers to ensure that the patient would have access to appropriate care on discharge. HCW said that details of the ‘local services’ element of care could be formulated once a patient was admitted; however, it said that in this case there was no evidence that any contact had been made with local services, or any outline for the whole care pathway drawn up. HCW said that in addition, it was unclear in this case whether Miss S would ultimately decide to remain in south west England, or return to Wales. As a result, it had been uncertain which organisation would have been responsible for her care post-discharge.
