What the Trust had to say
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In its formal comments to the Public Services Ombudsman for Wales, the Trust said provision within its mental health service for eating disorder patients was limited. It said that the current position was that the treatment of such patients was led by community mental health teams, which included workers with varying degrees of expertise and interest in working with patients with eating disorders. It said that there was no specialist in-patient facility for patients with eating disorders within the Trust, and patients were therefore currently cared for in acute admissions wards at two sites. The Trust said its dietetic department also provided support, but this was not a specialist service, and was not separately funded for eating disorders.
Asked whether it had a specialist team or consultant specialising in the treatment of eating disorders, the Trust said that there was a limited service for patients suffering from bulimia nervosa. It said that this was an out-patient service provided by a consultant clinical psychologist one day per week. The Trust said that there was also a very limited unfunded psychological service providing out-patient cognitive behaviour therapy for patients with anorexic disorders who have a BMI of 15 or above. It said that only six patients could be seen at any one time due to the lack of a dedicated service. A consultant psychiatrist provided input for one session per week to assess patients, and there was also a whole-time-equivalent consultant clinical psychologist available for this work.
The Trust said that since November 2007 a small specialist steering group had been in operation, made up of one session from consultant psychiatrists with a special interest in eating disorders, one whole-time-equivalent clinical psychology post, and dietetic support. It said this steering group liaised closely with HCW, and met on a regular basis. The Trust said the steering group operated as a second opinion service for patients whom it was considered may require out-of-area treatment. It said relevant patients were assessed by this group, their needs were identified, and discussions then took place with HCW about specialist placement if that was necessary.
The Trust said that if the steering group had been in existence when Miss S was first referred by the PCT, it would have become involved in the case. It said Miss S’s case would have been taken to the second-opinion panel after being assessed by the identified consultant; a decision would then have been made jointly with HCW about how best to proceed.
Asked how patients requiring in-patient care were managed, and about the referral pathways to specialist care, the Trust acknowledged that before November 2007 the referral and decision making process had been unclear. It said that HCW had since reviewed its services and the situation had improved with the introduction of the second-opinion clinic. The Trust noted, however, that the amount of funding available for out-of-area in-patient beds remained limited.
When it was put to the Trust that one of the reasons given by HCW for turning down the funding request was that no post-discharge follow-up plan had been put in place, it said that it would have been difficult to provide a comprehensive follow-up care plan for a patient who had never been assessed by the service. The Trust said that from the correspondence on file, it appeared that there had been some doubt as to whether Miss S had intended to return to Wales. The Trust said it was therefore ‘confusing’ why it should be required to put in place a follow-up plan for a patient who had not been known to the service and who may not have been returning to the area.
In a written statement, the Welsh Consultant said that as far as he could ascertain, the first contact he had about the case was late in the afternoon of 26 October 2006, when he received a telephone call from the Staff Grade doctor. The Welsh Consultant recalled that the Staff Grade doctor requested the transfer of Miss S, who was ‘described as depressed, but whose symptoms were clearly those of anorexia nervosa’. The Welsh Consultant said he understood Miss S was refusing to eat and was either on, or being considered for, intravenous feeding. The Welsh Consultant said he did not feel the account given to him by the Staff Grade doctor was sufficiently accurate or detailed to allow him to accept the referral, and he therefore asked to speak to the patient’s consultant for further clarification.
The Welsh Consultant said that despite the inadequacy of the referral, the case was discussed by the ward team, and a bed made available subject to receiving adequate clarification from the English Consultant. The Welsh Consultant said that his team were extremely unhappy and concerned that the referral was ‘clearly inappropriate’ and that they had neither the therapeutic space nor the skilled staff required to manage a very ill anorexic patient.
The Welsh Consultant said that the next (and main) contact he had about the case occurred on 30 October 2006 (sic) when he had a telephone call from the English Consultant. The Welsh Consultant said that the English Consultant described a young lady with a clear and established eating disorder, who was losing weight fast and was in need of intravenous feeding and an urgent referral to a specialist eating disorder service. He noted that the eating disorder specialist who subsequently saw Miss S described her condition as that of ‘free-falling anorexia nervosa’. The Welsh Consultant said that the English Consultant had no doubt that Miss S was suffering from advanced anorexia nervosa and that she was in need of specialist, rather than general, psychiatric care.
The Welsh Consultant said he wrote strongly-worded letters in support of the case for urgent funding, and to facilitate the transfer of ‘a very ill lady’ to specialist in-patient care.
The Welsh Consultant said that he did not recall Miss S’s diagnosis of depression being raised as a primary issue of concern at any stage during or after the discussion he had with the English Consultant.
