Health Commission Wales
Jump to
Findings of the Public Services Ombudsman for Wales
It is clear from the evidence I have seen that the clinicians who were caring for Miss S in the south west of England were of the opinion that her condition was such that she required a period of in-patient treatment. The clinician who assessed her at the EDU also agreed that that would be appropriate. The Adviser has said that in his opinion Miss S required a period of in-patient treatment. I am entirely satisfied that that was the case.
I have considered whether the NHS should have paid for Miss S’s in-patient care. First, I should say that I have assumed that it is appropriate to regard Miss S as having been ordinarily resident in Wales throughout, given that before visiting the south west of England she lived and worked in south Wales and was registered with a GP there. The National Health Service Act 1977 placed a responsibility on the National Assembly for Wales (now the Welsh Ministers) to provide (to reasonable requirements) services for the treatment of illness. The Assembly delegated decisions about whether to fund in-patient care of patients with eating disorders to HCW, which has a policy (in draft at the time of the events complained about) that sets out its criteria for funding such treatment. Miss S had been assessed as requiring treatment, and the treatment being recommended was one which the NHS funds if certain criteria are met. In Miss S’s case this was a funding decision to be taken in Wales.
Normally, it would be expected that someone presenting with an eating disorder will undergo a period of out-patient treatment and, if that does not succeed, a funding request will be made by the patient’s consultant for a period of in-patient care. The same team will then usually be responsible for the patient’s care after he or she is discharged. However, this case was unusual in that Miss S first presented with her illness while she was away from home. As a result, she had not been assessed, or even seen, by the Welsh Consultant or his team. (Had this happened, and an aftercare plan been put in place, it is likely that Miss S’s treatment in the EDU, or a similar facility, would have been funded promptly by HCW and this complaint would never have arisen.)
However, that is not as matters stood, and I consider that HCW’s actions in this particular case were inflexible. While I acknowledge that no policy or procedure can cover every eventuality, it would have been open to HCW’s individual patient commissioning panel to have taken into account the obviously relevant factor that the reason Miss S had not been seen by her home clinicians was that she was not ‘at home’ when she presented with her illness. HCW has now said, in its comments on the draft report, that the panel does act flexibly when required. It has said, too, that in this specific case, the panel did consider all relevant factors; however, this is not reflected in the record of the panel’s deliberations (paragraph 35). It does seem to me that the evidence suggests that the panel did not take all relevant factors into account, and instead an overly prescriptive approach was taken. I consider that the inflexible approach in this case amounts to maladministration. I am particularly concerned that the panel did not appear willing to give weight to the opinion of the English clinicians who, after all, were directly involved in Miss S’s care, had assessed her in person, and were fully aware of the facts of the case. HCW says that it was not made fully aware of the severity of Miss S’s condition; however, there are letters to it from both the Welsh Consultant and English Consultant that set out the position. HCW says that its staff attempted, and failed, to get in contact with the Welsh Consultant by telephone, but there is no record of this on HCW’s files. HCW therefore failed, in terms of the Principles of Good Administration, to be sufficiently ‘customer focused’ to take account of Miss S’s particular circumstances.
While I note that HCW has since clarified that when it said Miss S should be assessed by a Welsh clinician, it would have been possible for the Welsh clinician to travel to the south west of England to do this, the letter it sent did imply that Miss S would be expected to return to Wales for assessment. It is not surprising that Miss S was reluctant to return to Wales for assessment given her physical and mental state. I am also concerned that the panel appears not to have considered the very relevant issue of whether it was in Miss S’s best interests to return to Wales at that point; not only because of her clinical condition, but also because her sources of support, in the form of family and friends, were in south west England, not Wales. I consider that the failure to take into account relevant information amounts to maladministration.
Turning to HCW’s requirement that arrangements for follow-up care should be in place before an in-patient admission can go ahead, I acknowledge the general logic behind this requirement, and that significant investment in in-patient treatment has previously been undermined by poor follow-up arrangements at the local level, over which HCW has no control. That said, I am not persuaded that Miss S should have lost her opportunity for in-patient treatment on the basis of HCW’s poor previous experiences, and because some local services may not have adequate follow-up arrangements in place. I am also mindful of the Adviser’s comment that before Miss S was admitted, it would only have been possible to make the most basic of discharge plans. I have no doubt that a robust aftercare plan would have been necessary in the longer term, and certainly before Miss S was discharged, but at the time of the issues complained about, it seems unlikely that anything more than a very brief plan, of limited value, could have been drawn up with the urgency that was needed.
In addition, it was unclear where Miss S might ultimately be discharged. She might have wanted to return directly to Wales or, alternatively, preferred to have been discharged to the south west of England where her sources of support were strongest. As mentioned above, this is an important consideration, and one which I note is mentioned in the Mental Health Act 1983 Code of Practice. It seems to me that, again, HCW was being unreasonably inflexible in insisting that a firm discharge plan be put in place before Miss S was admitted to an eating disorders unit. This demonstrates an excess of inflexibility in decision making, which I consider to be maladministration.
The Adviser has said, and I agree, that it would have been possible to have drawn up a plan (if that were required) which outlined that, on discharge, Miss S would have been cared for by a particular team in Wales or England, depending on where she ultimately decided to stay. This could have been revised over time as she moved closer to discharge, and arrangements made with the local funding body in the area where she was going to live. I cannot accept that Miss S should effectively have been penalised for not knowing (when she was frail and very poorly) where she would live after she was discharged. There will inevitably be patients who live (for example, for work reasons) in a different part of Wales, or indeed the United Kingdom, away from their family, and it is not unreasonable for them to want to be with their families when they are very ill or recovering from serious illness. I consider that in this particular case HCW has, unreasonably, failed to take into account this relevant issue when considering the funding request. I consider that this amounts to maladministration.
I have identified above a number of examples of maladministration on the part of HCW in this case. Later we explain how this led to injustice or hardship to Miss S and her mother. I uphold the complaint against HCW.
