Events leading to the complaint
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Miss S works for the Trust and lived in its area. In September 2006 she took some time off and went to stay with a friend in the south west of England. She attended an out-patients clinic on 28 September 2006, was diagnosed with depression, and was prescribed an antidepressant. She received out-patient care and was subsequently admitted informally to a general psychiatric ward, managed by the PCT, on 27 October 2006 due to increasing concerns about her low mood and the small amount she was eating and drinking.
On 31 October 2006 the PCT's notes include an entry stating that a staff grade doctor on the psychiatric team (the Staff Grade doctor) had telephoned the Trust and spoken to the Welsh Consultant. The note of the conversation in the PCT's records includes:
'Phone call made to [the Welsh Consultant] who stated they would not take anyone with an eating disorder. Explained to [the Welsh Consultant] that this was secondary to her primary problem which was low mood and fleeting suicidal thoughts. [The Welsh Consultant] not very helpful and stated he would only speak to the consultant ... and not to the people below her.'
Miss S's consultant psychiatrist at the PCT (the English Consultant) wrote to the Welsh Consultant on the same day asking him to 'arrange transfer of this lady's care to [the] Trust'. In her letter she explained that since her admission, Miss S was continuing to show symptoms of depression, and was only eating and drinking small amounts. She noted that Miss S's Body Mass Index (BMI) was 16.5. She concluded:
'[Miss S] presents with a moderate depressive illness and suicidal ideation. She is loosing [sic] weight and at times has failed to drink adequately. ... She denies any body image distortion necessary for a diagnosis of anorexia but she certainly has been avoiding fattening foods and is maintaining a low BMI although she denies any self induced vomiting, urging, or excessive exercise.
'[Miss S] would like to return to Wales where she is currently living. ... We do not feel that we would be able to discharge her ... to travel to Wales for purely out-patient treatment. Despite a lot of support here ... she required admission to hospital and if she were to return to her own accommodation she would be living on her own and we would have concerns as to her risk of self harm and neglect.
'Since admission to the ward, [Miss S] has eaten and drunk enough to maintain her weight at 47 kg and not to become dehydrated. ... Our hope is if her mood lifts in response to her increase of anti-depressant last week that things may improve enough for her to be maintained in the community rather than require admission to a specialist eating disorder unit.
'I understand that you have limited resources available for the treatment and supervision of patients with an eating disorder, but we feel that [Miss S] could be held within a PCLT [Primary Care Liaison Team - a non-specialist mental health team] setting. ... However we feel strongly that [Miss S's] care needs to be transferred back to Wales where she is resident and works.'
The Welsh Consultant decided not to accept the transfer request.
On 15 November 2006 Miss S was referred to the EDU for assessment. By this stage her BMI had fallen to 15.4. On 30 November 2006 the EDU wrote to the English Consultant's registrar to inform her that they would be prepared to admit Miss S subject to funding being secured.
The letter included:
'The [EDU's] clinical team consider [Miss S's] referral to a specialist eating disorders and inpatient service as appropriate and urgent given her rapid rate of weight loss and her current low BMI; plus her positive motivational state.'
On 1 December 2006 the English Consultant wrote to HCW's Case Administration Manager to request funding for Miss S's admission to the EDU. She explained that they were requesting funding from HCW as Miss S was resident in Wales and registered with a Welsh GP. Her letter noted that Miss S's main sources of social support were in the south west of England.
Following a telephone call from the Case Administration Manager, the English Consultant wrote to her again on 4 December 2006. She explained that they had approached the Welsh Consultant about transferring Miss S's care to him, but 'his view was that her needs would not be met in the acute inpatient unit in his area and he was therefore reluctant to transfer her'. On 5 December 2006 the Case Administration Manager faxed over a clinical pro forma for the team to complete.
On 12 December 2006 the Case Administration Manager contacted the Staff Grade doctor to say that Miss S should be transferred to the Welsh Consultant's team. The Staff Grade doctor wrote to the Welsh Consultant the same day. He noted that the Welsh Consultant had previously felt unable to manage Miss S on an acute in-patient ward. He said that Miss S's depression had improved, but her weight had continued to reduce since her admission. He explained that he had spoken to the Case Administration Manager, and that she had told him that HCW was not willing to fund Miss S's care until she had been transferred to the Welsh Consultant's team. The Staff Grade doctor said that if the Welsh Consultant felt unable to care for Miss S, he should explain this to the Case Administration Manager in writing.
The Welsh Consultant wrote to the Case Administration Manager on 14 December 2006. He explained that he had had no involvement in Miss S's care, as she had become ill whilst in south west England. He said that he had been asked to take on Miss S's care, but 'the transfer did not take place due to the deterioration in [Miss S's] health and the revision of her diagnosis to that of eating disorder'. He went on:
'As you may know, I am a general psychiatrist who works in a very busy generic adult psychiatric service. I have no specialist expertise in the treatment of eating disorders and no access to any of the specialist resources and trained staff that can manage patients with serious eating disorder safely and effectively.
'In common with [the English Consultant's] team, we feel that Miss [S]'s needs can no longer be met from within the generic adult psychiatric provision and that her current condition should be assessed and treated by a specialist eating disorder service. I believe that Miss [S] has already been referred and provisionally accepted for assessment by [the EDU] which is part of the NHS.
'As we are unable to provide Miss [S] ... with the specialist care that she urgently needs, and as there is no specialist eating disorder service in Wales, I wish to recommend that funding is made available to allow Miss [S] ... to be transferred to the [EDU] for further assessment and treatment as soon as possible.'
On 19 December 2006 solicitors instructed by Miss S wrote to the Case Administration Manager threatening legal action if HCW did not agree funding for Miss S's treatment at the EDU. HCW's Chief Executive replied on 20 December 2006. His letter concluded:
'To place the patient in the [EDU] would not be in her best interests as she clearly wishes to return to Wales. Therefore [HCW] recommends that the patient is transferred to Wales in order for local services to remain engaged with the patient and for local services to be fully involved in the patient's care pathway. [HCW] cannot be expected to cover for deficits in local services.'
On 2 January 2007 the Case Administration Manager wrote to the Welsh Consultant to outline HCW's criteria for commissioning in-patient treatment for eating disorders. She explained that it was necessary for the patient first to be referred to, and receive treatment from, the local area consultant psychiatrist. She then listed fourteen specific criteria for funding to be agreed (reproduced as an Annex to this report).
The Welsh Consultant wrote to the Case Administration Manager on 3 January 2007. He said he understood that Miss S's condition had deteriorated further, and he did not feel there was any way forward, other than for Miss S to be admitted to a specialist eating disorder unit. The English Consultant also wrote the same day in support of the application for funding.
HCW's individual patient commissioning panel considered the funding request on 4 January 2007, and decided not to agree to it. A pro forma on HCW's file records the reasons
for the decision as being: 'No formal connection to local services. No clear pathway identified with regards to future care and support'.
The PCT was informed of the decision by telephone later that day. On 6 January 2007 Miss S was discharged to the private eating disorder centre, where she remained until February 2008.
On 11 January 2007 the Case Administration Manager wrote to the Welsh Consultant to tell him formally the panel's decision. She reiterated (almost verbatim) the paragraph quoted above from the letter to Miss S's solicitors.
Mrs S subsequently submitted a number of complaints, both to the Welsh Minister for Health and Social Services and to the PCT. Mrs S was dissatisfied with the PCT's initial response to her complaint, so the PCT commissioned an independent investigation by the Medical Director and Assistant Director of Nursing of another Trust. They completed their report on 18 October 2007. It recommended (amongst other things not relevant to this investigation) that:
'Staff should inform senior managers through the normal line management system where a patient's care and welfare is being undermined by resource issues. Where these are not subsequently addressed and the patient's condition is continuing to deteriorate to a point where there are substantial risks to their welfare, the concerns should be brought to the attention of the chief executive. This would have enabled a discussion of how best the [PCT] should manage the immediate clinical governance issues with the funding authority and if necessary to consider whether a transfer to a specialist unit should be made and funded in the interim by the [PCT] whilst further negotiations occurred with [HCW].'
