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Selected Investigations Completed August 2001November 2001 > Part II, Case no. E.2280/98-99
Complaint against: Bournewood Community & Mental Health NHS Trust (the Trust)
Complaint as put by Mr and Mrs X:
1. The account of the complaint provided by Mr and Mrs X was that, since March 1994, they had been acting as paid carers of Mr Y who had severe learning disabilities and autism. Mr Y had previously been an inpatient at Botleys Park Hospital, Chertsey (which has since been renamed Bournewood Resource Centre) for 31 years. The hospital is managed by the Trust. On 22 July 1997 Mr Y was readmitted to the hospital after he became disturbed and began injuring himself at a day centre which he attended. Mr and Mrs X were concerned about the circumstances of Mr Y’s admission and continued detention at the hospital, and about the standard of his care and treatment. Mr Y was finally discharged back into their care on 5 December 1997. Mr and Mrs X raised their concerns with the Trust on several occasions both before and after Mr Y’s discharge, but remained dissatisfied with the explanations which they were given. Their later request for an independent review was refused by the Trust’s convener.
2. The complaints subject to investigation were that:
1.2. the clinical decision to admit Mr Y to the hospital on 22 July 1997 was unreasonable; and
1.3. the clinical management of his admission was inadequate.
Investigation
3. The statement of complaint for the investigation was issued on 14 March 2000. The Trust’s comments were obtained, and relevant documents were examined, including Mr Y’s clinical and psychology records. Evidence was taken from Mr and Mrs X and from Trust staff. Evidence was also taken from Mr Y’s care manager (the care manager) from Surrey Social Services Department, and from Mr Y’s current community nurse (the community nurse), who is employed by Surrey Hampshire Borders NHS Trust: their actions are not the subject of this investigation. Two professional assessors were appointed to advise on the clinical aspects of the complaint. Their report is at paragraph 25. A considerable amount of written evidence was submitted. I have not put into this report every detail investigated; but I am satisfied that nothing of significance has been overlooked. In the context of this investigation, ‘admission’ refers to the admission to hospital of Mr Y without his giving, or being able to give, valid consent; and with a view to assessing him and providing appropriate treatment. The investigation has not been concerned with question of whether the Trust’s actions were lawful: it has only been concerned with the question of whether the Trust acted reasonably in connection with the clinical aspects of Mr Y’s care.
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Chronology
4. I set out below certain key events.
22 July 1997
Mr Y was admitted to Villa 1 at the intensive behavioural unit (the IBU) at Bournewood Resource Centre, via the accident and emergency (A&E) department, following an incident at the day centre which he was attending.
23 July
The clinical director (learning disabilities) responsible for Mr Y’s care (the clinical director) wrote to Mr and Mrs X about the admission.
31 July
The clinical director wrote to Mr and Mrs X asking them not to visit Mr Y at present, and informing them that it was too early to give a date for his discharge. She asked for his clothes to brought in.
22 August
Mr and Mrs X wrote to the social services department expressing concern about the way in which Mr Y’s behaviour was handled on 22 July and that they were also concerned that he was becoming increasingly anxious and homesick.
22 August
An assessment, commissioned by West Surrey Health Authority, was carried out by an independent consultant psychiatrist in learning disabilities. His report, issued on 12 September, recommended that Mr Y should undergo further observation in an inpatient setting.
2 September
The clinical director wrote to Mr and Mrs X informing them that, following a post-admission meeting, it had emerged that Mr Y’s stay in hospital would be prolonged. She notified them of an individual care planning meeting arranged for 18 September and invited them to attend.
16 September
Mr and Mrs X wrote to the clinical director, stating that they were unable to attend the meeting as they were seeking legal advice about Mr Y’s position.
18 September
The individual care planning meeting took place.
9 October
A High Court hearing took place in which a writ of habeas corpus was sought on Mr Y’s behalf.
29 October
Following an Appeal Court ruling in relation to Mr Y’s informal admission, he was detained under Section 5(2), and then Section 3, of the Mental Health Act 1983.
31 October
A transitional care plan was issued. (Mr and Mrs X have stated that this plan was drawn up and issued by themselves.)
2 November
Mr and Mrs X visited Mr Y and considered him to be in a very poor state.
4 November
A meeting, attended by Mr and Mrs X, took place to agree a way forward which could lead to Mr Y’s safe discharge back into their care.
12 November
A care planning meeting was held to discuss Mr Y’s needs when he was discharged back to the care of Mr and Mrs X. The meeting was also attended by Mr and Mrs X.
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27 November
A set of behaviour management guidelines for Mr Y was issued by the Trust.
27 November
A report by two clinical lecturers in developmental psychiatry, commissioned by Mr and Mrs X’s solicitors, recommended that Mr Y be discharged from his section. This was commissioned specifically for a Mental Health Manager’s Hearing and a Mental Health Review Tribunal.
4 December
A multi-disciplinary care planning meeting was held. It was agreed that, subject to certain conditions, Mr Y would be discharged on a leave of absence under Section 17 of the Mental Health Act.
5 December
Mr Y was discharged to the care of Mr and Mrs X with a care plan and monitoring arrangements.
12 December
Following a Mental Health Act Managers’ review, Mr Y was formally discharged from his Section 3 detention.
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Mr and Mrs X’s evidence
5. Mr and Mrs X told the Ombudsman’s investigator that in March 1994 Mr Y was placed with them, as paid carers, under a ‘mentor resettlement programme’. The programme was initially operated by two separate organisations, but the Trust took over the administration of the scheme in 1995. As far as they were aware, all of the patients involved in the scheme, except Mr Y, eventually returned to the hospital. Mr Y’s placement with them was on a trial basis. He flourished in their care, and they were keen to secure his permanent discharge. However, despite review meetings no date for a formal discharge was ever set. They could see no reason why the Trust had constantly delayed Mr Y’s formal discharge as it was accepted that he had made considerable progress in their care. There had been some conflict between them and the Trust about Mr Y’s care, and they were required to implement a completely unrealistic care programme. They were also required to send Mr Y to a day centre one day a week. Although he did not like going, and he had to be sedated before being taken, the clinical director insisted that he went.
6. Mr and Mrs X confirmed that they were not contacted until later the same day that the incident took place on 22 July 1997. From what they understood, Mr Y’s outburst at the day centre which led to his readmission to hospital was no worse than on previous occasions. It appeared that he was disturbed by some new service users and started banging his head. They were not allowed to see him for a number of weeks after his admission, and neither was his specialist community nurse. They were very dissatisfied with Mr Y’s continued detention. When they were eventually allowed to visit him in November, they found him to be in a dreadful state emotionally and physically. His ward was kept locked despite later assurances that it was not. The clinical director had invited them to meet her, but they considered it futile to do so as it was clear to them that she had no intention of discharging Mr Y. They therefore applied for a manager’s review and a Mental Health Review Tribunal. In preparation for that they commissioned an independent report by two university lecturers in developmental psychiatry. They concluded that Mr Y should be discharged from his ‘section’. Mr Y returned home on Section 17 leave on 5 December and, following the manager’s review on 12 December, was formally discharged to their care and released from his ‘section’. He had lived happily with them since then.
7. Mr and Mrs X said that they believed that there had been a complete failure by the Trust in regard to Mr Y’s physical and emotional care, and there had been evidence of serious neglect. The care manager, who saw Mr Y on his return home to them, was also shocked by his appearance and wrote to the Trust seeking explanations. The Trust provided a report on Mr Y’s treatment, and accepted that there had been certain shortcomings. They detailed improvements which were being made as a result of the findings. Mr and Mrs X did not accept the explanations given, and put their own concerns to the Trust in September 1998. They remained dissatisfied with the Trust’s response and requested an independent review. That request was later refused by the Trust’s convener. Mr and Mrs X said that their main concerns were in relation to Mr Y’s detention; the failure of the system at Bournewood to provide for his needs; the physical and emotional neglect which resulted; and the delays in formally discharging him. They believed that Trust staff had conducted a campaign to discredit them as suitable carers.
8.On 16 March 2000 the Ombudsman’s investigator wrote to Mr and Mrs X stating:
‘…. When we met, you said that your key concerns were that there had been a complete failure of the system of care at Bournewood leading to Mr Y being physically and emotionally neglected; that there had been an unacceptable delay in discharging him formally to your care; and that the circumstances of his admission on 22 July 1997 and the delay in discharging him following that admission were unsatisfactory. You were also dissatisfied that neither you nor Mr Y had received an apology from the Trust. You said that, if the Ombudsman were to investigate your complaint, you would be content to leave to him the decision about which aspects merited his intervention.
‘With regard to Mr Y’s formal discharge, the Trust have acknowledged that there was an unacceptable delay, and I do not believe that an investigation by the Ombudsman into that issue would add a great deal to the explanations which you have already been given. The Ombudsman’s professional advisers are also of that view.
‘Turning to Mr Y’s basic nursing care during his admission between July and December 1997, I note that the Trust have addressed many of the issues raised and have accepted that there were shortcomings in the nursing care. As a result, they implemented an action plan to redress those shortcomings. I, and the Ombudsman’s professional advisers have therefore concluded that a re-examination of Mr Y’s basic nursing care, particularly in view of the passage of time since the events in question, would not add significant value to what you have already achieved by your own efforts.
‘I deal finally with Mr Y’s admission on 22 July, and subsequent detention. On the basis of professional advice received from the Ombudsman’s advisers, it is considered that an investigation into the admission decision per se and into the multi-disciplinary clinical issues surrounding Mr Y’s admission and management will be the most appropriate way of addressing your concerns. This will include such matters as the formulation of Mr Y'’s management plan, and the reasonableness and timeliness of the clinical decisions reached ….’.
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Evidence of the Social Services’ care manager
9.The care manager said that Mr Y was referred to her in May 1994 when he was on trial leave with Mr and Mrs X. Her role was to carry out a holistic assessment, to put in place a care package and to refer to other agencies if necessary. She visited Mr Y every six to eight weeks and had regular telephone contact with Mr and Mrs X. A community nurse also visited every six weeks, although there were periods when no nurse was allocated to visit. The care manager did not consider that families involved in the adult placement scheme were supported adequately by the Trust; and all placements, except Mr Y’s, eventually failed. She had difficulty in securing a psychologist to see Mr Y, and the approach by the Trust’s psychology department was seen by Mr and Mrs X as threatening. The care manager gained the impression that the psychologists thought that people like Mr Y should not be living in the community. Although Mr Y was still formally a patient of the Trust, he was not provided with a full service, and the clinical director made no home visits for two years.
10. The care manager said that the Trust laid down a number of conditions before they would consider discharging Mr Y into Mr and Mrs X’s care permanently. One was that Mr Y attended a structured activity outside his home environment, even though she considered that this was contra-indicated by Mr Y’s autism and his inability to deal with change. As a compromise, it was arranged for him to attend the day centre one day a week. The Trust had since suggested that there had been a slow build up of behavioural difficulties before the incident at the day centre on 22 July 1997. The care manager had not been aware of that. She was aware, however, that Mr Y had certain behaviours that could prove challenging at certain times of the year. At about mid-morning on 22 July the day centre staff contacted her. They said that Mr Y had become agitated, and that they could not calm him. Further calls reported escalating agitation, and the staff said that they had been unable to contact Mr and Mrs X. She did not go to the day centre as they had contacted her for information only. Following advice from a mental health outreach team, she asked Mr Y’s general practitioner (GP) to attend the day centre; but, because of boundary constraints, a GP in the day centre area (who did not know Mr Y) went to see him. Medication given by the GP failed to calm him down completely, and he was therefore referred to the hospital’s A&E department. She contacted the Trust at about lunchtime to let them know the position.
11. The care manager understood that, on arrival at the A&E department, Mr Y was seen by medical staff and a staff grade psychiatrist (the psychiatrist), who decided to admit him to Villa 1 at the IBU. She was not content about the admission; but it was a clinical decision and she felt that she could not argue against it. The clinical director later said that the admission was made on the recommendation of the care manager, but that was not so: she made no such recommendation. She was under the impression that Mr Y was being admitted only overnight for observation. She went to see Mr Y at about 6.00pm on the evening of his admission and agreed with the clinical director that Mr and Mrs X should not visit that evening. She thought that they could visit the following day. In the event, it was some time before they were allowed to visit him, and Mr Y’s community nurse was unable to visit for a week. In that respect there was a clash between the medical and social perceptions. The medical perception was that visits were inappropriate because of possible distress; but that approach failed to take account of social needs. She went on leave immediately after Mr Y’s admission; but, before doing so she wrote to the Trust with her observations. On return from leave, although she had difficulty gaining access to Mr Y, she was able to visit him as she had a role in a closure programme being operated by the Trust. The clinical director believed that Mr Y had an underlying health need. However, the care manager considered that the most appropriate place for an assessment to take place was in the home environment, not in a medical setting. She also had concerns about the Trust’s ability to draw on assessments from a wide range of sources and she pressed for a post-admission review.
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12. The care manager said that, at first, Mr Y settled in hospital. He then started to become increasingly distressed. She thought that could have been due to his change of environment. Although in theory Villa 1 was an unlocked ward, in practice it was locked most of the time because some of the patients would otherwise have wandered off. She was concerned about the standard of care and type of medication Mr Y was receiving: the staff were giving basic care for an acute mental health need rather than providing assessment. It was not until the post-admission review took place a month after Mr Y’s admission that she was able to convey to the staff details of his needs, likes and dislikes, methods of communication and so on. She considered the care provided to Mr Y at the hospital to be of a generally poor standard which could not possibly match that provided by Mr and Mrs X. There had been disputes between Mr and Mrs X and Trust staff; and she was aware of a lack of trust between them. After Mr Y was detained under the Mental Health Act, she chaired a number of meetings in order to help secure his discharge. These resulted in a care plan finally being put in place. At a meeting held on 4 November 1997, which was attended by all interested parties, Trust staff said that they would not discharge Mr Y without certain conditions being met. These included adherence by Mr and Mrs X to intensive behavioural guidelines relating to Mr Y’s care. However, those guidelines were hospital based, and would not translate to the home environment. In order to resolve matters she advised Mr and Mrs X to accept the conditions and to see how they got on with them. She recalled that, at that meeting, the clinical psychologist stated that she thought that people with severe autism should not be living in the community.
Evidence from the community nurse
13. The community nurse said that there was a ‘chasm’ between Mr and Mrs X and Trust staff as to how Mr Y should be cared for after the incident at the day centre. She did not believe that he should have been admitted and thought that he should have been discharged quickly. There was no doubt that the care given to him by Mr and Mrs X was ‘wonderful’. The community nurse said that she had been unable to visit Mr Y for the first week of his admission, but was allowed to do so after that. The ward was locked most of the time. In relation to Mr and Mrs X’s alleged lack of co-operation with Trust staff, the community nurse confirmed that, after Mr Y’s admission they had given her information on his daily routine, which she passed onto the Trust. At this remove she could not recall any instances of deliberate non-cooperation although there was clearly a lack of trust between the parties.
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The Trust’s response
14. In her formal response to the Ombudsman the Trust’s chief executive wrote:
‘…. On the two key points you wish to investigate, we would not consider either to be justified. The decision to admit Mr Y on 22 July 1997 for assessment and treatment of his mental health needs was subsequently endorsed by second medical opinion and found reasonable. I would refer you to the Trust’s Internal Review which sets out fully the circumstances which led to this emergency admission following a violent episode at the Day Centre.
‘However, whilst clinically appropriate the Trust concluded …. that:
“The circumstances surrounding the emergency admission and treatment of Mr Y were unusual and unlikely to be repeated. Distinctly the Trust was managing a contract with paid carers of an individual who had never been formally discharged …… Whilst Trust clinicians had some doubts about the appropriateness of Mr & Mrs X as carers, relationships between the two parties were never good …… it has to be questioned whether given past history and the transitional nature of the Villa 1 Service and its pending closure, if admission to the Bournewood service was the best option available or whether treatment in another unit should have been sought from the outset.”
‘Equally, although as our own Review and response to the complaint acknowledged, and for which regret was expressed, there were some shortcomings in Mr Y'’s overall care management, particularly in some elements of basic physical nursing care, the programme of treatment for his mental disorder was considered appropriate ….’.
15. Later in the investigation the chief executive wrote that all other patients who were transferred as part of the original ‘mentorship’ programme were subsequently found community placements after the Trust took over administration of the scheme. She also said that differences over funding between other agencies contributed to the delay in Mr Y’s formal discharge. The chief executive also wrote that there were no restrictions on Mr Y’s community nurse being allowed to visit him, and that Mr and Mrs X were encouraged to make contact, although they were at first advised that visits should be controlled for clinical reasons. There were times when the IBU was locked in order to protect patients, but it was a lockable rather than a locked facility.
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Trust staff evidence
16. The psychiatrist said that the clinical director asked him to see Mr Y when he arrived at the A&E department on 22 July 1997. He found Mr Y to be very agitated, and he had been punching himself. He clearly had severe learning difficulties and had no speech. He had been seen by a casualty officer and had no serious physical condition. The only information available was that given by a member of the day centre staff, who arrived with Mr Y. The psychiatrist said that he would have had access to Mr Y’s clinical notes; but at that time it was difficult to tell whether he had a psychiatric condition or a behavioural problem. He therefore decided to admit Mr Y for a period of observation in relation to a possible head injury. At that point he did not anticipate that Mr Y would remain in hospital for long, provided he settled down. He and the clinical director thought it best that Mr and Mrs X did not visit Mr Y for a while in case he wanted to go home with them. Mr and Mrs X were invited to come in to provide background information and to be involved in Mr Y’s care and discharge planning, but they declined to do so.
17. The psychiatrist accepted that it took a long time to finalise Mr Y’s care plans. He said that that was partly due to the lack of involvement of his carers. Mr and Mrs X went to some meetings but did not attend others. They were not satisfied with the final behaviour management guidelines, and wanted to ‘do their own thing’. The psychiatrist did not consider that the care plan provided for Mr and Mrs X was long: it was typical of a normal care plan. The Trust did not operate the national Care Programme Approach system and their Individual Programme Plan (IPP) was their own version of that. He saw Mr Y on a regular basis when he was in hospital, and he was satisfied that the interim management guidelines had been adhered to.
18. A clinical psychologist (the psychologist) said that she had had no direct involvement in Mr Y’s care until after his admission on 22 July 1997. The day after Mr Y’s admission the clinical director sent a referral to her and she asked a trainee clinical psychologist to see him in order to collect data to inform the psychiatrists. The trainee was working under the supervision of a senior clinical psychologist. Prior to that the only psychology involvement had been when a trainee clinical psychologist had visited Mr Y at home with Mr and Mrs X in 1996. At that time an assessment was started but was later discontinued because of Mrs X’s objections. Three visits had been made without difficulty; but, on a fourth visit, Mrs X had been abusive and objected to the involvement of the psychology services. The psychologist said that she had some reservations about Mr and Mrs X’s suitability as carers. When it became clear that Mr Y was not settling, she attended a multi-disciplinary meeting at which it was thought that a comprehensive assessment of Mr Y’s needs was necessary. As a result, an IPP review took place on 18 September 1997, which she chaired. It was decided at that meeting to draft a set of behavioural guidelines. As she had no staff to whom she could allocate the task, she undertook it herself in her spare time. As a consequence it took some time to complete the guidelines. They incorporated contributions from other disciplines, including speech therapy and nursing. She asked for Mr Y’s care routine to be obtained from Mr and Mrs X, as she wanted to ascertain whether the episode at the day centre was out of the ordinary. Mr and Mrs X were required under their contract with the Trust to keep a diary of Mr Y’s daily routine and make it available on request. However they were not willing to release their diary relating to Mr Y’s progress. She was not aware that they had offered to show the diaries to a member of staff at their home. The guidelines were not finalised until 27 November. However, a transitional care plan was issued on 31 October.
19. The psychologist said that, on 4 November (before the guidelines were finalised), a meeting was held with Mr and Mrs X. It focussed on the need to bring all parties together to agree on the overall care plan and programme for discharge. She found the meeting difficult as people not directly concerned with Mr Y’s care attended, and she was concerned about confidentiality. She had floated the idea that people such as Mr Y did better in a group home, but she did not say that she thought he should be discharged into such an environment. When the guidelines had been completed she considered that a further meeting was necessary in order to discuss them, as they needed to be amended to reflect home care as against care in hospital. The meeting took place on 4 December immediately prior to Mr Y’s leave of absence. It was arranged to discuss Mr Y’s home leave and overall care plan. The psychologist took the opportunity at the meeting to indicate that the guidelines would probably need amending to reflect the home environment. Following Mr Y’s final discharge two appointments were made to review his progress. The first was kept by Mr and Mrs X, but they cancelled the second. The psychologist said that although Mr and Mrs X had a contractual relationship with the Trust, they seemed to have difficulty separating their personal interests from their contractual obligations.
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20. A charge nurse, who was at the IBU at the time of Mr Y’s admission, said that Mr Y was very agitated when he arrived on 22 July 1997. He was punching his temples and was bruised. Although Mr Y’s care plan took some time to finalise, an initial ward-based plan was implemented fairly quickly. Mr Y remained disturbed for most of his stay at the IBU. Mr and Mrs X telephoned the IBU every day when Mr Y was first admitted, and the charge nurse usually spoke to them personally. When Mr and Mrs X later visited Mr Y they did not share information with the charge nurse. He said that he was involved in drawing up guidelines for Mr Y’s management. He explained that the care plan took a long time to develop as it was a comprehensive document involving several disciplines. He was aware that Mr and Mrs X felt that the guidelines were too structured, but they were aimed towards encouraging a consistent approach to Mr Y’s daily routine. They were intended to be reviewed by the community team and would be changed if necessary.
21. The clinical director said that she had been Mr Y’s responsible consultant since his admission in July 1997; before then she had last seen him in June 1996. On 22 July she was contacted by the day centre, and then by the care manager who told her about a serious incident in which Mr Y had become very disturbed and had harmed himself and assaulted others. It had been necessary to send him to the A&E department. The care manager had said that she had been concerned about Mr Y’s deteriorating condition of late. The clinical director had previously been made aware of that. After being told about the incident she tried to contact Mr and Mrs X several times without success. She therefore arranged for the psychiatrist to assess him. Mr Y was still very disturbed; and after further discussion with the psychiatrist and the care manager, it was decided to admit Mr Y to the IBU. The decision was not taken lightly as another patient had to be moved out to make room for him. She could not be sure at that time whether Mr Y’s continuing disturbed behaviour was due, in part, to his changed environment.
22. The clinical director said that immediately following Mr Y’s admission she had a long discussion with the care manager, and it was agreed that it would be advisable for Mr and Mrs X not to visit him for a few days in order to give him time to settle down. She wrote to Mr and Mrs X confirming the position and inviting them to make contact to discuss Mr Y’s treatment plan and to begin phased visits. However, they did not take up that, or subsequent invitations to meet her. Her plan was to investigate in depth Mr Y’s condition with a view to preparing him for return to Mr and Mrs X’s care. Although there were some reservations about them as carers, there was no evidence of any serious difficulties. Because of Mr and Mrs X’s lack of co-operation, it had been difficult to obtain a full background. It had been a time-consuming task carrying out a full assessment and drafting a care plan. However, a care plan was agreed at a review meeting in September, and an interim plan had been available from the first week of Mr Y’s admission. At a meeting on 27 November Mr and Mrs X raised concerns about the behavioural guidelines and the psychologist discussed those with them. Provisions were made for the final guidelines to be reviewed to reflect the home environment. On 5 December Mr Y went on Section 17 home leave to Mr and Mrs X and after a Manager’s Review on 12 December he was discharged from his section and fully discharged home to them. Given the available resources, she had been content with the overall care provided for Mr Y between July and December 1997.
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Further evidence of Mr and Mrs X
23. Late in the investigation Mr and Mrs X made a number of observations. For example, they stated that the clinical director made no home visits at all to Mr Y. They wrote that they did try to speak by telephone to the clinical director over the first few days of Mr Y’s admission but she did not return their calls. They subsequently discussed the position with the care manager and embarked on finding suitably qualified representation. Various parties they contacted did not receive a satisfactory explanation for the clinical director’s actions. Mr and Mrs X also stated that the only meeting they did not attend which they had been invited to was on 18 September 1997; and that Mr Y’s daily routine (paragraph 18) was issued by themselves for inclusion in the guidelines but was completely ignored by the psychologist. At the time of Mr Y’s admission nobody from the Trust approached them for information regarding him, and their offers of help were rejected.
24. In regard to the psychologist’s evidence (paragraph 19) that she had floated the idea that Mr Y did better in a group home, Mr and Mrs X referred to their solicitor’s note of the meeting in which the psychologist is reported as saying ‘I think he should have gone into a group home setting’. As for the psychologist’s evidence that they cancelled a second appointment following Mr Y’s discharge (paragraph 19) they pointed out that by then Mr Y was under the care of another NHS Trust and attended appointments with them. In regard to the charge nurse’s evidence (paragraph 20) Mr and Mrs X said that they had been shocked to find that views expressed at meetings were entirely contradictory to those he had previously shared with them. Mr and Mrs X also challenged the clinical director’s evidence (paragraph 21) that she was contacted by the day centre, that Mr Y had assaulted others and that his condition had been deteriorating. Those statements were not borne out by accounts given by other people.
25. I set out in this paragraph the report of the Ombudsman’s independent professional assessors.
Report of the Professional Assessors to the Health Service Ombudsman for England on the clinical decision to admit Mr Y to the IBU of the Trust on 22 July 1997 and on his clinical management thereafter with respect to the complaint made by Mr and Mrs X .
Professional Assessors: Consultant Clinical Psychologist and Clinical; Director for Psychological Services; Consultant in Forensic Psychiatry and Learning Disability.
1.3.1. This report is based on the documentation provided and on interviews held at Bournewood. Evidence has also been taken from the carers, Mr and Mrs X, the care manager, the psychologist, the clinical director and the psychiatrist.
1.3.2. The matters subject to investigation were:
1.3.2.1.1. that the decision to admit Mr Y to the IBU on 22 July 1997 was unreasonable; and
1.3.2.1.2. that the management of his case following admission was inadequate.
1.3.3. In so far as it has been possible we have limited our report to the two matters mentioned above. We feel that it is necessary to make comment on the context of the care, including the actions of some of the key players.
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Background
1.3.4. Mr Y was born on 23 February 1949. He has a severe learning disability and a diagnosis of Autism was made in 1956. He was first admitted to hospital care when aged 14. In March 1994 he left what was then Homewood Trust as part of its closure programme and was placed in the care of Mr and Mrs X. He attended the day centre from September 1995.
1.3.5. From the start there has been confusion and conflict with respect to the financial and contractual arrangements regarding Mr Y, and these surfaced many times in the documentation. It is clear that these disputes and uncertainties have been a factor in the poor relationship between Mr and Mrs X and what is now Bournewood Community and Mental Health NHS Trust.
1.3.6. Linked to the confusion over the contractual arrangements for Mr Y’s care was also a lack of clarity over who was responsible for his clinical care, and we feel that this also contributed to the problem. If the contractual arrangements had been sorted out, then his clinical care would have transferred to learning disability services in the area in which he lived with Mr and Mrs X. It is obvious that Mr and Mrs X are very committed to Mr Y and are able to provide him with a significantly better quality of life than he had before being admitted to their care. The diary extracts we have seen indicate a remarkable degree of personal commitment.
1.3.7. On 22 July 1997 Mr Y became agitated on the bus on the way to the day centre, and following his arrival his agitation increased. Reports of staff there indicate that they were unable to deal with this, and they contacted the team manager, who contacted Mr Y’s care manager. She initiated a sequence of events which led to him being given a sedative by a GP at 11.30 am and then being taken by ambulance to the accident and emergency department. Staff from Bournewood were summoned and the psychiatrist attended. Mr Y was transferred to the IBU shortly after 12 o’clock.
1.3.8. There appears to be some evidence that Mr Y’s behaviour at the day centre, and possibly at home (with Mr and Mrs X), had been challenging on occasions for at least some months prior to 22 July. However it does appear that the incident on 22 July was more extreme than the day centre were used to.
1.3.9. Mr Y’s admission to the IBU was expected by all parties to be relatively brief, but over time it became obvious that he would not be discharged and returned to Mr and Mrs X in the short term, and that his stay was going to be a prolonged one. In fact he was not discharged until 5 December 1997. During his time at the IBU there were disputes about the nature of his detention, his physical and nursing care, and the nature of his clinical management. It is these matters which have resulted in the present complaints.
1.3.10. Having outlined in brief the chronology of events which led up to his admission to the IBU we will structure the next part of this report around the matters subject to investigation.
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The Care Programme: 22 July 1997
1.3.11. The relationship between Mr and Mrs X and Bournewood had a long history of disagreements. Part of this was caused by the organisation which originally administered the contracts for failing to arrange a formal discharge for Mr Y, and also the requirement that Mr Y had to attend a day centre for at least one day per week. In the carers’ opinion he did not enjoy going to the day centre and they could see no reason for him to attend.
1.3.12. Mr and Mrs X had particularly poor relationships with the Trust’s clinical psychology department. In 1996 a trainee clinical psychologist had visited Mr Y at home on three occasions, but on a fourth occasion Mrs X objected to the assessment process. From the reports we have seen in the clinical psychology notes, Mrs X had refused to participate in a psychological assessment and had been verbally aggressive and insulting to the trainee clinical psychologist who was attempting to carry out the assessment, accusing her of not being good at her job. However Mr and Mrs X say that the problem was that Mr Y was upset by the psychology assessment.
1.3.13. In her interview with the investigator and the professional assessors the clinical psychologist said that, prior to the admission on 22 July 1997, she had some reservations about Mr and Mrs Xs’ suitability as paid carers for Mr Y. The clinical psychology notes of April-May 1996 indicate that Mrs X was unwilling to accept the traditional approach of most health professionals with regard to assessing and understanding the challenging behaviour which was being shown by Mr Y. According to the notes Mrs X believed that Mr Y knew her thoughts even when her non-verbal communication was neutral, and that his behaviour was influenced by the phases of the moon. (The care manager confirmed that his behaviour changed at certain times of the year). These beliefs, taken together with Mrs X’s general attitude to any formal assessment procedures – she believed that they made Mr Y’s behaviour worse – have almost certainly contributed to the view of a number of clinicians that there were doubts about Mrs X’s suitability as a paid carer for Mr Y.
1.3.14. The designated care manager for Mr Y was responsible for co-ordinating all aspects of his care. Clearly she had a key role in dealing with Mr and Mrs X, the day centre and the IBU. In an interview with the investigator, she described her involvement as visiting Mr Y every six to eight weeks and having regular telephone contact with Mr and Mrs X.
1.3.15. In her evidence the care manager said that she was not aware of any problems with Mr Y prior to the incident on 22 July 1997 and that she saw no evidence of a build up of behavioural difficulties before the incident. She challenged the Trust staff’s view that Mr Y had deteriorated in the period of time before the incident, and asked how they would be in a position to know since they had rarely visited him and had not consulted her. She did go on to say, however, that she was aware that Mr Y had more problems at certain times of the year, and in a letter to the clinical director dated 20 August 1997 she wrote that she had “shared with you on a number of occasions incidents and situations that I have become aware of when visiting [Mr Y] to monitor his progress.” She further said that the day centre staff had given no indication that they could not cope with Mr Y.
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The decision to admit on 22nd July 1997.
1.3.16. In a letter of 22 July 1997 to Mr Y’s cousin, the clinical director informed her that Mr Y had had to be readmitted due to a reported major crisis at the day centre. He was said to have been extremely and increasingly distressed, as a result of which he had to go to hospital for treatment. She stated that “we have all tried to contact Mr and Mrs X and unfortunately they are unavailable”.
1.3.17. The care manager was contacted at 10.10 am on 22 July by the team manager, and was fully involved in the events which led to his admission to the IBU. The care manager said in her interview with the investigator that it was a clinical decision with which she could not argue, and that she did not oppose the decision to admit because she had no authority to do so. She said further that she was under the impression that Mr Y was being admitted overnight for observation. She went on leave immediately after the admission but before doing so wrote to the Trust with her observations.
Management following admission
(a) The relationship between the Trust and the carers.
1.3.18. Once Mr Y was admitted to the IBU a decision was made by the Bournewood clinical team that Mr and Mrs X should not visit him. The care manager told the investigator that she had agreed with the clinical director that Mr and Mrs X should not visit that first evening but thought that they should go and see him the next day. However, in letters of 24 July to Mr and Mrs X and to the manager of the community team for people with learning disabilities (the manager) she confirmed that she supported the decision not to allow visits by Mr and Mrs X on the grounds that it would upset Mr Y. In her letter to the manager she wrote “I am happy with the suggestion that the community nurse take clothing up to Villa 1b if that would help support Mr and Mrs X, and to avoid a possible distressing situation to [Mr Y] should he accidentally see them and be confused by their presence.” In her letter to Mr and Mrs X that same day she wrote “With regards visiting [Mr Y] while on Villa 1b you will need to discuss this with the staff grade psychiatrist. Personally, though I appreciate how difficult it is for you not visiting, I am also aware that [Mr Y] may not understand what is happening if you visit and leave without him. This could cause [Mr Y] such distress that the agitation and stress might prolong his stay on the villa.”
1.3.19. It would appear that Mr and Mrs X did not immediately raise strong objections to Mr Y’s admission to the IBU on 22 July. They were not contactable until sometime after the incident, when the assistant team manager from the Day Centre made contact by telephone with Mrs X at 1.00 pm. By this time Mr Y was already at Bournewood. Their interpretation of the incident at the day centre, as explained to the investigator, is that it was no worse than the day centre had experienced before. They were very unhappy at being told they would not be allowed to see him for some time after his admission, but they were presumably reassured by the care manager on the telephone and in writing (24 July 1997) that not seeing Mr Y was in his own best interests and that his stay would be relatively short.
1.3.20. It became apparent to them, however, that Bournewood was not willing to discharge Mr Y home, and they were eventually told in a letter from the clinical director (2 September 1997) that his stay would be prolonged. They became increasingly frustrated by this and on 18 September consulted a solicitor.
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(b) The Psychological assessment
1.3.22. The psychologist was not directly involved in the admission on 22 July 1997. A formal referral was made to the clinical psychology department on 23 July 1997 but it was some time before psychology staff were able to respond. The psychologist made it clear to us that this was because of a chronic staff shortage, with there being insufficient suitably qualified and experienced clinical psychologists available at the time to undertake a fast response assessment and treatment service. The psychologist was head of special psychology services and took it upon herself to respond to the referral in what she has described as her “own time.”
1.3.23. The psychology assessment and formulation was also to include the contributions from speech and language therapy and nursing, which also accounted for some of the delay. However, the first full meeting of professionals to discuss the formal assessment did not take place until 12 September 1997, chaired by the psychologist, almost two months after the admission. At that meeting it was decided to draft a set of behavioural guidelines for Mr and Mrs X to follow. A transitional care plan was issued on 31 October, but the guidelines themselves were not finalised until 27 November 1997.
1.3.24. An important part of any assessment is a good history of the person, including accurate descriptions of what their behaviour has been like in the preceding days and weeks. The psychologist requested information from Mr and Mrs X, via those staff in contact with them, but it became clear that they were unwilling to release their diaries, or engage meaningfully with Bournewood. This is understandable given the history of the psychological assessment in April-May 1996, but the result was that important information was not available. However, it seems that details of Mr Y’s daily routine were passed to the Trust via the community nurse (paragraph 13)
1.3.25. There was no indication of whether or not Mr Y had been challenging at home; whether any challenging behaviour was similar to that being experienced by the hospital; whether the frequency of difficult behaviour was similar; whether there were different behaviours present in one setting than another; and so on.
1.3.26. The psychological formulation was therefore less of a comprehensive functional assessment than it might have been had there been full co-operation from Mr and Mrs X. The clinical formulation, presented in the behavioural guidelines for the staff and carers, which should be an analysis of the precipitating factors and functions for Mr Y’s behaviour, is largely speculative and not particularly related directly to Mr Y. Rather it relates to any person with the sort of diagnosis presented by Mr Y.
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(c) The behaviour guidelines
1.3.27. The behaviour management guidelines are very detailed and consist of a series of instructions to carers concerning Mr Y’s daily routine. In all they encompass more than 40 pages. Mr and Mrs X have always resisted such detailed guidance, but say that they agreed to implement it. Under these circumstances it might have been better not to have produced such detailed guidance but to have found ways of talking to Mr and Mrs X about the psychological aspects of Mr Y’s care in a way which allowed them to use procedures acceptable to them. Clearly the psychologist would have been unable to have done this, given the poor relations with Mr and Mrs X, nor would the clinical director for similar reasons. It appears also that Mr and Mrs X’s relations with the community nurse did not extend to accepting advice about how to analyse Mr Y’s behaviour.
1.3.28. With respect to the timeliness of the behaviour management guidelines which were eventually produced (dated 27 November 1997) these should undoubtedly have been produced earlier. We accept that there was not enough resource in the clinical psychology department, but also the extremely poor relationship between clinical psychologists and Mr and Mrs X probably was a contributory factor. If the guidelines had been produced earlier, then Mr Y’s discharge home would have been expedited.
(d) Co-ordination of the care plan.
1.3.29. The responsibility for developing and co-ordinating the inpatient care plan lay with the clinical director. During the course of the admission she wrote to many of the individuals involved in this case. We cite some of this correspondence since it illustrates her role as the main clinician co-ordinating Mr Y’s care, and charts the attempt to develop a coherent plan of care. They also demonstrate that the clinical director made considerable effort to engage Mr and Mrs X whilst maintaining the necessity of Mr Y remaining an inpatient.
1.3.30. The clinical director’s letter of 22 July 1997 to Mr Y’s cousin, informed her that Mr Y had had to be readmitted due to a reported major crisis at the day centre. He was said to have been extremely and increasingly distressed, as a result of which he had to go to hospital for treatment. She stated that “we have all tried to contact Mr & Mrs X and unfortunately they are unavailable”.
1.3.31. In a letter of 23 July to Mr and Mrs X, the clinical director informed them of Mr Y’s admission, stating that he had been assessed at the Accident and Emergency department by the staff grade psychiatrist covering the challenging behavioural services, and by staff from Villa 1, as a result of which the decision was made to admit him to Villa 1 immediately. She stated that she saw him early that morning and that he appeared comfortable and was said to have complied with all the care plan needs, not showing any agitation as a result of the change in environment. She stated that she was aware that the care manager had explained to Mr and Mrs X that it would be wise for them not to visit Mr Y until the staff felt that it would be appropriate for them to do so.
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1.3.32. On 23 July the clinical director wrote to a speech therapist, the clinical psychologist, an occupational therapist, and a home leader, with copies to other involved professionals, asking for their early assessment with a view for further recommendations for Mr Y’s care plan.
1.3.33. A letter of 28 July 1997 from the secretary to the psychology department, to the clinical director indicated that the referral had been allocated to a clinical psychologist in training under the supervision of the psychologist. It indicated that it was hoped that the referral would be acted upon by the end of the month.
1.3.34. A letter of 31 July from the clinical director to Mr and Mrs X referred to their raising queries with members of staff and the clinical director’s wish to avoid misunderstandings. She stated that Mr Y was keeping well and that there had been very few minor incidents and restless (not disturbed or aggressive) behaviour. She advised, following discussion with the charge nurse on the Villa, that visits be deferred for a further week, as the staff were arriving at the serious observational stage of their assessment. She emphasised that this should not been seen as punitive. She also confirmed that various clinical tests, for example blood, x-rays, EEG scan, would be organised to rule out any physical problems. She emphasised that setting a definite date for a discharge was not at that stage feasible. She referred to confusion about clothing and that it had been concluded that it would be good for Mr Y to have his own clothing although it had been her understanding that Mr and Mr X had been reluctant to provide the clothing.
1.3.35. A letter of 6 August 1997 from the clinical director to Mr and Mrs X, referred to the clinical director’s disappointment at Mrs X’s expressing concerns about his stay in the IBU. She noted that the Trust had been informed of a complaint that they had made. She discussed the responsibility of the clinical team to provide treatment for Mr Y and how it would be irresponsible of the team not to provide the clinical input that he needed. She stated that time was necessary for the team to complete its work and that patience would be needed to provide the team with this time. Again, the issue of clothing arose and the clinical director referred to a worry that they were not willing to release Mr Y’s clothing. She corrected an apparent misapprehension by Mr and Mrs X that Mr Y would be able to stay only for a month and informed them that the stay had no legally fixed limit. She reiterated that there was available to Mr and Mrs X the opportunity to meet with herself or the psychiatrist and expressed the hope that they would do so. She mentioned that Mr Y was happy and contented and that adverse incidents had been few and far between.
1.3.36. A letter of 18 August 1997 from the clinical director to the Health Authority’s learning disability manager summarised the progress of Mr Y’s assessment and treatment. The clinical director commented that, because of Mr Y’s initial agitated and unsettled behaviour, he had required p.r.n. (as needed) medication on a number of occasions, rendering a psychology assessment difficult. At the time of the letter, he was, the clinical director stated, settled and therefore amenable to assessment. She gave it as her opinion that Mr Y was probably suffering from a mood disorder and noted that, before he had been transferred from hospital to the care of Mr and Mrs X, he had been receiving mood stabilising medication which was subsequently discontinued, presumably due to his more settled behaviour. Mr Y had been resumed on such medication, in the form of Carbamazepine, by the clinical director.
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1.3.37. Again the clinical director discussed discharge and referred to various options. The idea was apparently to have Mr Y on medication for three weeks in a controlled environment, then to discontinue medication to assess the effects of its absence. The controlled environment would be the IBU. The second option was that he be returned to his carers and that information be garnered from them in the home situation. The third was seen as his being returned to his carers and information not being obtained. It was perceived by the clinical director that pressure was being placed by Mr and Mrs X for Mr Y’s discharge.
1.3.38. On 20 August 1997 the clinical director wrote internally to other members of the treating team to inform them that a second opinion had been sought, in view of the carers’ concerns, from a consultant psychiatrist in learning disabilities and that this would occur on 22 August.
1.3.39. A letter of 20 August from the care manager to the clinical director refers to apparent precipitants for disturbed behaviour in Mr Y, such as the weather, the resetting of the clocks to summer or wintertime and other such environmental changes. She also expressed concern about the apparently limited communication between the carers and the treating team, noting that, should historic information about Mr Y’s behaviour be needed, this would be a matter of approaching the carers directly. She suggested a meeting between the carers and the professionals with an independent chair. She also expressed concerns that Mr and Mrs X were still being asked not to visit Mr Y.
1.3.40. On 2 September the clinical director wrote to Mr and Mrs X informing them that his stay in hospital would be a prolonged one and invited them to a clinical meeting to discuss his progress on 18 September. She requested access to diaries and other documentation about Mr Y and asked that clothing be provided to him. On the 5 September Mr and Mrs X wrote to the clinical director expressing their disagreement with the approach to Mr Y’s care as outlined in the clinical director’s letter of 2 September.
1.3.41. On 12 September 1997 the consultant psychiatrist in learning disability wrote to the clinical director with a copy of his report. He suggested that Mr Y needed further observation in the IBU with respect to stabilisation on the carbamazepine, that there be links with his carers at the day centre regarding his future management and that regular meetings between the learning disability team and the community team, including the carers, should occur. He added the further comment that if this could not be brought about he could not recommend that Mr Y return to his existing community placement.
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1.3.42. On 15 September 1997 the clinical director wrote to the care manager. She referred to the seeking of an advocate for Mr Y. She stated that, although she had again written to Mr and Mrs X inviting them to come and see her, they had not done so. She noted the feeling on the part of Mr and Mrs X that it was ill-mannered for the community nurse not to telephone before she visited them and apologised for the lack of notice. She expressed her understanding that, subject to normal confidentiality, the intention had been that diaries would accompany Mr Y in the event of an admission as had occurred. On 16 September the care manager advised that the matter should be raised directly with Mr and Mrs X. On 15 September the clinical director wrote to Mr and Mrs X apologising for occasioning them distress as indicated in their letter of 8 September.
1.3.43. On 19 September the clinical director responded to Mr and Mrs X and expressed her regret that they felt unable to attend the meeting on the previous day. A further letter of 19 September to Mr and Mrs X again contained a request for the diaries and a commitment to maintaining their confidentiality.
1.3.44. On 23 September the clinical director wrote to Mr Y’s cousin in response to her last letter. It was pointed out by the clinical director that it had been not only the view of the treating team that he required an extended hospital admission, but also that of the second opinion consultant. Again she gave a commitment that the stay would be no longer than was necessary. On the same date the clinical director also wrote to a community nurse from the North Downs community team, thanking her for her behavioural assessment previously forwarded.
1.3.45. On 20 October the clinical director wrote to Mr and Mrs X. After clarifying some confusion about correspondence which apparently arose from letters being directed via the solicitor, she addressed their concerns about what they perceived as vigorous restrictions imposed upon their visits and reassured them that the visits had been discussed at some length at an IPP meeting at which the care manager was present. She again asked them to reconsider their providing diaries and other documentation about Mr Y and once more encouraged Mr and Mrs X to attend for a visit specifically to discuss his needs.
1.3.46. A letter of 29 October 1997 from the clinical director to Mr and Mrs X’s solicitors notes that in the light of an appeal court decision, it had been decided to detain Mr Y under Section 5(2) of the Mental Health Act 1983 for his own health and safety and for a further assessment to determine whether he needed to been detained under Section 3 the Mental Health Act 1983.
1.3.47. A note from Mr and Mrs X refers to their visit on the afternoon of Sunday, 2 November 1997 and reports that they found Mr Y in a very neglected state, hitting his head as a consequence of which, apparently, blood had spread to other parts of his body and the surroundings.
1.3.48. On 11 November 1997 the clinical director wrote to a voluntary organisation expressing some concerns about the presence at a planning meeting on 4 November of people who had not been invited by the treating team and about the volume of documentation being requested by an independent expert.
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1.3.49. On 20 November the clinical director wrote to the care manager asking for confirmation of the role of social services and the name of the key worker responsible under Section 117 of the Mental Health Act. On the same date the clinical director wrote to a mental health act co-ordinator, referring to the Mental Health Review Tribunal and noting that a date had not yet been set. She wrote on the same date to the director of mental health referring to the therapeutic programme package which had been prepared by the psychologist and noting that in its draft working form it had been implemented in the Villa a while ago but that the final version of the guidelines had yet to be compiled and circulated to all concerned. The letter contains a detailed discussion regarding the Section 7 leave of absence conditions.
Opinion and recommendations
(a) The decision to admit
1.3.50. Given the behavioural difficulties experienced at the day centre, and the difficulties in locating Mr and Mrs X, it was probably unavoidable that Mr Y be admitted to the IBU. However, we believe that serious consideration should have been given to his being sent home that same day once Mr and Mrs X had been located. Even if it was felt necessary to keep him overnight, it is difficult to see why he was not discharged the next day. If an assessment was deemed necessary consideration should have been given to its being conducted in the community.
(b) Management in the hospital
1.3.51. When planning for his admission and future needs, more consideration should have been given to Mr Y’s life with his carers in the period following his trial discharge as part of the resettlement programme. The general impression we have gained is that Mr Y had been content with them, although there were obviously periods of challenging behaviour. We note the difficulties clinical staff had in obtaining good quality information about his life, and the lack of rapport between Mr and Mrs X and the clinical team clearly presented some difficulties with this. However there were no compelling reasons for his continued absence from his home.
1.3.52. The process of assessment whilst Mr Y was at the IBU was too prolonged and Bournewood should have ensured that resources were available to speed up the process. We note, for example, that a psychological assessment was delayed due to the fact that Mr Y was receiving medication. This in itself should not have delayed the assessment. We note also that there were insufficient resources available to the psychology department. We believe that the Trust has a responsibility to ensure that sufficient resources are made available.
1.3.53. We do not believe that any of the clinicians were acting irresponsibly or maliciously. The clinical director was assiduous in her efforts to encourage contact with the carers, although her efforts were largely unsuccessful. It seems to us, however, that the clinical team backed themselves into a corner, partly by the relative slowness with which they implemented the assessment process, and partly by their interpretation of the poor relationship they had with Mr and Mrs X. In our opinion they ought to have put this to one side and should have proceeded with all due speed to conducting an assessment and discharging Mr Y.
1.3.54. Our main recommendations for the future are that admissions to the IBU should be strictly time-limited and that adequate resources should be made available to enable multi-disciplinary assessments to be carried out in the person’s home if at all possible, and, if not, as speedily as possible at the IBU.
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Findings (a) and (b)
26. The complaints subject to investigation were that the clinical decision to admit Mr Y to hospital on 22 July 1997, following an incident at a day centre, was unreasonable; and that the clinical management of his admission was inadequate.
27. As is evident, the case is complex and the evidence is extensive. It is appropriate to place matters in context. Mr Y, who is now 52, has a diagnosis of severe learning disability. He was admitted to hospital when he was 14. In March 1994 he left Botleys Park Hospital as part of a closure programme, and he was placed in Mr and Mrs X’s care. He attended a day centre. Mr and Mrs X dispute the Trust’s evidence concerning their lack of co-operation, and they have submitted various documents in support of their case. Whatever misgivings the Trust have had about Mr and Mrs X, the Ombudsman’s assessors have confirmed that they were highly committed to Mr Y’s care, and were able to provide him with a significantly better quality of life than he had before. The incident at the day centre, which led to Mr Y’s readmission to hospital, happened after Mr Y had been living with them for over three years.
28. Mr and Mrs X’s essential concern is that Mr Y’s behaviour on the day in question was no worse than on previous occasions, and that there was no need for him to be admitted. It is unfortunate that they could not apparently be contacted at the time of, or shortly after, the incident: had that been possible, matters might have been resolved quickly. However, in their absence, the day centre staff were unable to contain the situation, and contacted the care manager. She arranged for a GP to attend Mr Y. Medication given by the GP failed to calm Mr Y down completely, and he was therefore referred to the hospital’s A&E department, where he was seen by the psychiatrist. He found Mr Y to be very agitated, and that he had been punching himself. The psychiatrist found it difficult to tell whether Mr Y had a psychiatric condition or a behaviour problem, and therefore decided to admit him for a period of observation. Mr Y was placed in the IBU. The expectation was that the admission would be relatively brief.
29. The assessors have stated that, although there appears to be some evidence to indicate that on occasions Mr Y’s behaviour had been challenging before the incident, it was reported that his conduct on 22 July was more extreme than the day centre were used to (paragraph 1.3.8 of their report). They have advised that, in view of the situation which presented itself at the time, Mr Y’s admission was probably unavoidable. I accept that advice. I therefore do not uphold this aspect of the complaint.
30. However, it seems to me, that the decision to admit Mr Y, in itself, does not represent the crux of the matter. The assessors have advised that serious consideration should have been given to discharging Mr Y on the same day, after Mr and Mrs X had been located. They consider that even if it was felt necessary to keep him overnight, it is difficult to see why he was not discharged the next day. Any further assessment could have been conducted in the community. I agree.
31. I find it unsatisfactory, especially given the background and the nature of the incident in question, that Mr Y was not discharged back into Mr and Mrs X’s care for another four months. It is evident that this protracted stay was due to a range of interrelated issues and problems associated with Mr Y’s clinical management. I have little doubt that these can, in part, be attributed to historical factors. It is clear that, for several reasons, not least of which was a long delay in formally discharging Mr Y from the hospital before the incident in question, the relationship between Mr and Mrs X and Trust staff was severely strained. The care manager has stated that although Mr Y was still formally a patient of the Trust after March 1994, he was not provided with a full range of services. It is difficult to escape the conclusion that had Mr Y’s position in the community been confirmed and rationalised much earlier, many of the later tensions could have been prevented, and a more comprehensive and mutually acceptable package of community care arranged. As it turned out, an atmosphere of mistrust developed; and there were disputes over matters such as access to diaries kept by Mr and Mrs X, and visiting arrangements. Mr and Mrs X were also convinced that Trust staff were attempting to discredit them in order to justify their actions.
32. These problems, it would seem, hampered the drafting of behavioural management guidelines. There are conflicting perceptions of Mr and Mrs X’s co-operation with Trust staff. The Trust have said that they consider Mr Y’s programme of treatment to have been appropriate, and staff have pointed out that a number of factors hindered the completion of a comprehensive care plan. However, the fact remains that it was several weeks after Mr Y’s admission before a post-admission meeting took place, and four months before behavioural management guidelines were finalised. This, inevitably, had an adverse effect on Mr Y’s management, and delayed his discharge. The assessors have also pointed out that the fact that Mr Y was receiving medication should not have delayed his psychological assessment; and they have referred to insufficient resources which were available to the psychology department. I note, in addition, that the review conducted by the Trust questioned whether treatment in another unit should have been sought from the outset (paragraph 14).
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33. The assessors do not believe that any of the clinicians were acting irresponsibly or maliciously; and I do not underestimate the difficulties which the above set of circumstances presented for all concerned. However, the crucial consideration was, of course, Mr Y’s welfare. I feel that the Trust staff could, perhaps, have made more effort to put aside their poor relationship with Mr and Mrs X, and to have adopted a more flexible approach. In my view they should have taken more positive steps to expedite the necessary arrangements. I recommend that the Trust implement the recommendations made by the assessors in paragraph 1.3.54 of their report. I uphold the complaint in respect of the shortcomings identified.
Conclusions
34. I have set out my findings in paragraphs 26 to 33. The Trust have asked me to convey through my report – as I do – their apologies to Mr and Mrs X for the shortcomings I have identified and have agreed to implement my recommendations in paragraph 33. They have told me that they have already established a community based Intensive Assessment and Treatment Service, and that all assessments are now carried out in the patient’s own home if at all possible.
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