The most common failing we see in our casework involving discharge planning in mental health services (and in our health casework more broadly) is the involvement of patients, their families and carers in decision-making.
Patients’ own views are sometimes not fully considered when services are making decisions about the risk of discharge from inpatient care. The long-promised reform to the Mental Health Act aims to give people detained under it as much involvement as possible in their own care planning.
We cannot underestimate the importance of communicating effectively with families and carers about the day discharge happens. If families are not expecting discharge, or are unable to prepare for it, then patients are not given the best chance of being able to stay at home with the right support.
The cases we have investigated show where the duty to take a person-centred view of discharge has not been met. The planning for where an individual is being discharged to and their support system beyond the hospital, including signposting to voluntary and community sector organisations, has not been good enough. To break the readmission cycle, a joined-up view of the social factors involved in this transition is just as important as looking at the physical or mental health aspects.
Trust not involving a patient’s family in discharge risk assessment and giving incorrect information on self-help support after discharge
The complaint
Mr N was experiencing low mood and had privately expressed suicidal thoughts to his family. He was also using drugs as a coping mechanism for his mental health issues.
After an altercation, Mr N rang the police and told them he was having suicidal thoughts. The police took him to a hospital emergency department.
The local mental health Trust did a risk assessment before discharging Mr N the same day, with a care plan and contact information for self-help support organisations. But the contact details for these organisations were out of date. He tried to call them but could not get in touch with most of them.
The Trust did not involve family and carers in the discussion about Mr N’s discharge.
Mr N contacted his GP and they put in place a medication and follow-up plan. He sadly took his own life a month later.
What we found
If the Trust had consulted with the family, it might have reached a different assessment of risk level. Information from the family could have provided a fuller picture of Mr N’s mental health concerns and could have been valuable to the Trust’s psychiatric liaison team in its assessment.
In line with NICE guidance, the Trust should have contacted a local drug and alcohol recovery support group on behalf of Mr N, which would have increased the chances of a more successful follow-up.
We found that the Trust’s care had not met its own standard for family and carer involvement as well as best practice guidance set out by the Royal College of Psychiatrists and The Carers Trust. The Trust accepted this failing.
We recognise that a more thorough risk assessment, with documented input from family and carers, may have led to more support for Mr N. It is also possible that if Mr N had successfully made contact with mental health support organisations, he may have been able to access further assessment and therapies.
More than one month had passed from the time Mr N last received care from the Trust. We could not say the service failings were a direct cause of his death, but the uncertainty of not knowing if more intervention or in-depth assessment might have prevented Mr N’s death was a significant injustice for his family.
Putting things right
Following our recommendations, the Trust put in place a system for regularly checking the accuracy of leaflets provided at discharge to make sure this does not happen again.
The Trust apologised to Mr N’s family for not following best practice and briefed staff that, where possible, clinicians should lead on referral to other support services, including mental health organisations and drug and alcohol recovery support services.
Close family not updated on day of patient’s discharge from hospital
The complaint
Ms E had been detained in hospital under Section 3 of the Mental Health Act for urgent treatment. After being discharged from the section, she stayed in hospital as a voluntary patient to continue treatment.
She was granted leave over Christmas to visit family and returned to hospital in the new year. She was granted another week of leave before the hospital held a review to make a discharge plan. Ms E was joined by her mother-in-law for the discharge meeting, with the aim to fully discharge her by the end of the day.
Ms E’s partner said staff had not communicated with him or invited him to any review meetings, including the discharge meeting. The Trust said it did not need the consent of close family members when discharging patients, although it encourages patients to invite family to be part of the discussion.
What we found
According to the principles of ‘The Care Programme Approach’, which was in place at the time of Ms E’s hospital admission, individuals have a choice about whether to consent to involving their families in planning and decision-making if they have capacity to.
As a voluntary patient, Ms E had capacity to consent and was free to invite who she wanted to the planning meetings. But there was still a responsibility on the Trust to make sure it got the views of everyone involved in the care plan, even if they did not attend the review meeting.
We could see that Ms E’s partner had said he wanted her care records before she was discharged and an update from staff before overnight leave was granted. Staff were happy to give this reassurance.
But there was no evidence that the Trust contacted Ms E’s partner to discuss her progress before her final discharge from the hospital, even though Ms E had consented to her partner being updated. Ms E’s partner and children were unprepared and not reassured about her discharge and return home that day. This caused distress for the family and made an incredibly difficult time even worse for them.
Putting things right
We recommended that the Trust should apologise to Ms E’s family for the impact of failing to update all of them about Ms E’s progress before it discharged her. We said it should explain how it will make sure it follows its own plans before discharging patients in the future.
Failings in how a Trust assessed a patient when they requested to be discharged
The complaint
Ms A had a history of anorexia nervosa (an eating disorder and serious mental health condition), depression, anxious personality disorder (a mental health condition that affects how someone thinks, perceives, feels or relates to others) and autism. She had received care from the Trust on various occasions over a six-year period.
She began to have suicidal thoughts and made several attempts to take her own life. After one attempt to take her own life, Ms A was taken to hospital by ambulance and later admitted to an inpatient mental health unit. During her stay, the Trust discussed a plan to reduce and eventually stop some of her medications. Ms A was unhappy about these changes and asked to be discharged. The Trust agreed to discharge her.
After Ms A attempted to take her own life the following day, she was readmitted and then discharged from the emergency department the next day, with follow-up from a psychiatric liaison team. Care coordinators had put plans in place for video consultations. When the Trust could not contact Ms A two days later and a police welfare check was ordered, it was found that she had sadly taken her own life.
What we found
We found failings in how the Trust assessed Ms A when she asked to be discharged from the mental health unit. Documentation for the assessment lacked detail to show that the team had approached Ms A’s request with sufficient professional curiosity. We would expect staff to ask and challenge Ms A on what had changed during the admission to lead her to no longer feel suicidal and how they could support with any concerns about medication changes. The Trust had not explored whether discharge was genuinely the best option for Ms A at that time. Although the Trust’s decision not to detain Ms A was in line with the Mental Health Act code of practice, there was a missed opportunity to try and advise Ms A to stay in hospital.
But we found that the Trust’s actions in the immediate lead-up to Ms A’s death were appropriate.
Putting things right
We recommended that the Trust should apologise to Ms A’s family for failing to do the assessment correctly. We also recommended that it make a payment to recognise that the family have been left not knowing whether Ms A’s death could have been avoided.
We also said the Trust should produce an action plan to show how it will prevent similar failings from happening again. And that it should share this with Ms A’s family, us, the CQC and NHS Improvement.