An independent investigation into the care and treatment of Adult 1

Information given to relatives about the MHA and the Nearest Relative (NR) rights Adult 2 was not told her rights as the NR, specifically that she could formally request that the local authority consider the patient’s case with a view to making an application for admission to hospital. The Trust must ensure that relevant organisational policies are aligned to the MHA and the MHA Code of Practice. The Trust must also provide training on the role and rights of the NR to frontline staff to ensure that correct advice is given to NRs.

MHA and NR rights Adult 2’s right to request that the local authority consider the patient’s case with a view to making an application for admission to hospital was dismissed or not given due consideration. The responses to her requests were not in line with the MHA and MHA Code of Practice. The Trust (or the Council if MHA AMHP assessments are no longer covered by a Section 75 agreement) must ensure that requests from NRs are considered and responded to appropriately. An evaluation of current practice and policy is advised to ensure it is clear about how to manage NR requests for an MHA assessment.

MHA and family involvement Concerns raised by family and other professionals were not given due consideration and were not responded to as requests for MHA assessment. The Trust must ensure that policy guidance includes the management of requests by family and other professionals, when concerns are expressed about a person’s mental health, that the policy is in line with best practice, and that appropriate training is provided to relevant staff.

MHA and urgent requests for assessment The family was left unsupported and without access to mental health support services over a weekend. There was an over-reliance on emergency services responding if a crisis occurred before the planned assessment. The Trust must ensure that urgent requests for assessment are considered and responded to in line with the least restrictive principle of the MHA. When a date for a mental health assessment has been agreed, patients and families should be provided with a clear plan to follow if a crisis occurs before the assessment takes place.

MHA assessments and documentation The crisis team did not record their rationale for not completing an MHA assessment at home. Recording this would have ensured practice was in accordance with the least restrictive principles of the MHA. The Trust must ensure that crisis team staff comply with policy expectations by recording their decisions and the actions taken or not taken as part of MHA assessment requests.

Section 17 leave standards There is no evidence of a risk assessment being carried out before Section 17 leave was granted. Section 17 leave was not always recorded correctly. The Trust must ensure that risk assessments at Hospital 2 are up-to-date and complete before Section 17 leave is agreed. Section 17 leave must also be documented correctly, including the start and return times of the patient, and the patient’s presentation on their return from Section 17 leave.

MHA and involving the NR at detention and discharge There is no record of information being provided to the NR about Adult 1’s detention and discharge. The Council must ensure that the NR is provided with information about a patient’s detention. The Trust must ensure that the MHA Office communicates with the NR when decisions are made about changes to the patient’s detention.

Involving families in assessments and care planning Neither the inpatient team nor the early intervention team (EIT) clinicians sought out family views, even when direct representations were made to the service by family members. The Trust must ensure that Hospital 2 and EIT staff seek to involve family members (or other relevant third parties) and that family evidence/collateral information is used appropriately, particularly when the patient is unable or unwilling to engage in meaningful interactions themselves.

Discharge standards There was no post-discharge follow up from Hospital 2, which contravenes policy. The Trust must ensure that when patients are discharged from hospital, post-discharge follow up is conducted in accordance with Trust policy and national guidance.

Application of the Mental Capacity Act (MCA) Adult 1 was taken to hospital under the MCA and remained in general hospital for an extended period of time (greater than 10 hours) without formal assessment under either the MCA or the MHA. The Trust and the Council must ensure that there is a clear escalation process which has been agreed with RCHT if a patient awaiting an MHA assessment is deprived of their liberty in the emergency department for an extended period of time.

Application of the MCA On several occasions Trust staff assessed Adult 1 and found him to be lacking capacity. Ambulance Trust 1 also found him to be lacking capacity on one occasion. But the assessments were not documented in accordance with the policy of either Trust. The Trust and Ambulance Trust 1 must ensure that assessment of mental capacity is documented in accordance with the relevant Trust policy.

System management of safeguarding referrals Safeguarding referrals were not robustly followed up when passed back through primary care and we were unable to determine how the Council assured itself that duties conducted on its behalf were completed as required. The Integrated Care Board (ICB), the Council and the Trust must ensure there are clear pathways for managing a safeguarding adult referral where there is a mental health and social care component; these should be supported by robust and detailed assurance processes.

Being open and involving families in serious incidents There was a lack of clarity about the implementation of new policies and processes in the transition to PSIRF this meant the process was not transparent for families, which led to great distress. The Trust must ensure there is clarity in the PSIRF policy about involving families in the investigation of incidents and this involvement should be supervised and quality assured. Communication with families must be timely and unambiguous, in accordance with the principles of being open. This is set out in guidance about engaging and involving patients, families and staff involving a patient safety incident.