Independent investigation: John Rees, Pen Y Graig, Rhondda (2020)

Ann’s narration of significant events in her life and her aspirations are largely absent from the documentation available to this review. Although the interpretation of her parents and the professionals who worked with her as an inpatient are important, they are not Ann’s own account. Although CTMUHB has policies and procedures concerning person-centred care and conflicts of interest, the review raises questions of whether and how they were invoked.
• CTMUHB should provide assurance to the Regional Safeguarding Board that its process of encouraging people with mental health challenges to contribute to the information gathering concerning their medical, psychiatric and family history is being reinforced and embedded in practice. This is to ensure that significant events in patients’ lives and, separately, what matters to them are captured in their own words. Separately, CTMUHB should advise the Regional Safeguarding Board of the actions it is taking to ensure that conflicts of interest are disclosed – most particularly when staff are, or have been, closely related to a patient.

Ann’s serial “Did Not Attend” appointments resulted in her case being closed to the Domestic Violence service. When Ann was in hospital there were two occasions when she Did Not Attend outpatient appointments (because outpatients had not been informed that Ann was an inpatient) resulting in her discharge from outpatients, and subsequently from the Primary Care Mental Health Service; and when Ann did not attend a “3 day follow-up appointment” on a ward where she had been an inpatient, no further appointment was offered.
• A history of missed appointments is a risk marker. CTMUHB and other relevant services should provide the Regional Safeguarding Board with evidence of proactive engagement with patients with mental health problems lost to follow-up appointments to reduce the risks arising from their failed attendance.

There was merit in some of Mr P ’s challenges [Mr P is Ann’s father] concerning Ann’s inpatient and outpatient care and treatment. On many occasions he had sought to bring Ann’s deteriorating mental health to the attention of professionals. He was comforted by glimpses of her progress but conflict and distress resulted when these were repeatedly halted. Generally, however, as the volume and complexity of complaints escalate, there are challenges in closing cases at the same time as additional complaints are opened. This impacts significantly on the handling of complaints, on staff and on the service available to other complainants.
• Complaints provide valuable feedback to services. CTMUHB should provide the Regional Safeguarding Board with evidence of (i) how it “triages” and works with patients and families who use the complainants process frequently; (ii) how it works with complainants who self-identify as having language based difficulties such as dyslexia, using voicemail, printing on coloured paper and/ or screen-reading software such as Texthelp, for example; (iii) how it facilitates and uses feedback and complaints’ feedback specifically, concerning mental health service patients and their relatives; and (iv) how it supports staff who report feeling distressed and/or intimidated by complainants.

Granting and withholding leave of absence are subject to legal provisions. Assessment of inpatients’ mental capacity to consent to their treatment, give instruction concerning information-sharing and related matters, such as leaving the ward, should be undertaken regularly.
• CTMUHB should advise the Regional Safeguarding Board of what has been done since the its internal review to ensure that (i) the provisions of the Mental Health Act (1983) as amended and the Mental Capacity Act (2005) are correctly enacted; (ii) the systems in place now ensure that informal patients receiving inpatient care, whose treatment falls outside the MHA, are not denied leave; and (iii) it is promoting learning networks and a rolling programme of inter-professional training concerning the MHA, the MCA and the interplay between them.

The adequacy of hospital discharge planning has implications for the use of community services and future readmissions.
• CTMUHB should inform the Regional Safeguarding Board of the ways in which the Mental Health (Wales) Measure (2010) is enacted and how its activities and those of local authorities are being changed and improved. In addition, the outcome of an operational audit to ensure that the specific statutory and regulatory requirements are met should be shared with the Regional Safeguarding Board.

On 5 May 2020, Ann’s parents contacted mental health services. They knew that her mental health had declined and, as advised, they sought help during this crisis. Responses to their phone calls fell short of their expectations. Since Ann did not have a Care and Treatment Plan in place, she did not have a crisis plan.
• CTMUHB should provide evidence to the Regional Safeguarding Board of its effective engagement with patients and their families in crisis planning. This should include the preparation of a brief accessible guide, in relevant formats, for staff to read through with patients and their families. Its purpose is to enhance people’s understanding of likely service responses during mental health crises.

News and media reporting wields great influence, most particularly when it includes graphic accounts of tragedies and other eventualities. How these stories are reported is of keen interest to the individuals and families affected by the incidents.
• A whole systems approach - in which partnership is imperative - is required if all University Health Boards, local authorities and the police are to be alert to the impact of news and social media reporting concerning their post incident processes. For example, if there is to be a Root Cause Analysis, it should be made explicit that this is a confidential process, the content of which will not be shared with the public. The NHS Delivery Unit, with the assistance of Welsh Government, is well placed to initiate such work with the police, local authorities and individuals who have been affected by incidents, accidents and tragedies.