Mersey Care NHS Foundation Trust

3. Mr A complains that the Trust inappropriately discharged him from its CMHT in December 2022. He says the Trust labelled him a ‘troublemaker’ and decided to discharge him prior to his assessment.

4. He says this decision caused him a lot of distress and he was left without any mental health support in the community. He adds the decision caused him to think about suicide and he felt victimised by the Trust.

5. Mr A would like the Trust to acknowledge what went wrong, apologise, and take steps to improve its service.

6. Mr A is a gentleman in his early 50s with a history of depression and self-harm. Following admission to hospital in November 2018, he received outpatient mental health support from the Trust’s CMHT up until his discharge from the service in December 2022.

7. A CMHT is a community based, multi-disciplinary mental health service which provides assessment and evidence-based treatment for patients with moderate to severe mental health needs. They can also support patients who need specialist input due to the complexity of their needs.

8. Not all patients need support from the CMHT and the majority of patients who experience depression are managed by their GP.

9. In September 2022, Mr A had an appointment with a consultant psychiatrist who decided to stop one of his medications. They also recommended that Mr A engage with a service that helps patients to step down from the CMHT back to the care of his GP. This service is called the ‘Step Forward’ service. Mr A was unhappy with this plan, and the CMHT asked a different psychiatrist to review this decision.

10. On 30 November a different psychiatrist reviewed his care and agreed with the decision to stop the medication and refer Mr A to the Step Forward service. The psychiatrist noted that Mr A was unhappy with this decision.

11. Mr A was discharged from the CMHT on 12 December, and he declined referrals for onward support via the Step Forward service. He also declined referrals to other agencies, such as his local talking therapies service.

15. The GMC’s Personal Beliefs and Medical Practice guidelines outline that doctors must recommend treatment based on an assessment of need and clinical judgement regarding the efficacy of the proposed treatment(s). They cannot recommend treatments that are not suited to the needs of the patient.

16. In this case, Mr A had a diagnosis of depression and so the assessment of needs and recommended treatments should have aligned with the guidelines for this diagnosis. NICE guideline NG222 outlines that both pharmacological and psychosocial interventions are recommended for treating depression.

17. The GMC’s guidelines also state that doctors must also accept a patient’s decision to refuse any investigation or treatment. They cannot pressure a patient into following the proposed treatment plan.

18. The Trust treated Mr A’s depression with medications that were appropriate for this diagnosis. This included a combination of two antidepressants (mirtazapine and venlafaxine) and an antipsychotic (sulpiride). The sulpiride was discontinued after concerns about side effects were discussed in Mr A’s September appointment. Our psychiatrist adviser confirmed that all drugs were prescribed at therapeutic doses.

19. During the consultation in September, Mr A was also advised that he could be referred to a service called Step Forward. This service aims to help people transition from the support of the CMHT back to the care of their GP. Our psychiatrist adviser confirmed that the support offered by this service, as outlined on its website, was appropriate to the needs Mr A had.

20. Mr A was unhappy with this proposed plan, and the Trust arranged for a different psychiatrist to review his care. This review took place on 30 November, and supported the plan proposed in September. The review concluded that further medication changes were unlikely to be helpful for Mr A, and that a referral to the Trust’s Step Forward program would likely be of more benefit.

21. On discharge from the service on 12 December 2022, Mr A declined the Step Forward referral and a referral to a talking therapies service, which would have provided support with coping skills and helpful routines following discharge. He was also documented to have declined to develop a crisis plan with the Trust.

22. Our psychiatrist adviser noted that whilst Mr A expressed a preference to continue care under the CMHT, his needs could be fully met outside this service. This is because the CMHT’s function is to manage more complex mental health needs, and Mr A had no further complex issues to address. Mr A is entitled to his preference, but the Trust should not offer care that its psychiatrists felt was not required and/or was inappropriate to his needs.

23. We have seen no indications of service failure regarding the decision to discharge Mr A from the CMHT. This is because the decision was fully explained to and explored with him, and a second opinion sought when he expressed dissatisfaction. He was offered the recommended treatments for depression, which included medication and therapeutic options, and our psychiatrist adviser has confirmed these were appropriate in his clinical context.

24. Whilst Mr A wanted to remain under the CMHT, there was no clinical reason for him to stay under this service. He declined the referrals for ongoing care to support this transition, which the doctors had to respect.

25. There is also nothing documented to indicate the Trust decided to discharge him because he was a ‘trouble maker’. Out psychiatrist adviser confirmed there were no value-based comments in the Trust’s documentation of the decision. The discharge decision appears to have been clinically appropriate, and the Trust appears to have taken Mr A’s concerns about this seriously. This is reflected by it asking a second psychiatrist to review the decision before discharging him from the CMHT.

26. We have seen no indications of service failure regarding the decision to discharge Mr A; however, we recognise that transitions such as this can be stressful and distressing for patients. The distress does not mean they are clinically inappropriate, but we recognise that Mr A had a difficult experience.

1. We have carefully considered Mr A’s complaint about Mersey Care NHS Foundation Trust (the Trust) and have seen no indication that the Trust inappropriately discharged him from its Community Mental Health Team (CMHT). This is because the evidence indicates there was no further clinical need for him to remain under this service and the Trust fully considered Mr A’s onward care needs.

2. We recognise that changes and transitions in mental health care can be distressing for patients, and that Mr A struggled a lot with the decision to discharge him from the CMHT. Our decision does not detract from his difficult experience.