Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust

3. Ms D complains about the inpatient care she received from Northumberland, Tyne and Wear NHS Foundation Trust (the Trust), between January and April 2023. She complains the Trust: • insisted she take medication without explaining its purpose or considering an alternative approach • refused to provide antibiotics for infections • placed her on an acute ward when she did not have an acute need • woke her every 15 minutes overnight • told her GP she experienced delusions, resulting in restrictions to her driving licence.

4. Ms D says the medication staff gave her caused significant weight gain, leading to self-worth, self-esteem, and body image issues. She says this has impacted her financially because she had to buy new clothes. She also worries about the effect the weight gain will have on her future health.

5. She says that the lack of antibiotics meant her infections at the time went untreated and she remained unwell for much longer than needed. Restrictions in her driving has affected her day-to-day life because errands are more complicated to complete.

6. By making the complaint she hopes to gain an understanding of the care she received. She would like the Trust to apologise for any mistakes we identify.

7. Ms D has a diagnosis of schizophrenia and schizoaffective disorder. She was admitted to hospital, detained under the Mental Health Act in January 2023 where she remained as an inpatient until she was discharged home on a Community Treatment Order (CTO) in April.

Medication options

10. Ms D complains that when the Trust detained her under the Mental Health Act, it made her take medication that she did not want, without providing information about the medication she would take. She says staff refused to consider any alternatives and based its rationale on incorrect historical information about her mental health.

11. The Trust said Ms D required Aripiprazole, which is an anti-psychotic, but refused to take it on the belief she did not need it. It said staff offered Ms D oral tablets, or an injection. It said she was discharged with the same medication, which she expressed no desire to appeal, and had continued that medication on a lower dose at home.

12. NICE Psychosis and Schizophrenia in Adults: Prevention and Management (March 2014) directs staff to prescribe oral anti-psychotic medication alongside psychological intervention. It is explicit in saying that the intervention requires the medication.

13. The records show that staff prescribed Ms D Aripiprazole because it was an anti-psychotic, which is what the guidance says should happen. It chose Aripiprazole because she had responded well to it on previous admissions. She had also been discharged into the community on the same medication in 2012, and a doctor noted that at the time, it enabled her to move forward with societal norms such as living independently, forming a new relationship, and returning to the workforce.

14. We cannot agree with Ms D’s complaint that staff refused to advise her what medication they wanted to prescribe, because her refusal of the proposal is reflected in the records at multiple points. There is also clear evidence she had taken it for longer periods in the past. We cannot agree either, that Ms D was offered no alternative, because the records show she was offered an Olanzapine injection.

15. This indicates that whether alternative options were discussed or not, the outcome would always have included an anti-psychotic medication of some kind, in some form. Whilst we appreciate Ms D felt she did not need either, we can see strong evidence to show that the Trust’s prescription of antipsychotics was in line with national guidance.

Antibiotics

16. Ms D complains that the Trust refused to provide antibiotics for infection, despite her overt symptoms of sinusitis and of a suspected vaginal, or urinary infection.

17. The Trust acknowledged Ms D’s request for antibiotics, but following tests and an examination, said she had no identified infection.

18. NICE Management of Sinusitis (September 2023) says that acute sinusitis usually resolves within 12 weeks and should not routinely be treated with an antibiotic.

19. The records show Ms D requested antibiotic treatment for this condition several times during her inpatient stay. Ms D was assessed for this problem three times over the course of a month. Each assessment was completed by a different staff member and on each occasion, staff declined antibiotic treatment because there was no evidence that she needed it.

20. National guidance does not direct staff to utilise antibiotic therapy, so even if staff did confirm a diagnosis of sinusitis, this still would not have been treated with antibiotics. Having worked within the guidance, we can see no evidence that the refusal was wrong.

21. Ms D described to staff a longstanding vaginal infection. The record show she told staff that she had undergone urine testing before, but the infection did not show.

22. NICE Urinary tract infection (lower): antimicrobial prescribing (October 2018) advises antibiotics based on a positive urine swab result. The lab tested Ms D’s urine on 27 January, with a negative result. She also underwent examination on 27 February, which the records document did not indicate further treatment. On discharge, staff also wrote to Ms D’s GP to highlight her belief and request a follow up.

23. The guidance shows what should have happened, and we can see that staff did act within that framework. We therefore cannot see any indications of a failing.

Ward placement

24. Ms D does not believe that she should have been placed on an acute ward. She says it was loud and disruptive which negatively affected her unnecessarily, as she did not have an acute need.

25. The records show Ms D was initially taken to the 136 suite for initial assessment before the bed allocation team identified space on a ward. We reviewed the Trust’s information page for the ward Ms D was admitted to. It says the ward is for females who have a mental illness and require assessment and treatment in hospital.

26. The opposite of acute is chronic, which means a condition or problem is ongoing over a longer period. Different staff from the hospital, community team and social services all documented in the lead up to the Section, and in the days following that Ms D was adamant she did not need to be admitted and had no mental health issues. Therefore, we cannot identify the problem even through her eyes, as chronic.

27. It seems from the records that Ms D objected to admission to any ward. Because she was being detained as an inpatient, this was unavoidable. We can also see through the records that Ms D’s overall preference was to be moved to a private hospital.

28. Considering there was no evidence from staff, or from Ms D that the problem was chronic, combined with advertised services of her admitting ward, we think this decision appeared appropriate.

29. Whilst we can recognise that disruptions on the ward at times caused Ms D concern, we were also reassured to see that Ms D reported no incidents with other patients so whilst she naturally felt unsafe in an unfamiliar environment, that concern proved to be unfounded.

Night disturbance

30. Ms D complains that staff woke her every 15 minutes each night when they checked on her because they would bang heavy doors or shine a torch onto her face. She says this led to exhaustion because she could not get any real rest.

31. The Trust did not comment on this complaint.

32. Relevant to Ms D, the Trust’s Observations and Engagement Policy (2019) says that observations above the general hourly level should be implemented if the patient has poor adherence or non-compliance with medication programmes. This also applies if the patient experiences paranoid ideas where they believe that other people pose a threat. In these cases, intermittent observations should take place every 15 to 30 minutes. We can appreciate the disruption caused to Ms D when these checks woke her.

33. The records show that Ms D began on intermittent observations every 15 minutes when she was first admitted to the ward. Staff recorded Ms D’s repeated refusal to take prescribed anti-psychotic medication and her concerns that she may be attacked by male staff. When we consider the reasons set out in the records, we are satisfied these are consistent with the reasons set out in local policy. She remained on intermittent observations until 10.30pm on 26 January, roughly 24 hours after she arrived.

34. Staff documented that Ms D slept peacefully for the next two nights, so it seems hourly observations did help. However, she then complained of being disturbed again on 28 January, and staff agreed to request permission for her to move to a special pilot called Sleep Well.

35. Sleep Well was a pilot at the time, designed to promote a protected sleep period between midnight and 6pm. The Trust’s Observations and Engagement Policy says that changes to observations must be agreed by senior staff or through a multidisciplinary team approach (MDT). The records reflect this, highlighting that Sleep Well meant Ms D would not receive physical hourly checks in that six-hour period. The records show senior staff agreed to the pilot, which was reassessed daily and Ms D spent the remainder of her stay on this pilot, though it is worth noting the records show that she was often up and active at night.

36. When we consider the records, we can see that Ms D was unable to gain quality sleep because of those checks. In total the records document that she faced this problem for a single night, and then for two consecutive nights. We can acknowledge how tired she must have felt and how much that affected her overall outlook, but we can also see that these actions were necessary, considered and wholly in line with local policies.

Driving licence

37. Ms D says the Trust told her GP that she experienced delusions. She says this resulted in the GP advising the DVLA, who in turn, decided to restrict her driving.

38. The Trust has not commented on this.

39. The DVLA fitness to drive says that a person with schizophrenia must not drive during acute episodes, must be free of any medication that prevents driving, is adhering to a treatment plan and has been stable for at least three months.

40. The records show that a judge upheld Ms D’s section at tribunal. The tribunal record shows they considered evidence from independent non-clinical sources who had expressed concerns prior to her detention. Community staff recorded that Ms D believed NHS staff were stalking her, and her repeated intention to seek an injunction against the crisis team. Hospital staff also observed delusional beliefs aimed at several institutional and authoritative bodies, such as the police, housing, and NHS, which Ms D regularly encouraged other patients to consider in their own situations.

41. We have seen strong evidence to show that multiple sources shared the opinion that Ms D was delusional prior to and during her inpatient stay. A judge also agreed at tribunal. However, the DVLA guidance shows that many other factors would have prevented her from driving, in the event she was able. Even without documented delusions, the lack of adherence to community engagement and subsequent Sections would have led to the same outcome.

42. The challenges Ms D faces in managing her mental health must be stressful and it is clear that at times, her experience is quite scary. Having carefully considered what happened in line with national and local standards and guidance, we are satisfied that each decision was in line with those policies, and in Ms D’s best interest. She told us she sought to gain a better understanding of the care she received, and we sincerely hope this report provides the clarification she seeks.

1. We have carefully considered Ms D’s complaint about Northumberland, Tyne and Wear NHS Foundation Trust (the Trust).

2. We have seen no indication that anything went wrong. This does not take away from Ms D’s experience, but it does mean we will not take any further action.