Avon and Wiltshire Mental Health Partnership NHS Trust

5. Ms V complains about Avon and Wiltshire Mental Health Partnership NHS Trust’s (the Trust’s) decision to discharge her on 7 April 2024.

6. Specifically, Ms V complains the Trust discharged her too soon and did not act on concerns regarding the discharge raised by her family and care coordinator (this is someone who manages a patient's medical treatments and support services).

7. Ms V says the Trust’s actions left her unsafe at home and her psychosis escalated and led her to empty her home of her belongings. Ms V says ten days after discharge she required further sectioning and experienced a lengthy admission and recovery due to worsening of her mental health in the period she returned home.

8. Ms V says the experience has also worsened her fears and anxieties.

9. As an outcome to her complaint, Ms V is seeking an acknowledgement of failings, service improvements and a financial remedy to recognise her financial and sentimental loss of her property.

10. Ms V has bipolar effective disorder, a manic-depressive illness. Records show on 3 March Ms V’s family reported she became very distressed in the middle of the night, and she barricaded herself into a bedroom.

11. The records show at the time she reported feeling that her partner and her sister's husband were a threat to her, and she did not feel safe. We recognise that this must have been a frightening experience for her.

12. Her family broke into the room, and she appeared to be unresponsive. Understandably worried they called an ambulance. By the time the paramedics arrived, Ms V was alert and breathing again, with no obvious concern for her physical health.

13. Ms V told the paramedics she was taking some, but not all, of her prescribed medication for her mental health. She told paramedics she did not feel that an assessment of her health was needed or that she lacked insight into her current mental state and associated risks.

14. The paramedics took Ms V to a hospital emergency department (ED) for a formal mental health assessment, and she complied.

15. We understand, whilst in ED, records show Ms V engaged well with the assessment. She told the Trust she could not go back home as she did not feel safe there any longer. Records show Ms V told the Trust she believed that she would be killed by her partner (who lived separately) and her sister's husband, if she went back home.

16. The Trust noted that she had been relatively stable for over ten years. It considered her relapse to be the result of her not keeping up with her medication alongside recent stressors including the death of her father and caring for her mum. Ms V had been taking less than her prescribed dose of medication as she felt it was causing side effects.

17. We understand that Ms V had also been under physical and emotional abuse from her partner over the last 15 years. Ms V’s family says that her partner was arrested for assaulting her during that time.

18. The records show the ED assessment determined Ms V presented with relapse of bipolar affective disorder including psychotic symptoms and associated risks. That met the threshold to keep her in hospital for further assessment.

19. On 4 March, as part of its assessment the Trust documented significant concerns regarding Ms V behaviour and agitation. It prescribed her multiple doses of medication to calm her down.

20. The following day she was admitted to the Trust under section 2 of the Mental Health Act. This is the compulsory admission of a patient to a hospital for up to 28 days for a detailed assessment of their mental health assessment, for their own safety and to inform the next steps of their care.

21. On 7 April the Trust discharged Ms V. On 17 April police were called to her house, and she was sectioned again the following day.

25. Following her admission in March, the Trust explored Ms V’s reasons for reducing her medication. Ms V explained she did not like the side effects, particularly swelling and itching in her legs. The Trust offered an alternative drug or a slow-release injection, but Ms V refused both options.

26. Ms V’s regular prescription was 15mg of aripiprazole, a drug used to balance mood and thoughts. Ms V offered to take 5mg and the Trust agreed a compromise of 7.5mg.

27. The records show Ms V’s clinical improvement from 19 March. On that date, Ms V said she felt better and ready for discharge. She accepted she may have needed admission. She denied psychotic symptoms and reported she was doing well on aripiprazole at a dose of 7.5mg, although she wanted to reduce this to 5mg.

28. Ms V remained cautious about medication but agreed to continue. Her family said she had improved but did not think she was ready for discharge.

29. On 25 March, Ms V agreed to remain in hospital informally while discharge planning continued.

30. The Trust recorded her daughter’s concerns about relapse and agreed Ms V would remain in hospital informally while discharge planning continued. The Trust also planned to refer Ms V to a local intensive service (crisis team in the community) to support her after discharge.

31. A discharge care plan approach (DCPA) meeting took place on 28 March 2023 with Ms V, her community care coordinator, ward staff and family members. Ms V said she felt very well on 7.5mg aripiprazole, reported no side effects, and says the lower dose suited her better. She also said the voices she was hearing had improved and described them as more positive and less distressing.

32. Ms V remained keen to return home as soon as possible, but the Trust explained it needed to arrange support from the crisis team in the community and confirm practical discharge agreements.

33. Ms V said she was willing to stay in at the Trust until after the weekend, in line with medical advice, while waiting for confirmation that her former partner’s belongings had been removed from her home.

34. Ms V’s daughter again raised concerns about whether her mother would cope safely at home, particularly with washing, showering and other daily tasks. Ms V says she was managing her personal care on the ward and did not believe she needed carers at home. The Trust agreed the crisis team would assess this after discharge and community support could be arranged if needed.

35. During the meeting Ms V’s community care coordinator highlighted Ms V had previously relapsed on less than 10mg of aripiprazole. They raised concern Ms V remained clear that she wanted to continue on the reduced dose.

36. The discharge plan was for Ms V to remain on the ward until at least 3 April, while community care coordinator arranged crisis team follow-up, which records show was expected to involve at least weekly visits after discharge and then review accordingly to needs.

37. The purpose of admission under a section 2 detention is to reduce immediate risk to the individual so they can be safely supported in the community. It was not expected Ms V would return her to her previous level of health before she was discharged. The records show the team put in place follow-up plans to monitor her ongoing recovery in the community.

38. NICE guidelines on shared decision making say collaborative care involve a person and their healthcare professionals working together to reach a joint decision about care.

39. In the DCPA meeting, we recognise this was appropriately followed with guidelines. The DCPA meeting was organised specifically to discuss Ms V’s progress and plan her care and discharge going forward. Relevant and important people in her care (her family and community care coordinator) were invited to contribute, and their opinions were heard and noted in the records.

40. The Trust discussed the next steps with everyone. Ms V’s daughter’s concerns were noted as being social care issues that could be managed in the community. Ms V also highlighted she was managing her own personal care in the hospital at that time.

41. The community care coordinator’s concern was also discussed. Ms V had shown improvement on a reduced dosage and made it clear it was her intention to remain on the lower dose.

42. There was no obvious disagreement to the plan to move to discharge after the weekend. We consider this demonstrated a collaborative meeting.

43. The DoH code of practice sets out the importance of maintaining independence and using the least restrictive methods of care possible. This supports the Trust’s decision to manage any personal care issues in the community.

44. However, NHS guidance on prescribing say patients with mania should normally take a dose of at least 15mg of aripiprazole.

45. Ms V showed improvement on 10mg and did not deteriorate when the dose reduced to 7.5mg in hospital. Ms V only agreed to 7.5mg as she felt this reduced the side effects. She also agreed this dose reduced the risk she would stop the medication altogether after discharge.

46. We asked our adviser if the decision to discharge on a lower dosage was supported in this circumstance.

47. Our advisor explained, hospital admission would not usually continue when a patient is clinically ready for discharge, especially if they want to leave.

48. They explained Ms V is over 65 years and may respond to lower doses of medication while being more sensitive to side effects. They highlighted Ms V had shown significant clinical improvement on the 7.5mg dose and her mania was controlled.

49. They explained they considered this compromise reflects the least restrictive action and demonstrates and collaborative care.

50. Our adviser also explained patients with psychosis can sometimes minimise or be guarded about symptoms. However, with more severe illness are usually less able to mask symptoms.

51. Taking the guidance, records and our adviser’s explanation into account, we are satisfied the community care coordinators concerns were explored and the level of medication on discharge was in keeping with DoH guidance to minimise hospital admission.

52. It is documented on 29 March, the day after the meeting, Ms V’s daughter emailed the Trust with concerns about discharge in relation to her mother’s home environment, including clutter and belongings left by Ms V’s former partner. There is no indication of concerns raised about Ms V’s mental health. Ms V daughter asked for longer admission to address these issues.

53. On 5 April, the records state Ms V’s daughter and the community care coordinator supported discharge planning. The records do not show any further clinical concerns at that stage or objections on the ground of Ms V’s health.

54. Ms V was discharged on 7 April, more than a week after the meeting. In the final call to discuss arrangements, Ms V’s daughter agreed with the planned discharge.

55. Based on the records, NICE guidelines on shared decision making and information from our adviser, we have seen the decision to discharge Ms V on 7 April was made collaboratively, taking account of her improvement and considering her intentions going forward.

56. This was in line with guidance on collaborative decision making. Ms V was not discharged on the recommended dose of aripiprazole, however we are satisfied this decision was supported by her clinical improvement and made in conjunction with her, again in line with collaborative decision-making guidance and the DoH guidance on detention under section.

57. Finally, we have seen the Trust considered the concerns about personal care and again responded appropriately ensuring community support was available, in line with the DoH guidance.

58. Overall, the Trust managed the discharge in line with guidance, and we see no indications of anything went seriously wrong.

59. We thank Ms V for bringing her complaint to us. We can see it was clearly a very difficult period for her. We hope are detailed consideration reassures her about the care she received.

1. We are sorry to learn of Ms V’s distress following her experience with Avon and Wiltshire Mental Health Partnership NHS Trust (the Trust). We acknowledge the difficult circumstances around this complaint, and the impact this had on Ms V.

2. We have carefully considered Ms V’s complaint about the Trust. Having done so, we have decided we will not investigate this complaint further. This is because we have not seen any signs anything went seriously wrong with the Trust’s decision to discharge Ms V from her care.

3. We understand this was and continues to be an upsetting time for Ms V. Our decision is not made without recognition of the upsetting experiences she had with her discharge and its outcome.

4. We have explained the reasons for our decision below and we hope this provide Ms V with some reassurance about the care she received.