Hertfordshire Partnership University NHS Foundation Trust

6.Miss E complains about aspects of the care and treatment provided to her brother, Mr E, by Hertfordshire Partnership University NHS Foundation Trust (the Trust) between December 2020 and January 2022. She says the Trust:

•treated Mr E with lithium, after he self-reported a diagnosis of bipolar disorder, without obtaining his previous health records, and did not follow lithium treatment guidelines

•had no next of kin recorded in Mr E’s records.

7.Miss E says the events contributed to the death of her brother and caused significant distress and anxiety to her and her family. Miss E tells us that as no next of kin was on file, the Trust was not able to confirm important information about Mr E’s medications and wrongly treated him for bipolar disorder. She says Mr E suffered side effects from the lithium medication and was at significant risk of an overdose.

8.Miss E is seeking a financial remedy from the Trust.

9.Mr E’s GP referred him to the Trust’s Adult Community Mental Health Service (ACMHS) in October 2020. The Trust completed an initial assessment in February 2021, during which Mr E reported experiencing poor mental health since the age of 25 and a previous diagnosis of bipolar disorder. Following this, the Trust arranged for him to see a psychiatrist and completed a risk assessment the same day.

10.In March, Mr E contacted the Trust as he had not yet received an appointment with the psychiatrist. He followed up again in late March and was informed that he was awaiting allocation of a care coordinator.

11.In April, a trainee doctor conducted a telephone review with Mr E where they discussed lithium treatment with him. Following the review, the Trust contacted Mr E’s GP to request lithium be started at 200mg once daily, and the GP prescribed this.

12.Mr E continued lithium treatment, including regular blood tests to monitor levels. In June, he informed the Trust that he had run out of lithium. After discussions with his GP, the Trust issued a new prescription. In July, Mr E reported feeling no improvement from the lithium, and a speciality doctor increased his dosage to 500mg once daily.

13.In October, Mr E told the Trust he was feeling depressed with a low mood and fleeting thoughts of self-harm. In November, Mr E had his first face-to-face appointment with a doctor from the Trust. Mr E confirmed he still had low mood and fleeting thoughts of self-harm, following which his lithium dosage was increased to 600mg once a day with a plan to review after three months.

14.Mr E sadly died by suicide in January 2022.

Lithium treatment for bipolar disorder

18.Miss E is unhappy that the Trust treated Mr E with lithium after he self-reported a diagnosis of bipolar disorder. She also says that when the Trust treated Mr E with lithium, it did not do this in line with the appropriate lithium treatment guidelines. Miss E told us that Mr E suffered side effects from the lithium medication and said he was at significant risk of an overdose.

19.Miss E says the Trust accepted Mr E’s self-reported diagnosis of bipolar disorder and explained to us that Mr E did not have this condition. Miss E confirmed that Mr E’s previous healthcare providers had diagnosed him with schizoaffective disorder. She believes the Trust should not have accepted the information Mr E gave without confirming with previous healthcare providers or checking his medical records. Miss E feel these events contributed to Mr E’s death.

20.In its complaint response, the Trust explained it is not clear who diagnosed Mr E with bipolar disorder as the doctor involved in Mr E’s care no longer works for the Trust. The Trust said that it started Mr E on lithium treatment as an alternative to antipsychotic medication after Mr E reported he did not tolerate them.

21.As part of its investigation, the Trust completed a serious incident review. The Trust found there was no record of it attempting to obtain Mr E’s medical records from his previous healthcare provider. The Trust said that whilst it is acceptable for clinicians to have independent views and reach diagnoses, it would have been good practice to obtain Mr E’s previous records.

22.The Trust also highlighted in its review that the two risk assessments it carried out were not of sufficient quality and the lithium treatment was not carried out in line with guidelines. The Trust apologised to Miss E for there being elements of Mr E’s care which fell below its usual standard. It also assured Miss E that learning had been taken which would be used to improve practice and the quality of care it provides patients.

23.Our adviser explained that when the Trust initially assessed Mr E, it should have confirmed whether the information he gave was correct by getting relevant information from any previous primary, secondary or private health services.

24.The relevant NICE guidance says:

‘When assessing suspected bipolar disorder:

• undertake a full psychiatric assessment, documenting a detailed history of mood, episodes of overactivity and disinhibition or other episodic and sustained changes in behaviour, symptoms between episodes, triggers to previous episodes and patterns of relapse, and family history • assess the development and changing nature of the mood disorder and associated clinical problems throughout the person's life (for example, early childhood trauma, developmental disorder or cognitive dysfunction in later life) • assess social and personal functioning and current psychosocial stressors • assess for potential mental and physical comorbidities • assess the person's physical health and review medication and side effects, including weight gain • discuss treatment history and identify interventions that have been effective or ineffective in the past • encourage people to invite a family member or carer to give a corroborative history’.

25.Our adviser explained there is insufficient evidence that the Trust completed a comprehensive assessment, including obtaining relevant mental health history from Mr E’s previous GP or other NHS mental health service providers.

26.In the absence of Mr E’s previous health records, and no family member being able to corroborate his history, critical information regarding Mr E’s treatment history and diagnoses was missed. The Trust relied solely on Mr E’s account which we do not consider to be in line with guidance on assessing a patient in this situation. The Trust’s own serious incident report acknowledged it would have been good practice to obtain Mr E’s previous medical records. We have found failings here as the Trust made no effort to obtain Mr E’s previous medical history.

27.We understand that Miss E has significant concerns about the Trust accepting what Mr E had told it in relation to bipolar disorder. Miss E strongly believes Mr E had never had this condition.

28.We obtained Mr E’s GP records. The GP records indicate that bipolar disorder was an active problem for Mr E and suggest he was diagnosed with the condition around June 2008.

29.Whilst we consider it would have been good practice for the Trust to obtain Mr E’s previous health records to confirm the information Mr E had told them (specifically in relation to a bipolar diagnosis), we cannot say it reached the wrong conclusion as the records we obtained indicate Mr E had previously been diagnosed with bipolar.

30.If the Trust had obtained these records, it is likely it would have reached the same conclusion.

Medication

31.A trainee doctor started Mr E on lithium following an appointment with him in April 2021. The letter the Trust sent to Mr E’s GP says the lithium is for a diagnosis of bipolar disorder.

32.The relevant NICE guidance says:

‘If an alternative antipsychotic is not sufficiently effective at the maximum licensed dose, consider adding lithium.’

33.In the Trust’s letter to Mr E’s GP, it says that Mr E had previously been on antipsychotic medications (olanzapine and quetiapine). However, there is nothing recorded about the dosages of these medications. It is therefore not clear whether the maximum licensed dose of antipsychotics was trialled with Mr E before lithium was added. When we obtained Mr E’s GP records, the details of the previous dosages of antipsychotics were unfortunately not included in this.

34.Given the Trust did not know what doses of antipsychotic medications Mr E had previously been on, and we have not been able to ascertain this via Mr E’s records, we cannot say for certain whether the Trust’s decision to start him on lithium as a treatment for bipolar disorder was in line with the relevant NICE guidance.

35.The relevant NICE CKS on lithium says:

‘People taking lithium should be advised:

• To carry a lithium card.

• That regular blood tests are important and the results should be recorded in their lithium record booklet.

• About what adverse effects to expect.

• How to recognize the symptoms of lithium toxicity.

• Not to take over-the-counter nonsteroidal anti-inflammatory drugs.

• That episodes of diarrhoea or vomiting, or any form of dehydration, will lead to sodium depletion and therefore increased plasma lithium levels.

• To maintain their fluid intake, particularly after sweating (for example, after exercise, in hot climates, or if they have a fever), if they are immobile for long periods, or if they develop a chest infection or pneumonia.

• That if a dose is missed they should take it as soon as possible; but if yesterday's dose was missed then they should not double today's dose.

• Not to stop taking lithium abruptly, and that non-compliance may lead to a relapse.’

36.Our adviser noted that after adding lithium, the Trust asked Mr E’s GP to arrange blood tests to check his blood lithium level, thyroid function and renal function after one week of starting lithium. Our adviser said these actions were appropriate. However, they added there is no evidence of the Trust advising Mr E of the things listed above, such as to carry a lithium card.

37.The Trust’s own incident report acknowledges that Mr E was not given a lithium card and confirms the checklist was not completed. We have therefore found failings in how the Trust handled Mr E’s lithium treatment.

38.The Trust’s incident report also highlighted that neither of the two risk assessments it completed during the early part of Mr E’s care were sufficient. It highlighted that neither assessment provided a risk formulation which anticipated worsening mental health and the need for an active risk management plan.

39.The relevant NICE guidance says:

‘Carry out a risk assessment in conjunction with the person with bipolar disorder, and their carer if possible, focusing on areas that are likely to present possible danger or harm, such as self neglect, self harm, suicidal thoughts and intent, risks to others, including family members, driving, spending money excessively, financial or sexual exploitation, disruption in family and love relationships, disinhibited and sexualised behaviour, and risks of sexually transmitted diseases.’

40.Our adviser said there is insufficient evidence in the records that the appropriate care planning and crisis planning was completed.

41.During Mr E’s last appointment with the Trust, he mentioned having fleeting thoughts of harming himself but said he had no plan to do this. Our adviser explained there is no documented evidence to come to conclusions about any increased risk apart from low mood and fleeting thoughts of harm, which are risk factors for suicide and self-harm. We find the absence of these risk assessments and management plans to be a failing, and not in line with the above NICE guidance.

42.To summarise, we have found failings in relation to the Trust not carrying out a full assessment (including obtaining Mr E’s previous records), not handling the lithium treatment appropriately, and the lack of appropriate risk assessments.

Impact

43.Miss E believes these events caused Mr E to suffer side effects from lithium medication, put him at risk of an overdose and overall believes the events contributed to his death. We acknowledge the concerns she has here.

44.Our adviser explained there is no evidence within the records to suggest that Mr E suffered any major adverse effects from lithium and confirmed there is no evidence the medication itself contributed to his death. There is one entry in Mr E’s records from an appointment in August 2021 where he confirmed he had suffered from a few headaches which had then settled. We are pleased to see there were no major side effects from the lithium and no evidence to suggest Mr E experienced an overdose.

45.Our adviser explained that after Mr E told the Trust about his previous bipolar diagnosis, the focus was the trial of lithium. Our adviser said the Trust did not discuss other psychosocial interventions including crisis and risk management. Our adviser confirmed this means there would have been a lack of a comprehensive treatment plan.

46.Our adviser also confirmed that due to lack of appropriate care and crisis planning, Mr E would not have had access to support from extended community mental health team professionals. From the records, it appears Mr E was not given information about crisis and out-of-hours contacts for support if he needed it. We consider these points to have been a clear injustice to Mr E as he may have been left without the support or resources he needed during his mental health struggles.

47.We cannot definitively say the failings we have identified directly contributed to Mr E’s death as there is too much that is unknown. We cannot know what would have happened if staff had properly completed care and crisis planning. It is possible Mr E would have been offered additional support, monitoring or treatment, and if he had engaged in this, it is possible the risk of him taking his own life would have been reduced, although this can never be entirely removed.

48.It is also possible staff would have decided any risk was low as Mr E had reported he had no intention of acting on his thoughts of self-harm. Therefore, it is possible the Trust may not have put any additional support in place. The decision in November to review Mr E after three months may well have been clinically appropriate, and it is possible he would not have engaged in any additional support if it was offered.

49.A strategy for suicide prevention was launched in England in 2023. Data behind this showed that children and young people, middle aged men and those in contact with mental health services are priority groups for support. The data shows that the relationship between suicidal thoughts, self-harm and suicide is not straightforward and that most people who have thoughts of self-harm do not go on to die from suicide.

50.The study found that a quarter of adults reported thoughts of taking their own life at some point, but the number who attempted suicide was much lower. That said, we also recognise that the suicide rate amongst patients with bipolar is higher than in the general population (National Library of Medicine, Suicide risk in bipolar disorder: a brief review, 2019) and so monitoring and risk assessing a patient like Mr E is even more important.

51.We include this information here to highlight that reporting thoughts of self-harm alone is not an indicator that someone will attempt to take their own life. This is not to excuse the lack of proper crisis and care planning, which we consider to be a considerable failing. We are just unable to conclude whether proper assessment would have prevented Mr E’s death.

52.We consider there were missed opportunities to mitigate risks in Mr E’s care. The fact that Miss E will never know whether the situation may have been different is in itself, a significant injustice to her. We can understand that these events have exacerbated to her grief and raised concerns about the quality of care Mr E received.

53.Miss E explained these events have caused significant distress and anxiety to her family. We have found failings in Mr E’s care, and the uncertainty surrounding his death have exacerbated the distress they felt from his death itself. We acknowledge the extremely difficult situation that she and her family have experienced. We do also acknowledge that these tragic events will have caused Miss E and her family distress regardless of the failings we have found.

54.As a result of this complaint, and the serious incident report the Trust completed, it has highlighted multiple areas for improvement. The Trust has confirmed there to be additional training for staff on suicide risk, learning on lithium guidelines with specific learning from Mr E’s case being issued to staff, and learning from this case in relation to the importance of gathering collateral information from previous healthcare providers. The Trust has also apologised to Miss E.

55.We are pleased to see the Trust has taken these events seriously and has taken appropriate remedial actions to avoid the same things from happening again. We consider these actions to be in line with our principles for remedy. We have also completed a precedent check as part of our investigation. We are pleased to see that we have not had any comparable complaints about the Trust since the events of this case.

56.Given the severity of the injustice to Mr E, Miss E and their family, we do not consider this to be completely remedied. For that reason, we do make recommendations at the end of this report.

Next of kin

57.Miss E is unhappy that the Trust had no next of kin recorded on Mr E’s file. She explained to us this meant the Trust was unable to confirm vital information about Mr E’s medications. She also said that if a next of kin was on file, the Trust would have been able to confirm with her that Mr E had not previously been diagnosed with bipolar and would have subsequently identified it was wrongly treating him for it. Miss E tells us that during a local resolution meeting with the Trust, it told her it did not know why no next of kin was recorded.

58.In its complaint response, The Trust acknowledged there was no next of kin recorded in Mr E’s file and apologised for this. It also acknowledged that no record was made of whether Mr E chose not to name a next of kin. The Trust said that as Mr E was an adult with capacity it would have required his consent to contact his next of kin but accepted it would have been helpful to make a record in Mr E’s notes about why there was no next of kin.

59.The Trust confirmed it raised this issue with its single point of access team to prevent the same thing from happening again.

60.The term ‘next of kin’ does not have any legal definition in UK law. Being named as someone’s next of kin does not grant any legal rights or powers regarding decision making in care and treatment.

61.A medical next of kin is someone nominated to receive information about a person’s medical care. Our adviser explained that if there is no chosen next of kin, it will usually be assumed to be a close blood relative, spouse or civil partner.

62.The relevant GMC guidance says:

‘The people close to a patient can play a significant role in supporting, or caring for, the patient and they may want or need information about the patient’s diagnosis, treatment or care. Early discussions about the patient’s wishes can help to avoid disclosures they might object to.

Such discussions can also help avoid misunderstandings with, or causing offence or distress to, anyone the patient would want information to be shared with.’

63.The above guidance is clear in that the people close to a patient (which in this case would have been Miss E) can play a significant role in someone’s treatment or care. The guidance suggests there should be early conversations with a patient to discuss their wishes around this. It does not appear the Trust followed this guidance as through its own admission, there is nothing recorded in Mr E’s notes regarding a next of kin, or why one was not recorded.

64.Our adviser said that when a clinician becomes aware there is no next of kin recorded, it is reasonable to expect a conversation about the reasons for this as per the above GMC guidance, and to also document the reasons for no next of kin being recorded.

65.Given there was no next of kin recorded, and no evidence in the records about any conversations between the Trust and Mr E about this, we have found failings here. We consider there should have been a next of kin recorded, or documented evidence to explain why there was not one.

66.Miss E tells us the Trust staff were not able to confirm important information with her such as medications Mr E had been taking and information regarding his self-reported diagnosis of bipolar disorder.

67.We can appreciate Miss E’s comments here. That being said, we will never know for certain what Mr E’s decision about a next of kin would have been if the Trust had the relevant conversations with him. It is possible Mr E would have chosen not to name a next of kin, and therefore we cannot definitively say Miss E would have been able to share information about his medication or diagnoses with the Trust.

68.Miss E believes Mr E would have chosen to name her as his next of kin and said she would have been able to confirm important information about his previous care and treatment. Miss E will never know if this discussion took place and he chose not to name her, or the discussion did not take place at all. She will therefore never know whether different actions would have made a difference to Mr E’s situation. This has understandably caused Miss E distress.

69.We understand one of Miss E’s main concerns regarding there not being a next of kin is that she was not able to confirm information about Mr E’s previous medical history, specifically in relation to bipolar disorder. Miss E explained she would have been able to tell the Trust that Mr E did not have bipolar disorder which would have prevented Mr E from being treated with lithium. As we have already explained in this statement, we have seen evidence to support what Mr E told the Trust in relation to a bipolar diagnosis.

70.Our principles for remedy say that where maladministration or poor service has led to an injustice, the public organisation responsible should offer an appropriate remedy.

71.The Trust has acknowledged and accepted there was no next of kin recorded on Mr E’s file and agreed it would have been helpful for there to have been a record of why no next of kin was recorded. The Trust also apologised and said the issue had been raised with its single point of access team to prevent reoccurrence. We are pleased to see the Trust has taken some remedial actions here and we consider those actions to be in line with our principles for remedy.

72.Whilst we accept the distress this has caused Miss E we cannot say with any certainty that Mr E did not get the opportunity to nominate a next of kin. What we do know is that there is no documented evidence to support a conversation happened between the Trust and Mr E regarding this. As the Trust has taken appropriate actions in line with our principles, and we cannot be sure what happened, we have decided not to recommend the Trust carries out any further remedial action.

1.We are very sorry to learn of the events which led Miss E to make a complaint. We acknowledge the extremely difficult circumstances of the events, and we offer our condolences on the death of her brother, Mr E. We understand the importance of Miss E’s complaint, and we thank her for giving us the opportunity to look at it. Our final decision is to partly uphold this complaint.

2.We found the Trust failed to record a next of kin on Mr E's file or document a discussion with him about why there wasn’t one.

3.We found the Trust failed to obtain Mr E’s relevant psychiatric history, did not follow relevant guidance on lithium treatment, and did not carry out adequate risk and crisis planning. We found the Trust missed opportunities to mitigate risks in Mr E’s care. We also found the events caused uncertainty for Miss E and her family, which exacerbated the distress they felt from Mr E’s death.

4.We cannot know whether Mr E’s death could have been avoided had failings not happened. This is because there are too many unknown factors, and it is possible that a more robust risk assessment and crisis planning could have led to the same tragic outcome. Knowing the risk assessment and crisis planning should have been more robust, and the uncertainty around whether this could have changed the outcome, will cause significant distress to Miss E, who says these failings have amplified her grief at losing her brother.

5.We are making recommendations based on what we have found.

73.We make recommendations in line with our Principles for Remedy which say public organisations should acknowledge failures, apologise, make amends, and use the opportunity to improve their services. The Principles say we aim to ensure the public organisation puts the complainant back in the position they would have been in had nothing gone wrong. If that is not possible, the public organisation should compensate them appropriately.

74.Our Principles for Remedy are reflected in the NHS Complaints Standards which say organisations should offer fair remedies to put things right and identify learning and use it to improve services.

75.Through investigating this complaint, we found the Trust made no attempt to obtain Mr E’s previous healthcare records and did not follow appropriate guidelines on lithium treatment. We also found there was inadequate risk assessments and crisis planning. We have found those failings to have caused significant distress to Miss E and her family and caused uncertainty following Mr E’s death.

76.In line with our principles, we recommend that that within one month of the date of our final report, the Trust writes to Miss E to acknowledge the failings we have identified.

77.To decide on a level of financial remedy, we review similar cases where the person has experienced a similar injustice, along with our severity of injustice scale. We consider the injustice Miss E has experienced is level three on our scale.

78.We recommend the Trust pays Miss E £1200 within one month of the date of our final report.

79.The Trust should send us evidence it has completed all of the recommendations we have made.