Hampshire and Isle of Wight Healthcare NHS Foundation Trust

5. Miss B complains about Hampshire and Isle of Wight Healthcare NHS Foundation Trust’s (the Trust) management of her eating disorder whilst under the care of the Community Mental Health Team (CMHT) prior to her hospital admission in March 2024. In particular, Miss B states that:

• the care coordinator did not monitor her mental health face to face from September 2023 to March 2024 and failed to take her mental health diagnoses and eating disorder seriously • the Trust did not properly assess her capacity to make decisions regarding her care, in line with the Mental Capacity Act • the Trust did not follow its policy for sharing information with carers and did not have a carers communication plan which resulted in inappropriate communication with her family.

6. Miss B also complains about the Trust’s complaints handling. She says the Trust did not investigate her concerns properly and this led to an external investigation. She said the Trust’s lack of compassion and care during the complaint investigation added to her distress.

7. Miss B explains that the impact of poor mental health monitoring and treatment of her eating disorder led to her significant weight loss and hospitalisation in March 2024, for seven weeks. She says as a result of the Trust’s poor assessment of her needs and its poor communication with her and her family, she has lost faith in the community mental health team, and their ability to care for her. She says her eating disorder had a severe impact on her mentally, physically and socially, and her quality of life has decreased.

8. Miss B would like service improvements and financial compensation.

9. Miss B has a history of anorexia nervosa and complex mental health needs.

10. In September 2023 Miss B’s sister (who is also her complaint representative) contacted the Trust to raise concerns about the extent of Miss B’s weight loss and poor care and treatment of her eating disorder.

11. In March 2024 Miss B was hospitalised for seven weeks due to severe malnutrition.

12. On 23 April 2024 Miss B’s sister complained to the Trust on her behalf about the care and treatment she received prior to her hospital admission. The Trust responded on 9 August 2024 and sent a further response to outstanding complaint issues on 6 September 2024.

Health monitoring

16. Miss B complains her care coordinator did not monitor her mental health face to face from September 2023 to March 2024. She says taking into consideration her complex mental health needs which include PTSD, anxiety, borderline personality disorder, addiction recovery and diagnosed anorexia, the Trust’s lack of monitoring demonstrates that it did not take her mental health diagnoses and eating disorder seriously.

17. Miss B says if she had regular face-to-face monitoring, the care coordinator would have seen how unwell she was and recommended relevant treatment, which might have prevented her hospitalisation in March 2024. Miss B says communication over the phone does not provide the same level of care as physically seeing someone.

18. The records show that from 1 September 2023 to 22 March 2024, Miss B had 11 scheduled telephone appointments with her care coordinator, two of which did not go ahead due to cancellations. There was no face-to-face contact. The telephone appointments and a summary of the details discussed, are outlined below.

• 18 September 2023- Miss B returned her care coordinator’s call and the discussion centred on Miss B’s fluctuating weight ranging from 37kg to 42kg and chest and back pain. Miss B mentioned her upcoming face-to-face appointment with her GP on 19 September 2023. Miss B’s care coordinator completed a referral form to the Eating Disorders Team during the telephone session for Miss B’s GP’s attention. Miss B declined her care coordinator’s offer to arrange another appointment.

• 17 October 2023- Miss B’s care coordinator returned Miss B’s call. Miss B confirmed her GP had followed up with the Eating Disorder Service referral, and she was awaiting an appointment with the service. Miss B’s care coordinator praised her for starting a Dialectical Behaviour Therapy (DBT) course. They also discussed the difficulties Miss B was facing with her reduced appetite and cravings for drugs and alcohol. Miss B shared she did not give into her cravings. Monthly phone calls going forward were agreed and that Miss B would focus on her eating.

• 7 November 2023- Miss B discussed with her care coordinator the difficulties she was having at home and that she was feeling knackered, quite down and irritable. She reported that the DBT group was going positively.

• 22 November 2023- During this telephone appointment, Miss B shared the ongoing difficulties she was having at home with her cat and the impact on her relationship with her mum.

• 6 December 2023- Miss B discussed difficulties with her home life and family relationships. Miss B also gave hints of suicidal ideation and said through tears ‘I don’t belong’. Miss B shared she was still finding DBT helpful.

• 27 December 2023- Miss B reported that Christmas had gone well and better than she had anticipated. She shared that everything else was not going so well and spoke of a friendship that was likely going to end and her low, fluctuating weight. Miss B shared that her weight went down from 42kg to 37kg. Miss B was also keen to know when her next outpatient appointment was so she could come off her medication.

• 15 January 2024- Miss B discussed things that were going well, including using ‘cope ahead skills’, mindfulness practices and looking into coping strategies for her poor concentration, such as using fidget toys.

• 12 February 2024- Miss B said she was still attending DBT sessions and was seeing her GP about her eating.

• 26 February 2024- Miss B phoned to cancel the appointment as she was unwell. It was agreed that the session would be rescheduled for 4 March 2024.

• 4 March 2024-During this session Miss B said she had an appointment to see the Eating Disorders Team on 2 April and spoke of how worried she was about the appointment as it was her first time engaging with the team.

• 19 March 2024- Miss B rang to cancel the appointment as her pet was unwell. Unsuccessful further attempts were made to speak to Miss B on 20 March. Miss B was admitted to hospital on 22 March 2024 with severe malnutrition.

19. Miss B shared all her struggles in her appointments, both personal and clinical with her care coordinator and it is clear from the notes that her health was deteriorating. The main health concerns pertaining to Miss B’s eating disorder were Miss B’s low, fluctuating weight and the detrimental impact it was having on her mental health.

20. At times Miss B gave hints of suicidal ideation with a recurrent theme of low motivation. While most appointments went ahead as scheduled and appointments were scheduled monthly, there was no consideration in the notes to modify the mode of communication, i.e. face-to-face, in light of Miss B’s deteriorating health condition.

21. Miss B health was also monitored by other services and the Trust explained that Miss B’s physical health monitoring was undertaken by her GP and her dialectical behaviour therapist who frequently saw her face-to-face. It also said her consultant psychiatrist saw her once in-person during this period.

22. The records also show that Miss B was discussed in CMHT’S multidisciplinary team meetings on four occasions between September and October 2023 and it is noted that Miss B was losing weight rapidly at the meeting on 13 September 2023. Miss B’s unconfirmed weight was five stone in September 2023 at 27 years old. The multidisciplinary team meeting notes also include concerns raised by Miss B’s sister about her health and a request for an urgent face-to-face outpatient appointment.

23. According to NICE guidance NG69, treatment of anorexia should include monitoring of weight, mental and physical health, and any risk factors. While face-to-face monitoring is not explicitly mentioned in the guidance, our adviser says monitoring typically requires a mode of contact that enables adequate assessment and risk management, which telephone contacts are unlikely to fulfil, if used as the primary method of assessment.

24. Our adviser said Miss B’s known history of a complex eating disorder and the concerns raised by her family about her low weight meant that reliance on telephone contacts by her care coordinator was not justified. We note that the Trust also could not provide a justification for maintaining contact with Miss B over the telephone only.

25. As Miss B had a history of a complex eating disorder, and as there were concerns raised about her weight and mental health during this period, we consider that in line with NICE guidance NG69 the Trust should have assessed Miss B in person as this was the only way to ensure adequate monitoring and management of her condition. The Trust did not do this, and we find this to be a failing.

26. Miss B also added that the care coordinator worked in isolation from other services involved in her care, which adversely impacted on the overall care and treatment she received.

27. NICE guidance NG69 says support and treatment for anorexia nervosa should be multidisciplinary and coordinated between services.

28. The records show the Trust were aware of concerns raised by family members regarding Miss B’s weight loss. There was also an eating disorder referral completed on 18 September 2023 for Miss B’s GP’s consideration and a referral to the Eating Disorder Service was subsequently made.

29. As noted above the Trust discussed Miss B’s weight and engagement regularly in multidisciplinary meetings however, there is no evidence that the Trust liaised with other organisations in a collaborative way to meet Miss B’s health needs.

30. In its complaint response, the Trust acknowledged there was not much collaborative working as information was not regularly shared between Miss B’s GP and the CMHT. The Trust’s investigation also concluded that its notes and care plans did not detail what GP monitoring involved, did not record BMI or blood results, and did not set out actions if monitoring showed deterioration. The Trust accepted that each service cared for Miss B in isolation rather than considering her overall needs.

31. Therefore, we consider that the Trust did not act in line with NICE guidance NG69 as it did not provide a coordinated service for Miss B’s anorexia. We find this to be a failing.

32. We have gone on to consider whether having no face-to-face contact with her care coordinator or coordinated care, in the context of her overall health monitoring, would have had a material impact on her care.

33. Miss B says poor health monitoring contributed to her overall conclusion that the Trust did not take her mental health diagnoses and eating disorder seriously. Her physical and mental health deteriorated significantly during this period to the point that she was hospitalised for seven weeks with severe malnutrition.

34. Our adviser said when Miss B’s family raised concerns about her weight loss in September 2023, the CMHT should have provided an initial assessment and an actual or provisional diagnosis if possible.

35. Our adviser also said the CMHT should have identified risks and implemented and documented an integrated care plan, where required, with the involvement of Miss B’s GP and the eating disorder service with defined monitoring, including weight, BMI trend and relevant physical and mental health risks in line with NICE guidance NG69.

36. Our adviser said roles and responsibilities should have been clearly outlined, including escalation actions while awaiting specialist assessment and if risks change due to deterioration or low engagement. According to our adviser, Miss B’s care response was not sufficiently structured or coordinated and did not reflect the seriousness of her health condition.

37. Therefore, we consider that by not doing all the above, the Trust put Miss B at an increased clinical risk of deterioration, and we consider it is likely she would have experienced significant distress which would have contributed to her loss of trust.

38. As there were other organisations involved in her care, our adviser said it would be difficult to attribute the Trust’s actions alone to Miss B’s hospital admission in March 2024. However, we can say that there was a missed opportunity by the Trust to manage Miss B’s risk of her condition worsening to the extent she required hospitalisation.

39. In its complaint response, the Trust has apologised for Miss B’s poor health monitoring and identified actions for its community services, with an improved community mental health framework, to ensure there is a joined-up approach when providing care with a focus on providing treatment.

40. The Trust also said it would improve visibility on who would be providing Miss B’s ongoing care and the care coordinator offered to meet with Miss B’s family in November 2024.

41. Our NHS Complaint Standards say that organisations should be clear about how learning will be used to improve services and support staff. They also say that organisations should identify suitable ways to put things right for people.

42. We consider the actions the Trust have outlined are appropriate to ensure that it has learnt from this complaint, to prevent similar failings happening in future.

43. However, we consider the Trust still needs to do more to put right the impact caused to Miss B by this failing. Therefore, we have made a recommendation for this at the end of this report.

Mental capacity assessment

44. Miss B complains the care coordinator did not properly assess her mental capacity to make decisions regarding her care, in line with the Mental Capacity Act. She says her eating disorder would have impacted her ability to make reasoned decisions by virtue of the illness.

45. Miss B says if she had a mental capacity assessment, she might have received better health monitoring and prevented hospitalisation. She also says if she had an assessment and it showed that she lacked capacity, decisions could have been made in her best interests with family involvement.

46. The NICE guidance NG108 explains mental capacity is decision-specific, and an individual is assumed to have capacity, unless, on the balance of probabilities, proven otherwise. It also says organisations with responsibility for care and support plans should record whether a person has capacity to consent to any aspect of the care and support plan.

47. There is no evidence of a mental health assessment in the records. The Trust explained it did not record Miss B’s capacity or cognitive ability and acknowledged that the records do not demonstrate that any consideration was given to Miss B’s mental health issues and the impact on her ability to make specific decisions about her care and treatment.

48. This is not in line with the NICE NG108 guidance which says clinicians should consider and assess a patient’s mental capacity while caring for them. As such, we consider this to be a failing.

49. Given Miss B’s complex mental health issues and associated risks, capacity should have been considered and, if there was reason to doubt Miss B’s capacity, then it should be assessed and documented for specific decisions, in line with the NICE NG108 guidance.

50. Our adviser said a formal capacity assessment for Miss B’s ability to make decisions about her eating disorder mental health treatment, would have provided a starting point for further care planning.

51. Our adviser also said not having a capacity assessment would have reduced Miss B’s confidence on the quality of care and support she was receiving and a formal capacity assessment may also have provided an initial basis to consider sharing information with Miss B’s family towards acting in her best interests and optimising her care.

52. Miss B was understandably concerned about the lack of a capacity assessment which she feels she would have benefitted from, given her complex health needs. We cannot say what the outcome of any capacity assessment would have been, or whether Miss B would have been considered to have lacked capacity. Therefore, we cannot say what impact the lack of assessment had in this case.

53. Therefore, we can say that this was a further missed opportunity to improve on Miss B’s overall care and reduce the risk of her deterioration.

54. While there is no clear evidence that a mental capacity assessment would have prevented Miss B’s hospitalisation in March 2024, as admission may still have been required, our adviser said the absence of a documented capacity assessment likely contributed to uncertainty and inconsistent practice around consent and information sharing, discussed further below.

55. We note that the Trust has acknowledged that it did not assess and document Miss B’s mental capacity despite her health complexities which warranted a formal assessment. It also said it would improve its understanding of mental health capacity assessments by ensuring staff are up to date with annual training.

56. Our NHS Complaint Standards say that organisations should be clear about how learning will be used to improve services and support staff. They also say that organisations should identify suitable ways to put things right for people.

57. We consider the actions the Trust have outlined are appropriate to ensure that it has learnt from this complaint, to prevent similar failings happening in future.

58. However, we consider the Trust still needs to do more to put right the impact caused to Miss B by this failing. Therefore, we have made a recommendation for this at the end of this report.

Information sharing with family and carers communication plan

59. Miss B complains the Trust did not follow its policy for sharing information with carers and did not have a carers communication plan which resulted in inappropriate communication with her family.

60. With regards to information sharing with carers and family, the Trust’s Information Sharing Policy says consent to share information with a patient’s family must be sought and it is important that the practitioner records the patient’s decision about sharing information on each occasion they do so and the justification for the decision.

61. The Trust’s Information Sharing Policy also says when a patient does not consent to information sharing, this does not prevent practitioners from listening to the views of family members or prevent them from providing general information; this is echoed in the NICE NG225 guidance.

62. The Trust has explained that Miss B’s consent for sharing information was obtained and it had an information sharing form, though the consent decision was not always recorded on the form.

63. The Trust also acknowledged that the information it relayed to Miss B’s family did not always reflect Miss B’s time specific consent decision. For example, even though it was recorded in its progress notes on 23 March 2024 that Miss B had consented to sharing information with her mum and sister, the entry was not validated on the Trust’s system until 18 April 2024. This led to miscommunication with Miss B’s sister on 25 March 2024 when she was erroneously told that there was no documented permission to share.

64. The Trust also acknowledged that it had not followed up on Miss B’s sister’s request to speak to a clinician on the basis that there was no documented permission to share information with family. It also said while the Trust’s Information Sharing Policy says consent should be regularly checked, it did not mean that Miss B’s consent should be checked at every point of contact with her family, as was the misconception.

65. We have seen that the Trust did not clearly and accurately record Miss B’s time specific consent decisions and had misunderstood its information sharing policy when communicating with Miss B’s sister, regarding what types of contact can be made with family even if information sharing is declined. This is not in line with its Information Sharing Policy and NICE NG225 guidance and as such, we find this to be a failing.

66. Our adviser said failures in proper information sharing with family may have led to disrupted communication and undermined collaborative risk management for Miss B. Our adviser also said poor information sharing may have led to a degree of patient and carer distress and would have reduced effective care optimisation.

67. With regards to a carer’s communication plan, the Trust’s Adult Mental Health CMHT SOP, says the Trust will work with carers and families and will offer all identified carers the opportunity to complete a Carer’s Communication Plan. In addition, the service user experience in adult mental health services guidance says care plans should include the degree to which families and carers are involved, for example, in a crisis.

68. Our adviser said carer collaboration should be integrated in the general care plan and a carer communication plan may capture important information such as identified carers, what information can and cannot be shared, how carers can provide information, crisis or escalation contacts, when consent preferences are reviewed and where recorded, and what to do if carers are concerned about risk.

69. The Trust did not complete a carers communication plan. This is not in line with the Trust’s Adult Mental Health CMHT SOP or the service user experience in adult mental health services guidance and we find this to be a failing.

70. This would have undoubtedly led to disappointment for Miss B and her family and would likely have caused distress at an already distressing time when they were concerned about Miss B’s health. Our adviser said, given Miss B’s health complexities and her reliance on family support, a specific carers communication plan would have been valuable for her and her family.

71. In its complaint response, the Trust acknowledged that it did not complete a carers communication plan. The Trust explained that it would roll out training to all clinical staff on how to utilise its clinical electronic recording system to ensure accurate note recording. It also said training would focus on information sharing and working with carers and families.

72. The Trust has confirmed that it has delivered this training, and has implemented an improved recording system, to improve communication with family. The Trust has also employed a carers worker.

73. Our NHS Complaint Standards say that organisations should openly identify instances when things have gone wrong and take responsibility for these. They should make sure staff look at what action will be taken to learn from the experience to continuously improve services and help support staff.

74. We consider that in line with our NHS Complaint Standards, the Trust did identify where things went wrong and has demonstrably taken learning from this to improve its services. We consider the actions the Trust have outlined are appropriate to ensure that it has learnt from this complaint, to prevent similar failings happening in future.

75. However, we consider the Trust still needs to do more to put right the impact caused to Miss B by this failing. Therefore, we have made a recommendation for this at the end of this report.

Complaint handling

76. Miss B complains about the Trust’s complaints handling. She says the Trust did not investigate her complaint properly and this led to the Trust carrying out an external investigation. She also says she had to wait for a number of weeks for the complaint outcome, after continuously asking for updates.

77. The Regulations say the organisation investigating a complaint should send the complaint response, ‘within the relevant period’. It defines this as ‘the period of six months commencing on the day on which the complaint was received’.

78. Our NHS complaint standards say organisations should take a thorough, proportionate, and balanced look into the issues raised in a complaint, give people fair and open answers to their questions based on the facts, and take full accountability for mistakes identified.

79. Miss B, via her sister, raised a formal complaint to the Trust in April 2024 expressing her dissatisfaction about her care and treatment. The Trust sent a formal acknowledgment of her complaint on 24 April 2024 and issued the complaint report on 9 August 2024 with an action plan appended.

80. The notes show that Miss B’s sister contacted the Trust regularly between March 2024 (when the complaint was initially logged as a concern) and August 2024 to ask for updates and the Trust responded each time with an apology and reasons given for the delay and next steps. This is in line with Our NHS Complaint Standards.

81. It took the Trust approximately four months to investigate Miss B’s complaint. This is in line with the Regulations.

82. We understand how frustrating it would have been for Miss B and her family to have received the investigation outcome later than expected, having to chase for updates and then being notified of the changes with the complaint investigator.

83. We can see that the Trust apologised each time it responded to Miss B’s sisters request for updates on the complaint investigation. It explained that the delay was related to the initial investigating officer having to take some time off work and not being able to respond to some questions pertaining to the outcome of their findings.

84. The Trust said as a result of the initial investigating officer remaining off work, it allocated the complaint investigation to another mental health practitioner. We consider the Trust has provided a valid reason why it had to assign the complaint to another mental health practitioner and the reasons the complaint outcome was issued later than planned. There is no evidence in the notes to suggest that the reassigning of the complaint to another investigator was for any reason other than staff absence.

85. We consider the Trust’s complaints handling was in line with the Regulations and Our NHS Complaint Standards and its reason for reassigning the complaint to a new complaint handler was unavoidable and properly explained to Miss B’s family at the time. As such, we have not found a failing with the Trust’s complaints handling.

1. Miss B complains about Hampshire and Isle of Wight Healthcare NHS Foundation Trust (the Trust) care and treatment. We appreciate Miss B’s particularly difficult health circumstances leading up to her hospitalisation in March 2024 and the ongoing impact of the issues raised in her complaint.

2. We have found that the Trust did not monitor and manage Miss B’s mental health diagnoses and eating disorder appropriately, and it did not carry out a mental health assessment which would have established whether Miss B was able to make decisions regarding her care.

3. We have also found that the Trust did not adhere to its policy for sharing information with carers and did not complete a carer’s communication plan. Finally, we have not found any failings in the Trust’s complaints handling.

4. As such, we partly uphold this complaint and recommend the Trust pays Miss B £1,000.

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

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

What we found

88. Through investigating Miss B’s complaint, we have found that the Trust failed to properly monitor Miss B face-to-face from September 2023 to March 2024 and failed to take her mental health diagnoses and eating disorder seriously in line with NICE guidance NG69. This meant there were many missed opportunities by the Trust to manage Miss B’s risk of her eating disorder worsening to the extent that she required hospitalisation.

89. We also found that the Trust failed to assess Miss B’s capacity to make decisions regarding her care in line with the Mental Capacity Act, as recommended by the NICE guidance NG108, and it did not follow its policy for sharing information with carers and it did not have a carers communication plan. These were further missed opportunities for proper care planning.

90. The lack of a documented capacity assessment would likely have contributed to uncertainty and inconsistent practice around consent and information sharing. The lack of information sharing led to disappointment for Miss B and her family and caused distress at an already distressing time when they were concerned about Miss B’s health.

What the organisation should do

91. Our Principles for Remedy say organisations should acknowledge poor service and take steps to put things right when this leads to an injustice of hardship.

92. Our Principles for Remedy say organisations should compensate people appropriately if they cannot return the person affected to the position they would have been in if the poor service had not occurred.

93. 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. Following this review, we recommend the Trust:

• pay Miss B £1000 for failing to take her mental health diagnoses and eating disorder seriously, for the missed opportunities to manage risks in her declining health and the associated distress caused by the failings identified • send us evidence it has done this within one month from the date of the final report.