Avon and Wiltshire Mental Health Partnership NHS Trust

7. Mrs J raises concerns about the care and treatment provided to her brother, Mr X, by Trust A and Trust B between 9 and 16 June 2023.

North Bristol NHS Trust 8. Mrs J says Mr X was admitted to Trust A on 9 June following a mental health crisis and self‑harm. She is concerned about the decisions made during his assessment and discharge. Specifically, she says: • Mr X was discharged on 10 June despite being unfit to leave, and without the full assessment that had been discussed • the family was not informed of the discharge decision.

Avon and Wiltshire Mental Health Partnership NHS Trust 9. Mrs J says Mr X was visited at home by the Intensive Support Team (IST) between 11 and 15 June. She is concerned about how his ongoing risk was managed during this period, particularly given that he was recorded as ‘high risk’ in his notes. Specifically, she says it: • missed opportunities on 11 and 12 June to appropriately escalate his care • did not communicate information to the family about his appointments.

10. Mrs J says Mr X died following a period of mental health crisis. She believes that decisions about his discharge, the management of his ongoing risk, and the lack of communication with the family contributed to his deterioration. She describes profound and lasting emotional impact on the family, including grief, trauma, anxiety, and symptoms of PTSD. They feel they have been left without answers or closure.

11. Mrs J would like an apology, service improvements, and a financial remedy.

12. In the early evening on 9 June 2023, Mr X arrived at Trust A’s Emergency Department (ED) with his brotherinlaw, presenting with mental health concerns and selfharm injuries. He was triaged to the emergency department assessment unit (EDAU), where a senior nurse assessed him, recorded his initial observations, and repeated them around four hours later, noting no clinical deterioration.

13. Later that evening, a senior practitioner from the mental health liaison team carried out a mental health assessment. During this assessment, Mr X disclosed a history of emotionally unstable personality disorder (EUPD), anxiety, and possible emerging psychotic symptoms. The practitioner assessed him as medium to high risk of further selfharm, with no identified risk to others.

14. The records show a discharge plan was agreed with Mr X. We note the family have consistently told us they disagreed with discharge and believed he should have been detained under the Mental Health Act. It made a referral to Trust B’s IST, a community mental health service providing shortterm, intensive support for people experiencing acute mental health difficulties. The IST planned to contact him on the evening of 10 June and visit him the following day.

15. On 10 June, the senior practitioner reviewed Mr X’s presentation and confirmed there was no change in his assessed risk. Mr X was then discharged. Trust A did not contact the family.

16. Between 11 and 15 June, the IST visited Mr X at home. He declined contact on 11 June but accepted a visit on 12 June after further self-harm. A registered mental health nurse (RMN) and recovery coordinator assessed his presentation as consistent with EUPDrelated paranoia. Evident by heightened suspiciousness linked to emotional distress, rather than psychosis, which involves a loss of contact with reality such as hallucinations or delusional beliefs.

17. On 13 June, a psychiatrist with an RMN reviewed Mr X and found no evidence of psychosis or mood disturbance. Mr X agreed to ongoing support, and staff scheduled a follow-up appointment for 15 June.

18. Mr X did not attend the appointment on 15 June. Staff made a follow-up call, but they did not inform the family about the missed contact. On 16 June, after failing to reach Mr X, the family and police carried out a welfare check, meaning they attended his home to confirm his safety after being unable to contact him. Sadly, they found Mr X dead later that day.

Findings Trust A Discharge Decision 24. Mrs J says Trust A discharged Mr X, on 10 June 2023 during a severe mental health crisis. She says Trust A had told the family a full assessment would take place, but this did not happen, and they were not informed of the discharge decision. She says these decisions contributed to his deterioration and eventual death.

25. Trust A explained Mr X was assessed in the ED on 9 June by a mental health liaison team practitioner. It said the practitioner concluded Mr X could be safely discharged with follow-up from the IST. Trust A said Mr X agreed to this plan and had capacity to make decisions about his care.

26. We reviewed the clinical records, considered the relevant guidance and asked our MHN adviser to consider whether the assessment and discharge were appropriate from a nursing perspective.

27. They explained that decisions to admit or discharge after self‑harm rely on clinical judgement, and it is not uncommon for people presenting to ED after self‑harm to be discharged with community follow‑up.

28. NICE NG225 guidance notes while admission can provide a safe environment, it can also cause distress, and decisions regarding admission should be based on individual circumstances rather than self-harm alone.

29. Our MHN adviser reviewed the full assessment documentation. They explained it was sufficiently comprehensive and showed that Mr X was seen on two occasions whilst in the ED. The documentation supported Mr X had capacity to make decisions about his care, including going home and receiving support from the home‑based treatment team.

30. Both our advisers agree Mr X's risk should have been categorised as 'high' under Trust A's operational policy. Our MHN adviser considered that, given the level of risk identified, consideration of escalation or discussion with a Clinical Service Manager (CSM) and senior medical staff would reasonably have been expected and should have been documented.

31. We note the assessing clinician recorded in follow up correspondence with Mr X's GP that he was at ‘medium to high’ risk of further self-harm. However, the specific contemporaneous risk assessment required by the policy was not completed. There is no evidence that a formal risk category was allocated in accordance with the Trust's risk assessment matrix.

32. However, our MHN adviser noted the policy does not require referral to a CSM in every high-risk case and does not clearly define the role of the CSM. The assessing clinician was themselves a senior clinician. We note Trust A accepts aspects of the policy are unclear and has told us it intends to review and update the policy. We agree the policy lacks clarity around the circumstances in which escalation should occur and the role of the CSM.

33. The records show Mr X was described as having capacity, consenting to future care, and not presenting with imminent suicide risk. Under the principles of least restrictive practice, the plan for home‑based treatment was clinically sound and aligns with the least restrictive principle set out in the MHA code of practice.

34. Our MHN adviser did not consider the circumstances required referral for a Mental Health Act assessment.

35. We recognise Mr X described his actions as a suicide attempt. We have considered the family's evidence that Mr X had used alcohol and drugs and expressed suicidal thoughts. However, both the contemporaneous records and our MHN adviser indicate staff assessed him as having capacity at the time relevant decisions were made.

36. Our MHN adviser explained under NICE NG225 guidance, the term ‘self‑harm’ is used to describe all acts of self‑injury or self‑poisoning regardless of intent, and therefore the self‑harm guideline remained the appropriate framework for assessing and managing his presentation. Wrist‑cutting is a common form of self‑harm.

37. Based on our MHN advice, we consider the overall assessment and the decision to discharge Mr X with home-based treatment were in line with national guidance and accepted clinical practice. However, Trust A did not complete the specific risk assessment required by its operational policy.

38. In addition, although Mr X's presentation reasonably met the policy criteria for a high-risk categorisation, there is no evidence that consideration was given to escalation or further senior discussion in line with the policy guidance. While the policy does not require referral to a CSM in every high-risk case, these omissions represent failings, which we address separately below in the impact section.

No communication of discharge

39. Mrs J says Trust A did not inform the family Mr X was being discharged on 10 June. She says if they had known, they could have helped him return home safely, for example by preparing the flat and ensuring the environment was suitable. She believes the lack of communication contributed to Mr X’s poor mental health and the family’s distress.

40. Trust A’s complaint response acknowledges there is no evidence the family were contacted on 10 June. It said it assumed the plan discussed the previous evening would continue and accepted that a follow up call ‘would have been appropriate’. Trust A also explained it had taken steps to address this through service improvements.

41. We asked our MHN adviser to consider how discharge decisions are normally communicated to families. They explained there is no single national standard for discharge communication from ED. However, general good practice in mental health care includes: • discussing with the patient what information can be shared • involving families or carers where appropriate • providing verbal or written information about the discharge plan • balancing confidentiality with safety.

42. The records show Mr X’s family had been involved in discussions during the assessment on 9 June, and there is no indication Mr X refused consent for information to be shared with them.

43. Involving families can support continuity of care, but communication must always take account of the patient’s preferences and capacity.

44. Based on the relevant guidance and evidence from our MHN adviser, we consider Trust A should have communicated more clearly with the family on 10 June. Communication was not in line guidance. This was a failing.

45. Understandably, Mrs J says the lack of communication contributed to Mr X’s poor mental health and caused distress to the family. We consider the impact of this failing below.

Trust B Missed opportunities to escalate care following deterioration on 11 and 12 June 46. Mrs J says the IST missed opportunities on 11 and 12 June to escalate Mr X’s care, despite clear signs of deterioration, further self-harm, and the concerning state of his flat.

47. She believes Trust B should have recognised the seriousness of his presentation and taken steps to ensure he was admitted to hospital or assessed under the MHA 1983.

48. The MHA 1983 is the legal framework that allows people to be detained in hospital for assessment or treatment when there is significant concern about their safety or the safety of others.

49. Trust B said Mr X declined a visit on 11 June. It said it reviewed him at home on 12 June, and the IST arranged a senior medical review for 13 June. The review did not identify psychosis or a need for antipsychotic medication. Trust B said this was the least restrictive option of suitable care. The MHA code of practice requires services to use the least restrictive option where safe to do so.

50. Our MHN adviser explained escalation decisions in crisis teams (such as the IST) rely heavily on clinical judgement and that there is no single national standard governing how teams must respond.

51. They agreed the IST acted within least restrictive principles. This was because Mr X was described as having capacity, was willing to work with the team, and had agreed to home treatment. They did not consider there were grounds for a mental health act assessment from a nursing perspective.

52. Trust B has a ‘did not attend’ (DNA) policy. The policy applies where a patient fails to attend without prior cancellation. On 11 June, the records show staff successfully contacted Mr X and he actively declined the visit. Because contact was made and the appointment was refused rather than missed, this was not treated as a DNA under the policy.

53. We also considered whether the IST should have escalated care on 11 June based on risk, given the recent selfharm with suicidal intent and the proximity to the crisis event on 9 June.

54. We have seen Trust B appropriately applied the DNA policy and the records show clinicians assessed Mr X as being at high risk of further self-harm but did not assess him as being at an immediate or imminent risk of suicide at that time. These are related but clinically distinct risk assessments.

55. Before considering our psychiatrist adviser’s view, it is important to clarify terminology and the different clinical frameworks used by our advisers. Mr X described the incident on 9 June as a suicide attempt, and our psychiatrist adviser agreed his stated intention was to end his life.

56. Our MHN adviser, applying the NICE NG225 self-harm framework used in nursing practice, explained all acts of self-injury or self-poisoning are categorised as ‘self-harm’ regardless of intent. The difference reflects the professional frameworks used by each adviser, not a disagreement about the seriousness of the event.

57. NICE NG225 guidance on self-harm says services should take a person’s recent history, intent, and current mental state into account when assessing risk, and should escalate care where there are concerns about safety or deterioration.

58. Our psychiatrist adviser said that declining the IST visit on 11 June, so soon after a suicide attempt, should have been treated as a concerning sign requiring further attempts to engage Mr X or escalation to senior clinical or psychiatric review.

59. NICE NG225 guidance also says new self-harm, worsening mental state, or substance misuse should prompt urgent reassessment and consideration of more intensive support. The IST’s visit on 12 June documented new self-harm, possible psychotic symptoms, substance misuse, and a substantial overdose.

60. The IST practitioners, who were mental health nurses, recorded Mr X was at ‘very high risk’ of further self-harm or suicide. Our psychiatrist adviser said this level of deterioration should have prompted the IST to seek urgent psychiatric input. A psychiatrist would likely have explored hospital admission or, if refused, a mental health act assessment.

61. Our psychiatrist adviser reviewed the senior medical assessment on 13 June. While some aspects were in line with good practice, there were significant omissions, including:

• no exploration of suicidal thoughts or intent • no mental state examination • no risk assessment • no capacity assessment • no collateral history • no rationale for not considering admission or a mental health act assessment • no safety netting • no exploration of substance use or protective factors.

62. GMC guidance says doctors must adequately assess a patient’s condition, take account of their history, and take prompt action if they believe patient safety is at risk. The omissions in the 13 June assessment did not reflect the standard of assessment expected under GMC guidance.

63. NICE CG78 guideline also says in a crisis, clinicians should consider short term sedative medication as part of a wider plan, and this was not explored or documented.

64. Some elements of the assessment were consistent with NICE CG78 guideline on borderline personality disorder, such as recognising long term psychotropic medication is not recommended for EUPD and psychological interventions are evidence-based treatment.

65. Conducting the assessment in Mr X’s home was consistent with NICE CG136 guideline on service user experience, which recommends assessing people in the least restrictive and most comfortable environment. However, we consider these positive elements do not mitigate the significant omissions in the assessment.

66. Given the deterioration documented on 12 June and the absence of a comprehensive assessment on 13 June, we are not satisfied the IST fully considered whether community management remained the least restrictive safe option.

67. We have carefully considered the differing clinical views of our advisers. Our MHN adviser emphasised capacity, consent, least restrictive practice, and adherence to local policy. Our psychiatrist adviser emphasised the severity of Mr X’s deterioration, the combination of risk factors, and the omissions in the 13 June assessment.

68. We recognise clinical judgement plays a significant role in crisis work. However, the documented deterioration on 12 June, combined with the lack of documented exploration of risk, intent, mental state, and capacity on 13 June, raises concerns about whether the IST fully considered the level of risk or the need for escalation.

69. Our psychiatrist adviser explained hospital admission provides 24-hour monitoring, a safe environment, and the opportunity for detailed assessment of mental state and risk, which cannot be replicated in the community.

70. It is reasonable to say it was more probable than not that admission at this point would have reduced Mr X’s immediate risk and provided an opportunity to stabilise his mental state before returning home.

71. On balance, we consider there were missed opportunities on 11 and 12 June to escalate Mr X’s care. The limited assessment on 13 June provides further evidence escalation had not been adequately considered following this deterioration. We go on to consider the impact of these failings later in our report.

Lack of communication about missed appointment

72. Mrs J says the IST did not communicate information about Mr X’s appointments or ongoing care between 11 and 15 June. She says the family were unaware of when he was being seen, how he was presenting, or what concerns staff had about his mental state. She says this lack of communication prevented them from supporting him and contributed to their distress.

73. Trust B said Mr X was an informal patient with capacity and the IST followed its noncontact procedure when he declined or missed appointments. It also said it had followed its DNA policy.

74. We reviewed Trust B’s DNA policy. This says when a patient does not attend a planned contact, staff should consider the patient’s risk, recent deterioration, and any relevant information from family or other agencies.

75. It also requires staff to create a documented response plan after the first DNA, which may include contacting the family, updating the risk assessment, ‘cold calling’ at the patient’s home, or escalating concerns to a senior clinician.

76. Our MHN adviser clarified the declined visit on 11 June did not constitute a DNA, as Mr X actively declined the appointment. The DNA policy therefore did not apply on this date.

77. On 15 June, Mr X did not attend his scheduled appointment. The records show the IST attempted to call him once and left a voicemail message. There is no evidence of any further attempts to contact him, nor of a documented response plan or discussion with a senior clinician.

78. Because this was a DNA, Trust B’s policy should have been followed. The DNA policy required the IST to agree and document a response plan, consider further call attempts, and escalate the situation within the team.

79. As a minimum, the IST should have considered contacting the family, attempting a cold call at Mr X’s home, or making additional efforts to reestablish contact.

80. The records do not show any of these steps were taken. There is no evidence the IST updated the risk assessment, contacted the family, discussed the DNA with a senior clinician, or considered a cold call or safe and well check.

81. Trust B told Mrs J it had followed its DNA policy. Our review shows this was not accurate. The actions required under the policy were not taken, and no response plan or escalation was documented.

82. Because the required steps were not taken, Trust B did not inform the family Mr X had not attended his appointment on 15 June. This meant they were unaware he had disengaged from support at a time when the IST had recently assessed him as being at very high risk. Not knowing this retrospectively caused the family avoidable distress and represented a missed opportunity for the family to step in and support him.

83. Based on the policy and the clinical context, we consider the IST should have taken additional steps to manage the noncontact on 15 June. The policy required a documented response plan and consideration of contacting the family.

84. Given the level of risk recorded and the deterioration noted on 12 June, we consider the IST’s actions fell below the standard set out in its own policy. This was a failing.

85. The inaccurate information provided in Trust B’s complaint response further compounded the family’s distress. On this basis, we find there was a failing. We address the impact of this failing in the impact section below.

86. We recognise how deeply distressing these events were for Mrs J and her family. They were trying to support Mr X during an extremely vulnerable period, and the lack of communication at a critical time left them feeling excluded, powerless, and fearful for his wellbeing.

Impact

87. For each Trust we have discussed the impact of the failings we have identified.

Trust A

88. Based on the evidence and clinical advice, we consider there were failings on 9 June in the risk categorisation, escalation process, and management of the discharge decision.

89. On 9 June, Mr X should have been categorised as ‘high risk’ under Trust A’s policy. Had this occurred, there should have been documented consideration of escalation or senior clinical discussion before discharge was confirmed. This escalation did not take place.

90. While we cannot say that escalation on 9 June would have led to a different decision about discharge or to detention under the Mental Health Act, it represents a lost opportunity for a more senior clinical review at a critical point in Mr X’s presentation.

91. Trust A has acknowledged there were failings in communication around Mr X's discharge on 10 June. The family were not informed he had been discharged, meaning they were unaware he had returned to the community at a time when he remained vulnerable. This deprived them of the opportunity to consider what support they might have been able to provide.

92. The family have told us this has caused them significant distress. They believe they might have been able to help if they had known he had been discharged, and they continue to live with uncertainty about what difference their involvement might have made.

93. Taken together, these issues represent two distinct failings. First, while we do not disagree with the clinical decision to discharge Mr X on 9 June, Trust A did not follow its own policy when determining his risk level and deciding on discharge.

94. This creates avoidable uncertainty for the family about whether a more senior review might have led to a different outcome. Second, the failure to communicate the discharge on 10 June meant the family were not given the opportunity to support Mr X at a time when he remained vulnerable.

95. Trust A has acknowledged this communication failing, apologised, and taken steps to improve its service. However, the family have described the distress this caused and the ongoing uncertainty about what difference their involvement might have made.

96. We have taken this into account when making our recommendations at the end of this report.

Trust B

97. From 11 June onwards, responsibility for Mr X’s care lay with Trust B’s IST. We consider there were missed opportunities on 11 and 12 June to escalate concerns and to reconsider whether community management remained the least restrictive safe option.

98. On 11 and 12 June, the IST documented clear deterioration, new self‑harm, substance misuse, and concerns about very high risk. Despite this, there is no evidence the team fully reconsidered whether hospital admission or a Mental Health Act assessment should be explored.

99. The limited assessment on 13 June did not adequately explore suicidal intent, mental state, capacity, or the rationale for not considering hospital admission or a Mental Health Act assessment.

100. We cannot say Mr X would have been detained or that admission would have prevented his death. Both advisers agreed detention was not a certain outcome.

101. However, our psychiatrist adviser considered it more probable than not that hospital admission at this stage would have reduced Mr X’s immediate risk, as it would have provided 24‑hour monitoring, a safe environment, and the opportunity for a fuller assessment.

102. In addition to these clinical issues, the failure to follow Trust B’s DNA policy on 15 June meant the family were not informed when Mr X disengaged from support. The IST attempted one phone call and left a voicemail but did not agree a response plan, escalate concerns within the team, or consider contacting the family, despite having recently assessed him as ‘very high risk’.

103. We also note Trust B’s complaint response stated the DNA policy had been followed, which was not accurate. This added to the family’s distress and contributed to their sense of being excluded from Mr X’s care at a critical time.

104. The lack of communication on 15 June meant the family were unaware Mr X had not attended his appointment. As a result, they were not alerted to concerns about his disengagement from services at a time when he had recently been assessed as presenting a very high level of risk.

105. The resulting uncertainty about whether their involvement might have reduced his immediate risk or altered the sequence of events leading to his death has caused significant emotional harm and undermined their confidence in the care provided.

106. We recognise how profoundly difficult these events have been for the family. They were trying to support Mr X during an extremely vulnerable period, and the missed opportunities and gaps in communication left them feeling powerless and excluded from his care.

107. The uncertainty about what might have been different has caused deep and understandable distress. We acknowledge the courage it has taken for the family to raise these concerns and the emotional toll of revisiting these events.

1. We are sorry for the loss of Mr X and recognise the significant impact his death has had on his family. Having carefully considered all the evidence, including independent clinical advice, we have identified failings by both North Bristol NHS Trust (Trust A) and Avon and Wiltshire Mental Health Partnership NHS Trust (Trust B).

2. For Trust A, we have identified a failing in the risk categorisation and escalation of Mr X’s care on 9 June. We consider this contributed to avoidable uncertainty for the family about whether a different clinical response might have reduced Mr X’s immediate risk.

3. We have not identified failings in relation to the decision to discharge Mr X on 10 June, but we have seen failings in relation to the communication of that discharge.

4. For Trust B, we have identified several failings. These relate to missed opportunities on 11 and 12 June to escalate Mr X’s care in response to clear deterioration. We have seen a limited assessment on 13 June which did not adequately explore risk, intent, mental state, or capacity. We have also seen a failure to follow Trust B’s ‘did not attend’ (DNA) policy on 15 June, which meant the family were not informed when Mr X disengaged from support.

5. We therefore partly uphold the complaint.

6. Given the impact of the failings we have identified, we are making recommendations to both Trust A and Trust B. These include apologies, financial remedies and action plans to address the issues we have identified and reduce the risk of similar failings occurring in future.

108. We make recommendations in line with our Principles for Remedy, which are reflected in the NHS Complaint Standards. These say organisations should identify where things have gone wrong, take responsibility, and find ways to put things right. They should also learn from complaints to improve services.

109. We expect organisations to take action to compensate people appropriately if they cannot return them to the position they would have been in if the poor service had not occurred. To decide on a level of financial remedy, we consider similar cases and our severity of injustice scale.

Recommendations to Trust A

110. We have identified a failing by Trust A in relation to: • the incorrect risk categorisation on 9 June and the missed opportunity to escalate Mr X’s care at that point • the failure to communicate Mr X’s discharge on 10 June.

111. We consider these failings contributed to avoidable uncertainty for the family and caused distress.

112. We therefore recommend Trust A: • writes to Mrs J within four weeks of the date of this report to acknowledge the failings we have identified and apologise for the impact this had.

• Pays Mrs J £300 within four weeks of the date of this report in recognition of the avoidable uncertainty and distress caused by the incorrect risk categorisation • Provides an action plan within 12 weeks of the date of this report explaining what steps it will take, or has taken, to address the failings identified.

Recommendations to Trust B 113. We have identified failings by Trust B in relation to the: • missed opportunities on 11 and 12 June to escalate care in response to clear deterioration • limited assessment on 13 June, which did not adequately explore risk, intent, mental state, or capacity • failure to follow Trust B’s DNA policy on 15 June, which meant the family were not informed when Mr X disengaged from support • inaccurate information in Trust B’s complaint response, which stated the DNA policy had been followed when it had not.

114. We consider these failings led to significant avoidable uncertainty about whether a different clinical response might have reduced Mr X’s immediate risk and caused considerable distress to the family.

115. We therefore recommend Trust B: • writes to Mrs J within four weeks of the date of this report to acknowledge the failings we have identified and apologise for the impact these had.

• Pays Mrs J £900 within four weeks of the date of this report in recognition of the avoidable uncertainty and distress caused by the missed opportunities to escalate care and the failure to follow the DNA policy.

• Provides an action plan within 12 weeks of the date of this report explaining what steps it will take, or has taken, to address the failings identified.

116. The action plans should be shared with us, the complainant, and the Care Quality Commission.

117. We appreciate the considerable understanding, and patience Mrs J has shown throughout our investigation, particularly given the circumstances and the concerns she raised about missed opportunities in her brother’s care.

118. We recognise revisiting these events is not easy and our decision may be difficult for her to read. We hope they provide clarity about what happened and the steps that will now be taken.