Summary: The Ombudsmen found no fault by the Council, Trust or CCG with regards to the care and support they provided to a woman with mental health problems. The Ombudsmen did find fault with a risk assessment the Trust completed. However, we are satisfied this did not have a significant impact on the care the Trust provided.

The complaint

1. The complainant, who I will call Mr X, is complaining about the care and treatment provided to his ex-wife, Mrs Y, by Nottinghamshire County Council (the Council), Bassetlaw Clinical Commissioning Group (the CCG) and Nottinghamshire Healthcare NHS Foundation Trust (the Trust).
2. Mr X complains that professionals involved in Mrs Y’s care failed to act when her condition deteriorated in early 2018. Mr X also complains that following an incident in February 2018, the Trust and Council imposed unfair sanctions on Mrs Y. Mr X says this means she is unable to access the care and support she needs.

Back to top

The Ombudsmen’s role and powers

3. The Ombudsmen investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, the Ombudsmen consider whether it has caused injustice or hardship (Health Service Commissioners Act 1993, section 3(1) and Local Government Act 1974, sections 26(1) and 26A(1), as amended).
4. If the Ombudsmen are satisfied with the actions or proposed actions of the bodies that are the subject of the complaint, they can complete their investigation and issue a decision statement. (Health Service Commissioners Act 1993, section 18ZA and Local Government Act 1974, section 30(1B) and 34H(i), as amended)

Back to top

How I considered this complaint

5. In making this final decision, I considered information provided by Mr X and discussed the complaint with him. I also considered comments and documentation provided by the Trust and Council. Furthermore, I invited comments on my draft decision from Mr X and the organisations he is complaining about and took account of what they said.

Back to top

What I found

Relevant legislation and guidance

Mental Health Act 1983

6. Under the Mental Health Act 1983 (the MHA), a person with a mental disorder who is considered to be putting their safety, or that of someone else, at risk, they can be detained in hospital against their wishes for treatment.
7. A person who has been detained for treatment under the MHA can be discharged back into the community under a Community Treatment Order (CTO). A CTO is intended to help patients to maintain stable mental health outside hospital and promote recovery.
8. A CTO includes conditions with which the patient is required to comply. These should ensure the patient receives treatment for the mental disorder. The conditions should also reduce the risk of harm to the patient and other people resulting from the mental disorder.
9. Failure to comply with the conditions attached to the CTO can result in the recall of the patient to hospital. The Mental Health Act Code of Practice that accompanies the MHA emphasises that this a decision for the responsible clinician.
10. Patients under a CTO are entitled to free aftercare services under Section 117 (s117) of the MHA. The statutory duty for providing, or arranging for the provision of, s117 aftercare services rests jointly with the local authority and local clinical commissioning group.
11. Mrs Y is on a CTO and so is entitled to s117 aftercare services. I have included the CCG within my investigation due to its statutory duty in this regard. However, I have also included the Trust as this is the service provider from which the CCG commissions mental health services.

Local policies

12. The Trust produces a policy entitled Preventing, minimising and managing aggressive and violent behaviour (2017). This sets out guidance for staff on how to deal with violent or aggressive behaviour exhibited by patients or service users.
13. Section 1.3 of the policy provides a definition of violence at work. This includes “[a]ny incident in which a person working in the Healthcare sector is verbally abused, threatened or assaulted by a patient or member of the public in circumstances relating to his or her employment.”
14. Section 6.1 of the policy says that “[r]isk assessments are a crucial component in preventing and minimising aggressive and violent behaviour.” Section 6.5 explains that risk assessments should be subject to “a regular timely review which must not exceed 12 months.”
15. Section 11.6 of the policy sets out that any response by staff to violent or aggressive behaviour should be “a proportionate, legal, acceptable, necessary and reasonable response to the circumstances and risk posed by the service user at that time.”

Key facts

16. Mrs Y has diagnoses of Delusional Disorder, Mixed Personality Disorder, depression and anxiety. In 2010, following a period of detention under the MHA, Mrs Y was placed on a CTO and discharged home.
17. At the time of the events complained about, Mrs Y was living at home with Mr X.
18. The terms of Mrs Y’s CTO required her to attend hospital every fortnight for a depot injection of antipsychotic medication.
19. Mrs Y was under the care of a Local Mental Health Team (LMHT – part of the Trust). As part of the support provided by the LMHT, Mrs Y received regular visits from her care coordinator, a community psychiatric nurse (CPN).
20. In addition, the Council funded six hours per week of support worker visits for Mrs Y.
21. In February 2018, the CPN and a support worker visited Mrs Y at home. The CPN and support worker said that, during the visit, Mrs Y approached them with a kitchen knife. They left the property immediately and reported the incident to the police. However, no charges were brought against Mrs Y.
22. The CPN reported the incident to the Council. At that point, the Council and Trust suspended home visits to Mrs Y pending further assessment of the situation.
23. In March 2018, a multidisciplinary team meeting agreed that health professionals would no longer visit Mrs Y at home. Instead, the meeting agreed Mrs Y would meet with a CPN at her regular depot injection appointments or at her GP surgery.
24. The Council also decided to withdraw Mrs Y’s social care support package.

Analysis

Deterioration

25. Mr X complained that the professionals involved in Mrs Y’s care failed to take action when her condition deteriorated in early 2018, despite her repeatedly requesting assistance. Mr X said Mrs Y's care plan contained crisis contingency measures that professionals failed to abide by. Mr X said this included the option of recalling Mrs Y to hospital for treatment to prevent further deterioration.
26. The Trust said Mrs Y was suffering from increased levels of anxiety and distress as a result of her ongoing divorce from Mr X. The Trust also acknowledged her reactions to this were exacerbated by her personality disorder diagnosis. However, the Trust said Mrs Y was not exhibiting any new symptoms that indicated a deterioration in her acute mental health. On this basis, the Trust said clinicians did not consider other treatment options (such as medication or recall to hospital) to be appropriate.
27. Mrs Y attended hospital for her depot injection on 1 December 2017. The administering nurse noted that she “[a]ppeared physically and mentally well” at that time.
28. Mrs Y made several calls to her CPN over the following week. She reported feeling anxious about living alone in a new property. At times, the CPN noted that Mrs Y was upset. However, he also noted that “[Mrs Y] expressed no thoughts of harm towards herself or others.”
29. The CPN visited Mrs Y at home on 8 December 2017. He noted Mrs Y “presented as settled in her mood and mental health state. She was calmly spoken and smiling throughout the entire visit.”
30. The care records suggest Mrs Y remained relatively stable over the following weeks. However, after a series of agitated calls from Mrs Y, her CPN visited her at home on 27 December 2017. Mrs Y again expressed her anxiety about the prospect of living alone. She also said she may take an overdose of her medication. As a result, the CPN agreed to leave Mrs Y with only limited medication and visit her the following day.
31. At the follow-up visit, the CPN felt Mrs Y’s presentation was much improved and that she was feeling better. At a further visit on 2 January 2018, the CPN noted Mrs Y “showed no deterioration in her mental health throughout the visit, nor expressed any concerns regarding her mental or physical health.”
32. A psychiatrist reviewed Mrs Y on 4 January 2018. He found her to be stable with “no evidence of agitation” and “[n]o psychosis”.
33. Over the subsequent weeks, the records show Mrs Y continued to express anxiety about the prospect of moving to another property and living alone. Nevertheless, the CPN also noted Mrs Y appeared more positive and was planning for the future.
34. On 17 January 2018, Mrs Y met with a psychologist, psychiatrist and social worker to discuss whether her CTO should be extended. The clinicians noted Mrs Y was going through a very stressful period. They found Mrs Y’s delusional thoughts would be exacerbated if she stopped taking her antipsychotic medication and that this would cause her additional distress. It was agreed Mrs Y’s CTO would be extended for a year to ensure compliance with her medication regime.
35. Mrs Y made several calls to the LMHT at the end of January and beginning of February 2018. She was noted to be upset and tearful. However, at two subsequent home visits on 5 and 6 February 2018, Mrs Y’s CPN and support worker noted she was “smiling and in good spirits” and “appeared bright in mood”.
36. On 14 February 2018, Mrs Y made a further call to her CPN. He noted she was very upset and felt unable to live alone. He also noted Mrs Y stated that she may harm herself. The CPN agreed to visit her later that day. He found Mrs Y distressed and noted that she “stated that she wanted to be in hospital due to going through a divorce.”
37. A further visit from a CPN on 15 February 2018 found she was still distressed. The CPN noted Mrs Y “does not appear to be psychotic, no delusional content to her speech or thinking…No obvious evidence of acute mental illness.” The CPN recorded his view that “[t]he ongoing issue relating to her divorce and the final settlement appears to be the well agreed driving force to her current level of emotional upset and distress.” Nevertheless, as Mrs Y was threatening to take all of her medications, the CPN removed them.
38. The following day, Mrs Y’s CPN visited her at home. He noted she was feeling better and appeared calmer. The CPN left Mrs Y with enough medication for a week.
39. The CPN and support worker visited Mrs Y again on 27 February 2018. This was when the incident with the knife occurred. I have commented on this in further detail under the ‘Trust sanctions’ section of this decision statement.
40. I have reviewed the clinical notes for the entirety of this period. These are detailed and appear to show members of the LMHT supported Mrs Y through a series of regular home visits and telephone calls.
41. It is apparent from the records that Mrs Y was very anxious during this period, though her presentation was variable. At times, she was noted to be distressed and at other times calmer and more settled. There is not, in my view, evidence to suggest a sustained deterioration in Mrs Y’s presentation.
42. Mrs Y’s conversations with members of the LMHT suggest the primary underlying cause for her distress was her ongoing divorce from Mr X. Her reactions to this situation appear in turn to have been exacerbated by traits associated with her personality disorder.
43. Nevertheless, I note clinicians from the LMHT reviewed Mrs Y twice during this period and did not identify any evidence of acute mental illness.
44. Mrs Y’s crisis contingency plan set out that she should be recalled from her CTO if “she is non-concordant with her medication and/or risks can not be met in the community”.
45. The clinical evidence shows Mrs Y was largely concordant with her medication, albeit she would made clear she would prefer not to take it. Although Mrs Y did sometimes fail to attend for her depot injection, these appointments were generally rescheduled promptly.
46. The records also show members of the LMHT also took appropriate action to safeguard Mrs Y when they believed her to be at risk. This included removing excess medication from the property until her condition had stabilised.
47. On this basis, I share the Trust’s view that there were no persuasive grounds for recalling Mrs Y from her CTO during this period.
48. In my view, the evidence suggests the Trust provided appropriate care and support to Mrs Y between December 2017 and February 2018. I found no fault by the Trust in this regard.

Trust sanctions

49. Mr X complained that, following the incident in February 2018, the Trust imposed unfair sanctions on Mrs Y. He said this meant she was unable to access the care and support she required. Mr X said these sanctions were based on an inaccurate risk assessment completed by Mrs Y’s CPN. Mr X also said the CPN had a conflict of interest as he had been involved in the incident in February 2018.
50. The Trust said the multidisciplinary team decided to withdraw Mrs Y’s home visits at a meeting on 27 March 2018. The Trust said this decision was informed by a risk assessment prepared by Mrs Y’s CPN but that he had not made the decision in isolation. The Trust said the risk assessment represented the CPN’s clinical judgement and contained relevant information. However, the Trust acknowledged it could review the risk assessment to put some of the historical information it contained into context.
51. The clinical records show Mrs Y’s CPN and a support worker visited her at home on 27 February 2018. During this visit, the CPN said Mrs Y entered the kitchen before returning with a kitchen knife. He noted Mrs Y “held this in a grip which made the knife point directly towards where both [the support worker and CPN] was sitting.” The CPN went on to note that Mrs Y “made a deliberate movement towards [the CPN and support worker].” At that point, they left the property. The CPN said he warned Mrs Y that he would be informing the police.
52. The CPN and support worker subsequently called the police and officers attended to arrest Mrs Y on suspicion of affray. Mrs Y told officers she had not intended to harm the CPN and support worker and was only attempting to demonstrate how distressed she was. Mrs Y was not charged and returned home.
53. On 5 March 2018, the Trust decided all face-to-face contact between Mrs Y and her CPN would now need to take place at her regular depot injection appointments. The Trust also agreed to convene a multidisciplinary team meeting to discuss the situation further.
54. The Trust convened the meeting on 27 March 2018. The meeting discussed previous incidents in which Mrs Y had acted aggressively towards professionals. The meeting concluded that Mrs Y continued to pose a risk to staff and confirmed that home visits would not recommence. However, the meeting heard Mrs Y would still be able to access her CPN at depot injection or GP appointments and by telephone.
55. The CPN completed a risk assessment the following day.
56. The Trust’s Preventing, minimising and managing aggressive and violent behaviour document (the policy) defines violence at work. This includes “[a]ny incident in which a person working in the Healthcare sector is verbally abused, threatened or assaulted by a patient or member of the public in circumstances relating to his or her employment.”
57. The policy makes clear the response of staff to such behaviour should be “a proportionate, legal, acceptable, necessary and reasonable response to the circumstances and risk posed by the service user at that time.”
58. I appreciate Mrs Y’s recollections of the visit on 27 February 2018 differ from those of the CPN and support worker. Mrs Y told police that she had not pointed the knife at the professionals and had simply been using it to demonstrate her distress.
59. Nevertheless, it is clear from the CPN’s contemporaneous notes that both members of staff felt threatened by Mrs Y’s behaviour. In my view, they could not reasonably have been expected to anticipate Mrs Y’s motives or intentions. It was appropriate for them to leave the premises in order to remove or reduce any risk posed by Mrs Y’s behaviour, therefore.
60. Section 5.6 of the policy states that “[w]hen a risk of potential violence is identified it is considered essential by the Health and Safety Executive and good practice for staff to communicate all risk concerns where appropriate to all relevant parties.” This can include the police.
61. As I have explained above, the professionals supporting Mrs Y felt she was not acutely mentally unwell at the time of this incident. There was no basis on which to recall her from her CTO, therefore. However, Mrs Y was still armed when Trust staff left her property. In the circumstances, I the CPN’s decision to contact the police was in keeping with the Trust’s policy. In my view, this represented the best way of reducing the risks Mrs Y’s behaviour posed to herself and others.
62. Taking everything into account, I found no fault by the Trust with regards to the actions of its staff on 27 February 2018.
63. In his representations to the Ombudsmen, Mr X also challenged the CPN’s risk assessment. He said the assessment was inaccurate and contained misleading information.
64. I note Mr X’s concerns. The evidence I have seen suggests the information contained in the risk assessment was taken from Mrs Y’s clinical records. This included reference to specific historical incidents and behaviours. I am unable to comment on whether these events were accurately recorded in the clinical records. However, there is evidence to suggest Mrs Y had behaved aggressively towards both health and social care staff in the past.
65. In my view, the risk assessment the CPN completed was lacking in detail. The CPN documented various risk factors in his assessment. However, he provided little context for the incidents and behaviours described. I would also have expected to see more detailed consideration given to how these factors contributed to the total risk posed by Mrs Y’s behaviour. I found no evidence of this consideration. This is fault by the Trust.
66. Nevertheless, I am not persuaded this had a significant impact on the decision to remove Mrs Y’s home visits. This decision was made by the multidisciplinary team at the meeting on 27 March 2018. The records provided by the Trust and Council suggest the meeting discussed the matter in detail and that all members of the team agreed it would not be safe for staff to visit Mrs Y at home. This was ultimately a matter of professional judgement for the officers involved.
67. I appreciate Mr X and Mrs Y found the restrictions placed on Mrs Y’s contact with the LMHT frustrating. However, the clinical records contain a clear care plan detailing how Mrs Y would access clinical support. This included regular meetings with her CPN (albeit not at home) and medication reviews. I found no evidence to suggest Mrs Y was left without support. I found no fault by the Trust, Council or CCG with regards to ongoing provision of care for Mrs Y.

Withdrawal of social care support

68. Mr X complained that the Council withdrew six hours of care per week from Mrs Y on the basis of the Trust's flawed risk assessment and did not undertake its own risk assessment.
69. The Council said that, following the incident on 27 February 2018, professionals concluded it would not be safe for support workers to visit Mrs Y at home. The Council said it explained this to Mrs Y.
70. Prior to this incident, Mrs Y received care visits each week amounting to six hours in total. These were primarily to prompt her to complete activities of daily living (such as preparing meals and maintaining personal care).
71. The case records show Mrs Y’s CPN told the Council about the incident on the day it occurred. The Council notified the care provider and visits were suspended with immediate effect.
72. A social worker discussed the case with the care provider. He established that Mrs Y’s behaviour could be unpredictable and that she was sometimes aggressive towards the attending care workers. In addition, the care provider advised him that many care visits were unsuccessful as Mrs Y would not admit the visiting care workers.
73. The multidisciplinary team meeting on 27 March 2018 (which the social worker attended) discussed the matter further. The professionals present agreed that, based on the information available to them, it would not be safe for health or social care staff to visit Mrs Y at home.
74. The social worker wrote to Mrs Y to explain this on 3 April 2018. He wrote that “[h]aving reviewed the current Care and Support Plan, which describes the tasks [care provider] staff have been supporting you with, I noted that the bulk of the work takes place in your home. Regrettably, the incident in question and your history indicate there is a significant risk of harm to staff seeking to support you at your property, so we have no alternative but to withdraw the social care support.” The social worker also made clear that the situation could be reviewed at a later date if there was sufficient evidence that staff would no longer be at risk.
75. The evidence shows the Council did work with the Trust assess the risk posed to staff by Mrs Y’s behaviour. However, I do not agree that the Council accepted the Trust’s views uncritically. In my view, the case records demonstrate that the Council made appropriate enquiries with the care provider and formulated its own risk assessment in collaboration with health colleagues. I found no fault by the Council I this regard.
76. I understand the Council recently reviewed the situation and has now reinstated some social care support for Mrs Y.

Back to top

Final decision

77. I found no fault by the Council, Trust or CCG with regards to the care and support they provided to Mrs Y during this period.
78. I did find fault with the Trust’s risk assessment of 28 March 2018. However, I do not consider this had a significant impact on Mrs Y’s care.
79. I have now completed my investigation on this basis.

Back to top

Investigator's decision on behalf of the Ombudsman