Summary: We have not found fault in the way the Approved Mental Health Professional carried out an assessment of Mr C to decide whether to make an application to detain him in hospital.

The complaint

1. Mr B complains on behalf of his father, Mr C. He says one of the nurses promised him that the Approved Mental Health Professional (AMHP) would contact him before carrying out an assessment to decide whether Mr C should be detained in hospital, but the AMHP failed to contact him. He says the AMHP did not take all the factors into consideration and did not properly consider whether detention in hospital was the least restrictive option.

Back to top

What I have investigated

2. I have investigated the actions of the Council which employs the AMHP. Paragraph 62 explains why I have not investigated the actions of the nurse.

Back to top

The Ombudsman’s role and powers

3. We investigate complaints of injustice caused by ‘maladministration’ and ‘service failure’. I have used the word ‘fault’ to refer to these. We cannot question whether a council’s decision is right or wrong simply because the complainant disagrees with it. We must consider whether there was fault in the way the decision was reached. (Local Government Act 1974, section 34(3), as amended)
4. If we are satisfied with a council’s actions or proposed actions, we can complete our investigation and issue a decision statement. (Local Government Act 1974, section 30(1B) and 34H(i), as amended)

Back to top

How I considered this complaint

5. I have discussed the complaint with Mr B. I have considered the documents he and the Council have sent, the relevant law, guidance and policies and both sides’ comments on the draft decision.

Back to top

What I found

Law and guidance

Mental Health Act 1983

6. A person can be detained for assessment in hospital under section 2 if both the following criteria apply:
• The person is suffering from a mental disorder which warrants their detention in hospital for assessment.
• The person ought to be detained in the interests of their own health or safety or for the protection of others.
7. Before it is decided that admission to hospital is necessary, alternative means of providing the care and treatment the patient needs should be considered. Decision-makers should consider whether there are less restrictive alternatives to detention under the Act.
8. An application for detention may be made by an Approved Mental Health Professional (AMHP) or the patient’s nearest relative. The AMHPs act on behalf of local authorities.
9. An application must be supported by two medical recommendations in accordance with the Act.
10. AMHPs are required by the Act to attempt to identify the patient’s nearest relative.
• Section 2 - When AMHPs make an application for admission under section 2 (assessment), they should inform the nearest relative that the application is to be (or has been) made and of the nearest relative’s power to discharge the patient.
• Section 3 - If an application for detention under section 3 (treatment) is made, AMHPS must consult the nearest relative, unless it is not reasonably practicable or would involve unreasonable delay.
11. Patients detained under section 2 may be discharged by their nearest relative. The nearest relative must give the hospital manager at least 72 hours’ notice. There are standard letters for this purpose which the nearest relative can use.

What happened

12. Mr C is an elderly man. He had a stroke in June 2018 and, sadly, his wife died while he was recovering in hospital. Mr B is Mr C’s nearest relative.
13. Mr C’s mood deteriorated and he was admitted to a mental health ward in July 2018. Mr B says Mr C was admitted to a mental health ward because there was a bed available and he says it had been indicated previously that he would go to a general medical ward.
14. Mr C moved to a rehabilitation ward on 12 October 2018 which was followed by a move to a care home on 6 November 2018 and he was planning to return home. He had a fall in the care home which led to a further hospital admission on 8 December 2018.
15. The social worker assessed Mr C on 26 November 2018 and said he needed long term residential care as it would be unsafe to return home. Mr C disagreed and said he wanted to return home so the social worker started a plan to return home with a package of care.
16. The social worker visited Mr C on 19 December 2018. Mr C’s mood was described as ‘very low’ and he expressed suicidal thoughts. He had stockpiled paracetemol at home and said he would like to take them although he was not sure whether he would have the ‘guts’ to do it.
17. The social worker contacted the Rapid Response Liaison Psychiatry nurse (RRLP) on 20 December 2018. The social worker said Mr C was ready for discharge from hospital and the plan was that he would return home, but he wanted to discuss the risk related to suicide.
18. The RRLP nurse expressed concern at the plan of a return home and said a Mental Health Act assessment would be needed as the risks were a lot higher if Mr C went home.

Referral form to AMHP – 20 December 2018

19. On 20 December 2018, the RRLP nurse made a referral to the AMHP to request an assessment of Mr C. The form said Mr C had suicidal thoughts and was at risk of an overdose. The details of the nearest relative were left blank on the form.
20. A different nurse spoke to Mr B in the evening and informed him of the plan to carry out an assessment of Mr C on the following day.
21. Mr B’s account of the conversation is as follows. He said:
• He told the nurse he could not support his father at the assessment because of the short notice. He had a sight impairment and would need to arrange a chaperone and transport to the hospital. He said it was not a reasonable timescale with less than a day’s notice.
• The nurse told him this was not a problem and the person conducting the assessment would call him prior to it taking place.

AMHP’s assessment – 21 December 2018

22. The AMHP and two doctors assessed Mr C on the following day.
23. One of the doctors, Dr K, told the AMHP that the nurse had a long conversation with Mr B the previous evening and Mr B was aware that the assessment was taking place.
24. Dr K also said the nurse had fed back that Mr B said Mr C’s expression of harming himself was in keeping with his character to some degree and that he had ‘been like this for 10 years and this is just what he is like.’
25. Dr K stated that ‘there has not been any suggestion of [Mr C] moving in with [Mr B] for a short time following discharge, he has his own life and also has a visual impairment.’
26. The AMHP considered Mr C’s medical and psychiatric history, his general history and the social worker’s assessment and care plan. She spoke to the ward receptionist to find out if there was any evidence Mr C had tried to harm himself whilst on the ward.
27. She had a long conversation with Mr C. She explained the purpose of her visit. She explained what a Mental Health Act assessment was.
28. Mr C said he could not cope and wanted to die. Mr C said this was the lowest point of his life. The AMHP asked Mr C whether he had made plans to end his life. Mr C said he had thought about taking an overdose and he probably would if he had the chance.
29. Both doctors said Mr C had depressive symptoms and there were risks around attempting to end his life. Mr C had few coping mechanisms. Both doctors agreed that Mr C needed to be admitted to hospital for assessment and treatment.
30. The AMHP said there were no less restrictive alternatives that would adequately minimise the identified risks. The decision was made to apply for a section 2 detention.

Conversation with Mr B – 21 December 2018

31. The AMHP spoke to Mr B later on the same day.
32. Mr B said the full package of care for a return home was arranged. However, he agreed ‘that [the mental health] ward is a solution for the short-term at this point in time, re Christmas and potential triggers.’
33. The AMHP informed Mr B of the outcome of the assessment. Mr B expressed the following concerns. He said that, if he had been able to talk to Mr C and explain the gravity of the situation, Mr C would have agreed to go to the mental ward informally. He had not been given this opportunity and he felt Mr C had not had adequate advocate representation in the assessment.
34. Mr B was concerned that the section 2 would be on Mr C’s record and how this would affect him now and in the future.
35. The AMHP explained the relevant law, the criteria and the reasons why the decision had to be made. Mr B asked for a review. The AMHP explained that the decision had been made and a review was therefore not possible. She explained Mr B’s rights as the nearest relative once a section 2 decision had been made. She agreed to send Mr B the nearest relative information and the sample letter of ordering discharge to hospital managers.

Conversation with Mr B – 21 December 2018

36. Mr B spoke to a senior social worker later the same day. He said he was unhappy that Mr C had been detained under the Mental Health Act. The social worker said she was unsure why Mr B was unhappy about this as he agreed that Mr C needed admission to hospital. Mr C said the detention could be stigmatising. The social worker said Mr B was aware of his right, as the nearest relative, to apply for a discharge and his right of appeal.
37. Mr B declined this. He said he agreed Mr C required support from psychiatric services, that he required hospital admission and that people were doing their best for him, but he just did not want him detained under the Mental Health Act.
38. It is our understanding that Mr C’s section 2 detention was ended on 9 January 2019, but Mr C remained in hospital as a voluntary patient until 1 April 2019.

Complaint – 28 September 2020

39. Mr B complained to the Healthcare Trust regarding Mr C’s treatment. During that complaint, it became apparent that part of his complaint related to the actions of the AMHP, who works for the Council. Therefore, Mr B made a complaint to the Council on 28 September 2020. He said:
• He spoke to the nurse on 20 December 2018 and she assured him that the person carrying out the assessment would call him before the assessment took place.
• The AMHP called him after the assessment. She carried out the assessment without speaking to Mr B first or allowing Mr B to support Mr C. The AMHP explained that she did not have time to ring him before the assessment.
• He told the AMHP that, if he had been able to support Mr C, he felt Mr C may have agreed to go to hospital voluntarily.
40. Mr B asked the following questions:
• Why did the nurse assure him he would be contacted when this was not the case?
• Why was the assessment done so quickly?
• Was his conversation with the nurse recorded so that the AMHP had access to it?
• Did the AMHP refer to his conversation with the nurse when she carried out her assessment?

Response – 28 October 2020

41. The Council responded to Mr B’s complaint and said:
• The AMHP did not have access to the nurse’s note of the conversation between Mr B and the nurse. The nurse did not contact the AMHP.
• The doctor gave the AMHP details of the conversation between Mr B and the nurse, but this did not include Mr B’s request to be contacted before the assessment.
• If a family member asked to attend, their request would be considered and the assessment time re-arranged, if possible. If that was not possible, the AMHP would explain the reason to the family member.
• There was no legal requirement for the AMHP to speak to the nearest relative before making a decision to apply for a section 2 detention but it was good practice.
• Most assessments under the Mental Health Act took place on the same day as the referral. In Mr C’s case, the assessment was postponed to the following day due to the availability of a Psychogeratrician to take part in the assessment.

Complaint – 9 November 2020

42. Mr B had further questions after receiving the Council’s responses. He said:
• Why did the AMHP not obtain the note of his conversation with the nurse or speak to him if she was made aware of the conversation?
• Had the AMHP considered less restrictive alternatives to hospital detention?
43. The Council responded and said:
• The doctor had provided details of Mr B’s conversation with the nurse, but this did not include Mr B’s request to be involved with the assessment. The AMHP relied on professionals to tell her any pertinent information she needed to know before making an assessment. It would not be standard practice to question whether the information was correct and to request information to check this.
• The Council said there had been a social work plan for Mr C to return home, but this plan was not viable because of the risks. They considered a stay in a care home but this option was not possible because of Mr C’s deteriorating mental health. The next least restrictive option was a stay in hospital on a voluntary basis. This was offered to Mr C but he would not agree to this. Therefore an admission to hospital was the least restrictive option.
• The Council set out the AMHP’s legal duties in terms of assessment and consultation and said the AMHP’s assessment was fully in line with the duties.
44. Mr B continued to pursue his complaint and had a meeting with the AMHP team manager on 12 January 2021 to further discuss his complaint. The Council wrote to Mr B on 20 January 2021 to confirm the outcome of the meeting, but the Council’s response remained the same.
45. Mr B took his complaint to the Ombudsman. He said his complaint related to three categories:

The referral.

• The form did not include his name as nearest relative and did not include the comments regarding the care package. The AMHP should have obtained this information.
• He also said the nurse told him he would be contacted prior to the assessment and this did not happen. He says the AMHP failed to pick up on this crucial information and should have done so.

Least restrictive option

• He said he told the nurse that he could have stayed with Mr C. He felt the AMHP should have tried to access the note of the conversation and then she could have considered this option.

Assessment

• Mr B said the AMHP did not fully assess Mr C’s situation. It was Mr B’s opinion that Mr C was low in mood but not suicidal. There was no evidence Mr B had attempted suicide. If the AMHP had contacted him, he could have explained this to her.
• Mr B said he had informed the nurse, in the telephone conversation, that Mr B would not have access to his medication and Mr B’s carers would be responsible for providing him with the medication so this would lower the risk of suicide. The AMHP had not taken this into consideration.

Analysis

The referral

46. I cannot comment on the referral form itself as the form was filled in by the nurse.
47. I can comment on the AMHP’s actions in relation to the information on the form. The AMHP had a duty to find out the identity of the nearest relative and she did so. She rang Mr B on the day of the assessment so she clearly had his details. The reason why the AMHP did not ring Mr B earlier was because she did not have the time, not because she did not have his details.
48. In terms of the comments on the care package, the referral form said the social care team were planning for a return home and did not have concerns about this plan so the information was included.
49. But, in any event, the AMHP also included the details of Mr C’s care plan and the social worker’s views on the assessment form. There is therefore no fault in that respect.
50. Mr B’s main complaint is that the AMHP did not speak to him before the assessment. I appreciate why Mr B is so concerned about this, particularly as he says the nurse promised him he would be contacted before the assessment.
51. I cannot comment on the conversation between the nurse and Mr B or the nurse’s account of this conversation but the evidence shows the AMHP was not informed of Mr B’s request.
52. I fully agree with Mr B that it would have been good practice for the AMHP to contact Mr B before the assessment. I understand why Mr B is so upset that this did not happen. However, I can only consider whether there was fault in terms of the law, guidance and policies the AMHP had to follow. As this was a section 2 application, the AMHP did not have a duty to consult Mr B. Therefore, I cannot say there was fault in the AMHP’s decision to go ahead with the assessment without contacting Mr B first.

Least restrictive option / assessment

53. There is evidence the AMHP considered other less restrictive options before deciding that the admission to hospital was the least restrictive option. She considered that a return home was too high risk in light of Mr C’s presentation.
54. Mr B says he told the nurse that he could stay at Mr C’s house and that he had ensured that the risk in relation to Mr C taking an overdose had been reduced. He says the AMHP did not fully consider this.
55. Unfortunately, there is no evidence that the nurse relayed the information about the medication. And in terms of Mr B moving in, the doctor told the AMHP that there was no suggestion of Mr B moving in with Mr C for a short time.
56. Mr B says the AMHP should have made further checks about the information the nurse provided, but I agree with the Council that the AMHP could rely on the information she was given. I cannot say it was fault that the AMHP did not double check or question the information. Ultimately, it is the responsibility of each person and each agency to provide the correct information.
57. Mr B has also complained about the assessment itself. His view was that Mr C was not at risk of suicide, but was just in a low mood. Mr B agreed with the AMHP that a short-term admission to the mental health ward was a solution for Mr C at that particular time, in light of Christmas and potential triggers, but he did not agree with the section 2 application.
58. I find no fault in the way the AMHP carried out the assessment. The AMHP considered the relevant factors, including Mr C’s history, his wishes and views, the views of other professionals and the opinion of the two doctors who were involved in the assessment.
59. The AMHP’s assessment shows that she knew that Mr B’s view was that Mr C’s expressions of harming himself were in keeping with his character and that he had been like this for 10 years. So there was evidence the AMHP was aware of Mr B’s view, when she did the assessment.
60. Ultimately, the AMHP had to use her judgment whether, on all the information she had, the assessment by the doctors and on the basis of her assessment, she was of the view that an application should be made. I fully appreciate that Mr B disagrees with the AMHP’s assessment but I cannot question the merit of a decision if there is no fault in how the decision was made.

Back to top

Final decision

61. I have completed my investigation and have not found fault by the Council.

Back to top

Parts of the complaint that I did not investigate

62. Mr B has complained about the actions of the nurse. Nurses are employed by the Health Trust and their actions are therefore out of the Ombudsman’s jurisdiction.

Back to top

Investigator's decision on behalf of the Ombudsman