Summary: Miss A complained about a hospital discharging her mother from a mental health hospital too soon and about a lack of follow-up care in the community. The Ombudsmen find no fault by the Council or Trust. There is evidence of suitable planning before Mrs B left hospital, and proportionate reviews after she returned home.

The complaint

1. Miss A’s mother, Mrs B, was detained in hospital under section 3 of the Mental Health Act 1983 (the MHA) in December 2019. Mrs B returned home in mid‑March 2020 and remained there until mid‑June 2020.
2. Leicestershire Partnership NHS Trust (the Trust) was responsible for Mrs B’s care in hospital. Leicester City Council (the Council) and Leicester, Leicestershire and Rutland Integrated Care Board (the ICB) were responsible for commissioning Mrs B’s post-discharge care. (At the time of the events Leicester City Clinical Commissioning Group were responsible for the health side of the commissioning responsibilities. The ICB took over its responsibilities on 1 July 2022.)
3. Miss A complains that:

• Services discharged Mrs B from hospital prematurely and without proper communication about the plan. Miss A said Mrs B and the family believed Mrs B was going home for one week of leave.
• There was inadequate follow-up support for Mrs B’s mental health and social care needs when she was in the community.
• Professionals did not listen to the family’s concerns about Mrs B’s health when she was in the community, and failed to properly review Mrs B quickly enough.

4. Miss A said that because of these failings Mrs B’s physical and mental health significantly worsened, including that she lost a large amount of weight. Miss A said these events also caused her avoidable stress and meant she had to endure undue pressure.

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The Ombudsmen’s role and powers

5. The Ombudsmen have the power to jointly consider complaints about health and social care. Since April 2015, a single team has considered these complaints acting on behalf of both Ombudsmen. (Local Government Act 1974, section 33ZA,as amended, and Health Service Commissioners Act 1993, section 18ZA)
6. 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) If it has, they may suggest a remedy. Our recommendations might include asking the organisation to apologise or to pay a financial remedy, for example, for inconvenience or worry caused. We might also recommend the organisation takes action to stop the same mistakes happening again.
7. Section 3 of the MHA allows people to be detained in hospital for treatment necessary for their health, safety or for the protection of other people. Section 117 of the MHA imposes a duty on health and social services to provide free aftercare services to patients who have been detained under section 3 of the MHA. Councils and ICBs cannot delegate these aftercare duties, regardless of the day‑to‑day arrangements for delivering a person’s aftercare. In view of this the relevant council and ICB will always be included in Ombudsmen investigations about section 117 aftercare. Mrs B was eligible for section 117 aftercare funding after she left hospital and, as such, the Council and ICB are included as organisations under investigation.
8. When considering complaints, if there is a conflict of evidence we make findings based on the balance of probabilities. This means we will weigh up the available relevant evidence and base our findings on what we think was more likely to have happened.
9. The Ombudsmen cannot question whether a decision is right or wrong simply because the complainant disagrees with it. We must consider whether there was fault in the way the organisation reached the decision. (Local Government Act 1974, section 34(3), as amended, and Health Service Commissioners Act 1993, sections 3(4)- 3(7))
10. 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)

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How I considered this complaint

11. I read the correspondence and supporting evidence Miss A sent to the Ombudsmen. I spoke to Miss A on the telephone. I wrote to the Trust, the Council and the ICB to explain what I intended to investigate and to ask for their comments and copies of relevant records. I considered all the comments and records they provided. I also considered relevant legislation and guidance.
12. I shared a confidential copy of this draft decision with Miss A along with the Trust, the Council and the ICB and invited their comments on it. I considered all the comments I receive in response.

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What I found

Relevant legislation and guidance

National guidance on discharge from hospital

13. Leaving hospital after an inpatient stay is part of a process and not an isolated event. Planning should start at the earliest opportunity and it should involve health and social care staff in the hospital and community working together. The process should lead to a personalised plan for each patient who is leaving hospital. At the time of these events the key guidance about this was the Department of Health’s 2010 guidance Ready to go? Planning the discharge and transfer of patients from hospital and intermediate care (the Discharge Guidance).
14. The Mental Health Act Code of Practice (the MHA Code) also notes that:

• “Before deciding to discharge or grant more than very short-term leave of absence to a patient…the responsible clinician should ensure that the patient’s needs for after-care have been fully assessed, discussed with the patient (and their carers, where appropriate) and addressed in their care plan…” (Section 33.13 of the MHA Code)
• “…the care plan should be prepared in close partnership with the patient from the outset, particularly where it is necessary to manage the process of discharge from hospital and reintegration into the community…” (Section 34.10 of the MHA Code)

Section 117 aftercare

15. Section 117 of the MHA requires councils and Integrated Care Boards (ICBs) to provide free aftercare services to certain people. This includes people who have been discharged from detention in hospital under section 3 of the MHA. They must provide these services from the point the person leaves hospital until the council and ICB decide the person no longer needs them.
16. Section 117 does not define what aftercare services are. The MHA Code gives some guidance on this. It details that:

• “After-care services mean services which have the purposes of meeting a need arising from or related to the patient’s mental disorder and reducing the risk of a deterioration of the patient’s mental condition (and, accordingly, reducing the risk of the patient requiring admission to hospital again for treatment for mental disorder)” (Section 33.3 of the MHA Code).
• Aftercare can “encompass healthcare, social care and employment services, supported accommodation and services to meet the person’s wider social, cultural and spiritual needs” (Section 33.4 of the MHA Code).
• Aftercare should aim to support people “in regaining or enhancing their skills, or learning new skills, in order to cope with life outside hospital” (Section 33.5 of the MHA Code).

The Care Programme Approach

17. The Care Programme Approach (CPA) is an approach used in secondary mental health care. It helps to assess, plan, review and coordinate treatment, care and support for people with complex mental health needs. The key guidance on this is: Refocusing the Care Programme Approach: Policy and Positive Practice Guidance (CPA guidance). Services should regularly review whether people still need support under CPA (Page 15 of the CPA guidance).

What happened

18. Mrs B was admitted to an acute hospital in the summer of 2019 because she had been vomiting and losing weight. She remained in hospital and came to be fitted with a percutaneous endoscopic gastrostomy (PEG) feeding tube.
19. A psychiatric liaison team reviewed Mrs B several times. In November 2019 the team decided Mrs B needed to be detained for assessment under the MHA owing to symptoms of depression and psychosis. Clinicians transferred her to an inpatient mental health unit for this assessment. At the start of December 2019 doctors detained Mrs B under section 3 of the MHA, for treatment.
20. Planning for Mrs B’s return home began in January 2020 and a family meeting took place that month. By March 2020 clinicians felt Mrs B was medically stable enough to leave hospital. The multi-disciplinary team had some concerns about the condition of Mrs B’s property (which she shared with her son) which they wanted to see resolved. The Trust began arranging periods of home leave for Mrs B with the intention of building these up until the hospital discharged her.
21. During a ward round on 16 March 2020 professionals recorded a plan for Mrs B to have one week of leave at home starting that day, and then to be discharged at the end of that week. Mrs B went home that day and the hospital discharged her on 20 March 2020.
22. While at home Mrs B received three visits a day from carers. A Community Psychiatric Nurse (CPN) was allocated to her and they monitored Mrs B largely via phone calls to the care company, but also through some direct contact with Mrs B and contact with her relatives.
23. In the middle of June Mrs B’s son, who lived with Mrs B, died instantly in a car crash. Miss A reports that Mrs B said she felt very low after this. The following day Miss A spoke to the CPN and noted that Mrs B had become incontinent and said she had reacted a similar way to her husband’s death. The CPN suggested to Miss A they try to arrange a respite placement for Mrs B. However, Mrs B had a fall later that day and remained on the floor all night. Paramedics came out and took her to an acute hospital.
24. On hearing this news the CPN spoke to a Consultant Psychiatrist and they asked a psychiatric liaison team to review Mrs B while she was in hospital. A doctor from the liaison service did so a couple of days into Mrs B’s admission and continued to do so at regular intervals. They noted they did not have any immediate concerns about Mrs B’s mental health but noted the potential for a significant mental health relapse.
25. At the start of July 2020 Mrs B left hospital and moved into a care home.

Analysis

Complaint that services discharged Mrs B from hospital prematurely and without proper communication about the plan

26. There is evidence to show the Trust began planning for Mrs B’s discharge from early in her admission. The records show a multi-disciplinary team took part in this planning and considered Mrs B’s after-care needs in a holistic, appropriate way.
27. At the start of January 2020 a ward round noted that, when Mrs B was ready to leave hospital, the intention was for her to go home. However, the team noted that Mrs B was not ready to be discharged. The team also noted the need to have a meeting involving Mrs B’s family in order to begin planning Mrs B’s discharge.
28. A family meeting took place in the middle of January 2020. This noted there had been an improvement in Mrs B’s mental state. There was a plan that when Mrs B went home the team would arrange for her to be supported by:

• A CPN,
• Carers, three times a day (to be arranged by adult social care), and
• A specialist team which would be able to look after her PEG tube.

It was also noted that Mrs B would build up to returning home via periods of home leave.

29. Staff visited Mrs B’s home and identified risks associated with it and actions that needed to happen before Mrs B could move back. An Occupational Therapist (OT) completed an assessment of Mrs B’s home at the start of February 2020. They recommended some equipment to help Mrs B. They also noted the plan for Mrs B to have more periods of home leave before she returned home permanently.
30. Overall, there is evidence the staff considered Mrs B’s mental and physical healthcare needs and her social care needs. In addition, the team involved Mrs B and her family in planning her discharge and took account of her wishes.
31. As noted above, the plan recorded on 16 March 2020 was for one week of home leave and for Mrs B to be discharged at the end of that week. However, on the same day the Prime Minister directed people to stop non-essential contact and travel due to the covid pandemic. Shortly after this the Trust’s community teams advised staff to reduce their face-to-face contact with service users.
32. An OT called Mrs B’s son the next day to check how things were. They then visited Mrs B the next day. The OT noted Mrs B’s sister was there and said she felt Mrs B was much better in herself and said she had no worries about Mrs B being back home. The OT noted Mrs B was welcoming and engaged in conversation and said she enjoyed being at home. The OT also noted that Mrs B was managing a good routine and felt motivated to do things. They also recorded that carers were visiting Mrs B three times a day.
33. Mrs B’s allocated CPN telephoned Mrs B on 20 March 2020 and noted they were not currently visiting people. Mrs B told the CPN she felt well and did not have any concerns.
34. On 20 March 2020 the OT discussed Mrs B’s case with a Consultant. They said Mrs B was doing well at home and had an allocated CPN and carers visiting three times a day. The hospital discharged Mrs B. The discharge summary noted the plan for a community CPN to follow things up.
35. This meant the hospital discharged Mrs B three days earlier than the initial plan. However, this was a result of the national response to the pandemic. Further, the Trust had taken steps to review the situation with Mrs B and people around her before discharging her. Overall, I have not found fault in the way the Trust planned for Mrs B’s return home from hospital.

Complaint that there was inadequate follow-up support for Mrs B’s mental health and social care needs when she was in the community; and

Complaint that professionals did not listen to the family’s concerns about Mrs B’s health when she was in the community, and failed to properly review Mrs B in a timely manner

36. As noted above, Mrs B returned home at a time when face-to-face contact was strongly discouraged. There is evidence to show that the Trust and Council both attempted to keep Mrs B’s situation under review within this context after she returned home. There is also evidence to show that they responded to concerns that Miss A raised.
37. Toward the end of March 2020 Mrs B’s allocated Social Worker phoned Mrs B’s care provider, Miss A and Mrs B’s sister to see how things were. All reported that they did not have any concerns and that Mrs B was settling in well.
38. Miss A spoke to Mrs B’s CPN on 27 March 2020 and raised concerns that Mrs B was not eating enough and might be becoming unwell again. Mrs B’s sister raised similar concerns with the CPN at the start of April 2020. The CPN said they would provide as much support as they could over the telephone. Following Mrs B’s sister’s call the CPN spoke to Mrs B’s Social Worker and to a Senior Carer from the care provider. The CPN asked the care provider to keep accurate notes of how Mrs B was and said she would keep things under review. A few days later, following another call with the care provider, the CPN asked the Social Worker to increase Mrs B’s care package (to make the calls in the morning and evening 15 minutes longer). The Social Worker did so.
39. On 16 April 2020 Miss A raised further concerns with the CPN. She said Mrs B was refusing to take medication or to accept the support of carers. The CPN said she would visit Mrs B to review her face-to-face. The CPN and a Consultant Psychiatrist visited Mrs B later that day. They considered Mrs B’s eating and drinking, her engagement with her carers and her general mood. The Consultant did not find a cause to re-admit Mrs B. They planned for the CPN to liaise closely with the care provider to check how Mrs B was, and to ask Mrs B’s GP to review her physical health.
40. Miss A continued to voice concerns about Mrs B during the following week. On 21 April 2020 the Consultant Psychiatrist asked Mrs B’s GP to review Mrs B’s physical health. On 23 April, on hearing back from the GP Surgery, the Consultant Psychiatrist requested a MHA assessment.
41. Following further liaison with the GP the MHA assessment took place on 28 April 2020. The Consultant Psychiatrist, a second Psychiatrist and an Approved Mental Health Practitioner (AMHP) assessed Mrs B at her home. They agreed that Mrs B did not need to be detained under the MHA. It was recorded that they had a “frank discussion” with Mrs B to say that if her dietary intake did not improve and if she continued to stay in bed they would need to re‑consider hospital admission. There was also a plan for the CPN to review Mrs B face‑to‑face the following week and to maintain contact with the carers.
42. The CPN spoke to the care provider on 30 April and 1, 4, 7, 11, 15, 22 May and 3 and 12 June. In these contacts the care provider reported that Mrs B was doing well – eating, taking her medication and allowing the carers to support her with personal care. The care provider said it did not have any concerns about the situation.
43. All the evidence noted above provides reassurance that the Trust took Miss A’s concerns about Mrs B seriously and took proportionate, appropriate steps to keep the situation under review. Mrs B’s return to hospital in June 2020 followed the tragic, unexpected death of her son. This could not have been foreseen and it dramatically altered Mrs B’s situation. Overall, I have not found fault in the way the Trust and Council reviewed Mrs B between March and June 2020. I have, therefore, not found fault with the ICB either.

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Decision

44. I have completed this investigation on the basis there was no fault by any of the organisations.

Investigator’s decision on behalf of the Ombudsmen

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Investigator's decision on behalf of the Ombudsman