Summary: The Trust and Council were at fault in not carrying out a carer’s assessment and not involving Mrs S during her husband’s period of treatment. There was also fault in record-keeping and delays in responding to the complaint. These failings caused an injustice to Mrs S as she lost the opportunity for additional support and is likely to have suffered additional distress. The Trust and Council have already taken action to address these failings and improve processes. The Trust and Council have agreed to pay Mrs S financial redress and the Trust has agreed to monitor and report on improvements in its complaints handling.

The complaint

1. Mrs S complained to the Council and Trust after they carried out a Mental Health Act 1983 (MHA) assessment of her husband on 4 September 2015 and the Trust’s Home Treatment Team provided home treatment to him until 13 October 2015.
2. Mrs S complains the Trust and Council did not arrange or provide a carer’s assessment for her, despite having identified a need and offering one to her on 4 September. She also complains staff did not ask her about any concerns she had about her husband’s behaviour or her own welfare during the MHA assessment or when the Home Treatment Team provided care to her husband.
3. Mrs S also complains staff copied and pasted records. She says consequently the records inaccurately recorded staff had consulted with her during their visits to her husband. She says this contributed to the failure to take her needs into account.
4. Mrs S says the issues she raised resulted in her being isolated and extremely vulnerable to her husband’s extreme and dangerous behaviour. She said she witnessed her husband experiencing verbally aggressive outbursts, panic attacks, sweating, shaking, crying, headaches, slurring words, and isolating himself from her, family and friends. She says she struggled to cope with the impact of her husband’s mental health in isolation. She says this had a negative impact on her own mental health which resulted in her referring herself to IAPT (Improving Access to Psychological Therapies) services, being prescribed anti-depressants, and being signed off work for a period of time from March 2016. She has also lost faith in the NHS.
5. Mrs S said she is also unhappy with the time the Trust took to respond to her complaints and the time it took for it to acknowledge failings in the service it provided to her.  She says this caused her additional stress and anxiety. She is seeking a small financial payment in the low hundreds of pounds. She is also seeking reassurance the Trust and Council have carried out the service improvements communicated in the Trust’s complaint responses, along with complaint handling service improvements.

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The Ombudsmen’s role and powers

6. The Ombudsmen have the power to jointly consider complaints about health and social care. Since April 2015, these complaints have been considered by single team acting on behalf of both Ombudsmen. (Local Government Act 1974, section 33ZA, as amended, and Health Service Commissioners Act 1993, section 18ZA)
7. 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).
8. 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.
9. 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.
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. As part of my investigation of this complaint I have considered:
• Information Mrs S and her advocate provided in writing and verbally
• Written information from the Trust and Council
• Relevant legislation and guidance
12. All parties had the opportunity to comment a draft of this decision, and I took their comments into account before making a final decision.

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What I found

13. A Mental Health Act 1983 (MHA) assessment is carried out to decide whether a person should be detained in hospital under the Mental Health Act. The people carrying out the MHA assessment will consider other community-based options such as support and treatment in the person’s home.
14. MHA assessments are usually carried out by an Approved Mental Health Professional (AMHP), a doctor who has had specialist training, and a registered medical practitioner. If the person being assessed under the MHA has a carer, the AMHP should support the carer and answer questions wherever possible.
15. The Care Act 2014 recognises the importance of supporting carers and the people they care for. The Care Act gives carers the right to support from their local authority, and they can get this support through a carer’s assessment. The Care and Support Statutory Guidance 2014 says that carer’s assessments must seek to find out the carer’s needs for support, and also the sustainability of the caring role itself. This includes the practical and emotional support the carer is providing.

Background events

16. Mrs S’s husband, Mr S, was assessed under the Mental Health Act 1983 on 4 September 2015, after he revealed he had plans to end his life. Mrs S was in the house at the time the assessment took place. The MHA assessment decided Mr S did not need to be detained in hospital under the Mental Health Act, and that he could be supported at home by the Home Treatment Team.
17. During the MHA assessment the professionals asked Mrs S if she was willing and able to care for her husband at home, and she confirmed she was. The AMHP said Mrs S would be offered a Carer’s Assessment to look at what support she might need herself.
18. The AMHP failed to follow-up on the recommendation to offer Mrs S a carer’s assessment, so no assessment took place.
19. The Home Treatment Team saw Mr S regularly, until he was discharged back to the care of his GP on 13 October 2015.
20. Mrs S complained the professionals did not arrange a carer’s assessment. She said staff did not speak with her about any concerns she had about her husband’s behaviour or her own welfare either during the MHA assessment, or during the period the Home Treatment Team was supporting him. Mrs S also complained that the Home Treatment Team copied and pasted information in her husband’s medical records. She said this meant the records wrongly showed that staff had consulted with her during visits to her husband. She said this error contributed to the failure to take her needs as a carer into account.
21. Mrs S says she was left isolated and extremely vulnerable to her husband’s extreme and dangerous behaviour. She says she struggled to cope with the impact of her husband’s mental health in isolation and without support. Mrs S says her own mental health suffered which led to her referring herself to IAPT therapy services, needing anti-depressants, and being signed off work for a period of time from March 2016. She says she has also lost faith in the NHS as a result of these events.
22. Mrs S says she wants a small financial payment in recognition of the suffering and trauma she experienced. She also wants reassurance that the Trust and Council have actually carried out the service improvements they set out in the complaint responses.

Analysis and findings

Failure to arrange or carry out a carer’s assessment

23. The Trust recognised that the AMHP did not follow-up on the recommendation to arrange a carer’s assessment for Mrs S. It apologised and said it had discussed the issue with the relevant team, with the individual AMHP during supervision, and with all the AMHP’s in the service. This was to ensure that staff complete referrals for carer’s assessments when appropriate. The Trust said that in future staff would record the offer of a carer’s assessment and the carer’s response on the patient record. If needed the Home Treatment Team would carry out the carer’s assessment. The Trust said its Access Team now includes a Carer’s Officer. They have a responsibility to check with all carers of patients under the Home Treatment Team that a carer’s assessment has been offered, and that where they want one, it is done.
24. The Council told us it has now introduced a checklist as part of the AMHP process, which prompts the AMHP to follow-up on recommendations made during a MHA assessment. The Council also said it will check the number of requests made by AMHP’s each month for carer’s assessments and will compare this with the number of referrals for carer’s assessments received.
25. The Trust told us it has put in place an Excel system to check that staff ask for carer’s assessments where appropriate. The Trust sent us evidence from the spreadsheet up to and including January 2019.
26. It was fault that Mrs S did not have a carer’s assessment. The Trust and Council have acknowledged this. This caused an injustice to Mrs S as she did not have an assessment of her needs as a carer and she lost out on the opportunity for additional support at a very difficult time. Mrs S says she was left isolated and vulnerable. She said her own mental health suffered significantly, and she needed to attend therapy, was prescribed anti-depressants, and was signed off work for a period of time. It is difficult to quantify how much the failings by the Council and Trust are responsible for Mrs S’s deteriorating mental health. It is possible the distressing circumstances she found herself in would have affected her mental health in any event. However, it is likely the lack of support will have added to this distress and suffering. I have therefore made recommendations later in this statement about what further action the Trust and Council should take to remedy the outstanding impact on Mrs S.

Failure to speak with Mrs S about her concerns about her husband’s behaviour or her own welfare

27. Mrs S said the staff carrying out the MHA assessment gave her the impression the Home Treatment Team would consult with her during her husband’s treatment. She expected staff would speak with her separately about her husband’s wellbeing. She said this did not happen, and she struggled to understand why staff did not consult with her in order to get vital information before her husband was discharged back to the care of his GP on 13 October 2015. Mrs S said only one person from the Home Treatment Team spoke with her. Other staff had copied and pasted notes into the records which gave the wrong impression that they had spoken with her.
28. Mrs S said staff did not consider issues about her safety as they did not ask her about any violent or abusive behaviour by her husband, and they assumed she was not in danger. Mrs S said she gave staff clues that she was in fear for her safety, but staff did not pick up on this or speak with her separately.
29. The Trust said the Home Treatment Team should always liaise with relevant family members. It apologised that Mrs S did not feel able to share her concerns or feel involved in the Home Treatment Team assessment. The Trust said it had addressed the issue with the Home Treatment Team staff, and they must specifically ask a carer if they have any concerns or information to share and ensure the carer is heard.
30. The Trust said the Home Treatment Team must document whether carers are present during visits. The clinical entries in this case were not clear on whether Mrs S was present or not. They were also not clear about whether staff had consulted with her about her views on Mr S’s current state or her own needs as a carer. If the Home Treatment Team document that a carer is present, they must document that they have spoken with the carer to identify any concerns relating to the patient or about their own needs as a carer.
31. The Trust said if the Home Treatment Team has not had any contact with the carer prior to the weekly multi-disciplinary team (MDT) review of the patient, they should contact the carer for feedback to inform the review, or for the carer to raise any issues about their own needs. The Trust said it hoped the various actions taken would ensure more opportunities for carers to express concerns away from the patient.
32. The Trust told us the Home Treatment Team does include relatives and carers in care, and it monitors this periodically. The Trust sent us anonymised evidence showing interaction between the Home Treatment Team and relatives and carers, including discussion about carer’s assessments.
33. It was fault that the Home Treatment Team did not adequately involve Mrs S as a carer during her husband’s period of home treatment. This caused an injustice to Mrs S as staff did not give her the opportunity to discuss her own needs as a carer, or to share her views about her husband’s needs. The Trust and Council have apologised for the fault and have taken action to improve processes for involving carers during home treatment. I am satisfied the Trust and Council have taken suitable action to minimise the risk of this happening again. However, I have made a recommendation later in this statement about what further action the Trust and Council should take to further remedy the injustice to Mrs S.

Staff copied and pasted records

34. Mrs S said the Home Treatment Team staff copied and pasted information in her husband’s medical records, which meant the records inaccurately said staff had consulted with her during visits to her husband. She said this error contributed to the failure to take her needs into account.
35. The Trust initially said it was unable to see where there had been copying and pasting from earlier entries in Mr S’s notes. It later said the Community Psychiatric Nurse (CPN) had taken records from the AMHP’s report and added them to the Full Needs Assessment. This was done as part of Mr S’s discharge from the Home Treatment Team. The Trust accepted the CPN failed to check with the AMHP or anyone else in the team about whether staff had completed a carer’s assessment. The Trust apologised and said the issue had been raised with both staff during supervision sessions.
36. It was fault that staff copied and pasted records which meant that information was inaccurate. This is likely to have caused an injustice to Mrs S as it meant the failure to complete a carer’s assessment was not identified at the time and acted on. The Trust has acknowledged the fault, apologised, and raised the issue with relevant staff. I am satisfied the Trust has taken appropriate action to address this, and it is not necessary for the Ombudsmen to make further recommendations.

Poor complaint handling

37. Mrs S said the Trust took too long to respond to her complaints or to acknowledge the failings that had occurred. She said there were administrative mistakes which led to unnecessary delays and duplication, and that there was little or no communication with her after she submitted the complaint. She said this made her feel ignored and unimportant.
38. Mrs S said after the complaint resolution meeting she asked further questions. The Trust’s further failure to respond within agreed timescales prolonged the impact of these events on her and caused her further distress.
39. The Trust acknowledged the delays in responding to Mrs S’s complaint and apologised. It said it had looked into and addressed the delays, workloads and priorities of the investigating officer. The Trust also said it had clearly outlined its expectations during supervision sessions.
40. The Trust told us the delay in responding to the complaint was due to a delay in getting clinical opinion and information from the staff involved.
41. It was fault that there were significant delays during the Trust’s investigation of Mrs S’s complaint. This caused an injustice to Mrs S as she was caused more distress by the prolonged complaints process. The Trust apologised and said it had looked into and addressed the delays with the investigating officer.
42. Due to the time that has passed since Mrs S’s complaint was investigated - almost three years - it is likely that some of the staff, systems and processes for investigating complaints at the Trust will have changed. The Trust has explained the reasons for the delay and the actions taken at the time to address this. It is unlikely the Ombudsmen can achieve any more than this by further investigation now. However, I have made a recommendation later in this statement about what further action the Trust should take in relation to handling complaints.

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Agreed action

43. The Trust and Council have already apologised to Mrs S and taken action to improve systems and processes around carer’s assessments and involving carers during home treatment. I am satisfied that appropriate action has been taken to minimise the risk of this happening again.
44. However, I recommend that within one month of this decision, the Trust and Council pay Mrs S financial redress of £400 in recognition of the impact of these failings on her. It is for the Trust and Council to decide how the payment of £400 should be apportioned between them.
45. I also recommend that within three months of this final decision the Trust reviews the effectiveness of changes made to its handling of complaints since these events. It should consider how these changes have impacted on the timeliness of investigating and responding to complaints, and consider if any further action is needed. The Trust should write to Mrs S and to us to explain the outcome of this review.
46. The Trust and Council have accepted these recommendations.

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Decision

47. The Trust and Council were at fault in not carrying out a carer’s assessment and not involving Mrs S during her husband’s period of treatment. There was also fault in record-keeping and delays in responding to Mrs S’s complaint. These failings caused an injustice to Mrs S.
48. I have completed my investigation as the Trust and Council have agreed to take the action I recommended.

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Investigator's decision on behalf of the Ombudsman