West Sussex County Council (18 008 685)

Category : Adult care services > Safeguarding

Decision : Upheld

Decision date : 22 Jan 2019

The Ombudsman's final decision:

Summary: Mrs X complained on behalf of her mother, Mrs Y. Mrs X complained the Council failed to safeguard Mrs Y, after it left her alone at home for 15 hours, after it made the decision to admit her to hospital under the Mental Health Act. The Council was at fault. It failed to complete a risk assessment or document its decision to leave Mrs Y alone. The Council agreed to apologise to Mrs X, and pay her £150 for time and trouble in pursuing her complaint, and for the uncertainty its actions caused her. It agreed to review its policy and procedures to ensure all Approved Mental Health Professionals are aware of the importance of risk assessments and documenting decisions.

The complaint

  1. Mrs X complained on behalf of her mother, Mrs Y. Mrs X complained the Council failed to safeguard Mrs Y after it left her alone at home for over 15 hours after it made the decision to admit her to hospital under the Mental Health Act. Mrs X said the Council failed to consult with her about its decision. Mrs X said the Council’s actions caused her frustration and distress, and left her mother in a vulnerable situation.

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The Ombudsman’s role and powers

  1. We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word fault to refer to these. We must also consider whether any fault has had an adverse impact on the person making the complaint. I refer to this as ‘injustice’. If there has been fault which has caused an injustice, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
  2. 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)

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How I considered this complaint

  1. I spoke to Mrs X about her complaint.
  2. I considered the Council’s response to my enquiries.
  3. I considered the Mental Health Act Code of Practice.
  4. Mrs X and the Council had an opportunity to comment on my draft decision. I considered the comments before I made my final decision.

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What I found

  1. A person suffering from a mental disorder may be detained in hospital for assessment and/or treatment under the Mental Health Act 1983 (the Act). An Approved Mental Health Professional (AMHP) employed by the Council is responsible for making an application to admit the person to hospital. Before doing this the AMHP must be satisfied that detention in hospital is the most appropriate way of providing the care and medical treatment the person needs.
  2. The AMHP making the application must attempt to consult the person’s nearest relative. A person can be detained under Section 2 of the Act for a maximum of 28 days to enable an assessment to be carried out in hospital. If the AMHP is applying to detain the person under Section 2 the nearest relative can give their view but even if they object they cannot stop the detention from going ahead.
  3. A person may be detained for assessment under section 2 only if:
    • the person is suffering from a mental disorder “of a nature or degree which warrants their detention” for at least a limited period, and
    • the person ought to be detained in the interests of their own health or safety or to protect others.
  4. AMHPs assess whether to make an application for detention. The objective of the assessment is to determine whether the criteria for detention are met, and, if so, whether to make an application.
  5. AMHPs may make an application for detention only if they:
    • have interviewed the patient in a suitable manner,
    • are satisfied that the statutory criteria for detention are met, and
    • are satisfied that, in all the circumstances of the case, detention in hospital is the most appropriate way of providing the care and medical treatment the patient needs.
  6. The Mental Health Act 1983 Code of Practice is statutory guidance for professionals on how to carry out their duties under the Act. It includes the following information and guidance.
  7. The Code of Practice says, “where the AMHP is the applicant, they have a professional responsibility to ensure that all necessary arrangements are made for the patient to be transported to hospital”.
  8. The Code of Practice says AMHPs should consult wherever possible with other people who have been involved in the patient’s care. This could include statutory, voluntary or independent services.
  9. The Code of Practice says “AMHPs should make decisions on which method of transport to use in consultation with the other professionals involved, the patient and (as appropriate) their carer. The decision should be made following a risk assessment carried out on the basis of the best available information”.
  10. The Code of Practice says AMHPs are required to identify the patient’s nearest relative. It says where possible, the AMHP should ascertain the nearest relative’s views about the patient’s needs. The Code of Practice says the AMHP should record their reasons if they do not consult or inform the nearest relative.

What happened

  1. Mrs Y had dementia and lived at home independently with help from the living well with dementia team. In 2017, the dementia team referred Mrs Y to the Dementia Crisis Service (DCS) after it had ongoing concerns for her welfare. The DCS is an NHS service which provides care related to dementia. The DCS arranged for carers to visit Mrs Y, however she refused to let them in on three occasions. The crisis team said Mrs Y was experiencing paranoid thoughts, was not taking her medication and had cut electrical cables in her house. Due to these concerns, the crisis team referred Mrs Y to the Council for an assessment under the Mental Health Act (MHA).
  2. In August 2017, an AMHP from the Council and two doctors visited Mrs Y, and assessed her under the MHA. Both doctors said the risks to Mrs Y were high and said the AMHP should admit Mrs Y to hospital under the MHA for assessment and treatment.
  3. The AMHP called Mrs X, to discuss the assessment with her and obtain her views as the nearest relative. Mrs X agreed Mrs Y should go to hospital. The AMHP decided to admit Mrs Y to hospital under section 2 of the MHA.
  4. The AMHP asked for an ambulance to transport Mrs Y to hospital at 2.40pm. At 7.50pm the ambulance had not arrived and had no estimated time of arrival. The AMHP said they discussed the delay with the DCS and decided to delay Mrs Y’s admission to hospital until the following day. The AMHP left Mrs Y in bed alone, and passed the case for the next day’s AMHP to deal with.
  5. Another AMHP arrived to see Mrs Y at 12.30pm the next day, and sat with her until the ambulance arrived at 6.15pm to take her to hospital, where she arrived at 7.15pm.
  6. Mrs X complained to the Council about its decision to leave Mrs Y alone at home for over 15 hours, after the AMHP had made the decision to admit her to hospital under the MHA. Mrs X also complained that nobody consulted with her about the decision to leave her alone. Mrs X asked what risk assessments the AMHP completed prior to deciding on leaving Mrs Y alone.
  7. The Council wrote back to Mrs X. It said the delay for the initial ambulance was unacceptable. The Council said it now uses private ambulance providers to transport patients, to ensure delays such as Mrs Y’s don’t happen again. The Council apologised for the AMHP not contacting her but said they did contact the DCS. The Council said neither the AMHP or DCS could have sat with Mrs Y overnight.
  8. Mrs X remained unhappy and wrote back to the Council. Mrs X asked again what risk assessments it completed, and asked again who authorised the AMHP to leave Mrs Y alone, after assessing her under the MHA.
  9. The Council wrote to Mrs X with its final response. It said it had not recorded or documented the decision to leave Mrs Y alone and it could not explain why it had not done so. The Council also said there was no record of the telephone discussion between the AMHP and the DCS. The Council said again that neither the AMHP, the DCS or the doctors involved in the MHA assessment could have remained at Mrs Y’s house overnight.
  10. Mrs X remained unhappy and complained to the Ombudsman.

My findings

  1. Having established the ambulance would not be available for transfer Mrs Y, the AMHP said they were ‘stood down’ because of the delay in the ambulance arriving. There is no evidence to show who decided to stand the AMHP down and leave Mrs Y alone. There is no evidence to show the Council completed a risk assessment, or any written notes to show how they considered the implications of leaving Mrs Y alone. That is fault.
  2. The Code of Practice says that consulting with the nearest relative is a significant safeguard for patients. Although the AMHP spoke to Mrs X about the decision to admit Mrs Y to hospital, it did not speak to her about the ambulance delay and its impact on Mrs Y’s transfer. The Council has already apologised for this.
  3. The Council said the AMHP discussed the decision to leave Mrs Y with the DCS. There are no written notes or records of the discussion. That is fault. It means the Council is unable to explain why it considered this decision was appropriate in the circumstances. Mrs X is therefore left uncertain about whether it properly considered the risks of leaving her mother at home alone, having already decided she needed to be detained for her safety.
  4. The Council decided to admit Mrs Y to hospital. It was the Council’s responsibility to ensure Mrs Y was safely admitted to hospital. It decided it was appropriate to leave her alone for a period of 15 hours, but it did not complete a risk assessment or document any of its considerations in reaching the decision. This caused Mrs X uncertainty and time and trouble in pursuing her complaint.

Agreed action

  1. The Council agreed within one month of the final decision to:
    • Apologise to Mrs X for leaving Mrs Y alone after it made the decision to admit her to hospital.
    • Pay Mrs X £150 for the time and trouble in pursuing her complaint, and for the uncertainty caused by failing to document its decision to leave Mrs Y alone.
    • Remind all AMHPs of the importance of keeping detailed case notes and written notes of all decisions.

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Final decision

  1. I have completed my investigation. I found fault leading to injustice, and the Council has agreed to my recommendations.

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Investigator's decision on behalf of the Ombudsman

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