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University Hospitals Plymouth NHS Trust (20 013 288b)

Category : Health > Hospital acute services

Decision : Not upheld

Decision date : 18 Feb 2022

The Ombudsman's final decision:

Summary: Mr B complained about the way his relative, Mr C, was discharged from psychiatric liaison services on two occasions over one weekend. We found no fault by the Council, Livewell Southwest or the Trust.

The complaint

  1. Mr B complains on behalf of his relative, Mr C. He complains about the way Mr C was discharged from psychiatric liaison services on two occasions over one weekend. Mr B says on the first occasion, Mr C was left to walk home a long distance at night without his phone or keys; and the second time he was discharged in hospital pyjamas. Mr B says Mr C should have been encouraged to stay in hospital as a voluntary patient, and that adequate follow-up support was not arranged. He said communication with Mr C’s family was poor, and staff did not take on board the information offered about him which could have helped. He also complains that social services told the police he had taken Mr C’s house keys, when this was not what happened.
  2. Mr B said Mr C was vulnerable and put at risk by the way he was discharged. He had to walk a long distance home alone at night, and break down his front door to get into his house. He also said Mr C did not get the follow up care he should have received. He said this caused worry and distress to him and Mr C.
  3. As a result of his complaint, Mr B seeks an acknowledgement that things went wrong, an apology and service improvements.

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The Ombudsmen’s role and powers

  1. 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 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).
  2. 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.
  3. 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

  1. I considered information sent to us by Mr B and spoke to him about his complaint. I wrote to the Council, Livewell Southwest, and the Trust, to tell them what I intended to investigate, and to request copies of relevant records. I considered the comments and documents they sent. I have also considered the law and guidance relevant to this complaint.
  2. I wrote to Mr B, the Council, Livewell Southwest, and the Trust with a draft decision. I considered the comments received before making a final decision.

What I found

Mental Capacity Act

  1. The Mental Capacity Act 2005 (the MCA) applies to people who may lack mental capacity to make certain decisions. Section 42 of the MCA provides for a Code of Practice (the Code) which sets out steps organisations should take when considering whether someone lacks mental capacity.
  2. Both the MCA and the Code start by presuming individuals have capacity unless there is proof to the contrary. The Code says all practicable steps should be taken to support individuals to make their own decisions before concluding someone lacks capacity. The Code says people who make unwise decisions should not automatically be treated as not being able to make decisions. Someone can have capacity and still make unwise decisions.
  3. The Code says, at paragraph 2.11, there may be cause for concern if somebody repeatedly makes unwise decisions exposing them to significant risk of harm or exploitation. The Code says this may not necessarily mean the person lacks capacity but further investigation may be required.

What happened

  1. Mr C attended the Emergency Department at Derriford Hospital following a deterioration in his mental health. However, he left before being seen. He returned the following day and was seen by the liaison psychiatry service. This is an urgent and emergency mental health service, managed by Livewell Southwest and based within Derriford Hospital. The Council’s Adult Social Care Out of Hours team were also involved in reviewing Mr C. As Mr C was not engaging or responding, he was referred for an assessment under the Mental Health Act 1983 (the MHA) but was not detained. A referral to the community mental health team was made to provide support for Mr C in the community, and to review his medication, and Mr C was discharged that evening at around 9.00pm.
  2. Mr C lived approximately 15 miles away from the hospital. Mr B told us that Mr C started to walk home and was picked up by someone and taken home. He said because he had no key to his flat, he broke a window to get in.
  3. The next day, Mr B went to Mr C’s home, and found the broken window and Mr C at home. He was concerned about Mr C’s presentation and called an ambulance. It was arranged for Mr C to go back to hospital. It is documented that on this occasion, while waiting to be seen, Mr C caused some damage to the Emergency Department. Mr C was placed on s136 of the MHA (used to take a person to a place of safety for up to 24 hours), and was taken to an inpatient unit, managed by Livewell Southwest, for a further assessment under the MHA.
  4. Mr C was again found not to meet the criteria for detention under the MHA. He was discharged that evening with a referral to the crisis team for support in the community.


  1. As Mr B has complained about several different issues, I have grouped these under separate headings, below.

First attendance at the Liaison Psychiatry Service

  1. As noted above, Mr C was seen and discharged on two separate occasions over the weekend. On the first occasion, the AMHP noted that Mr C had been assessed as “capacitous and able to make decisions with regard to his ongoing support in the community and wanted to go home”. It is also documented he also told the AMHP he did not want his family to be contacted or involved. As he had been assessed and not found to have an acute mental health issue, and was found to have capacity, the Trust said CDU staff could not override any of those decisions.
  2. Mr B was concerned that even though Mr C did not meet the threshold for detention under the MHA, he could have been encouraged to stay in hospital voluntarily. The records show that after the MHA assessment, the AMHP advised the CDU that Mr C could stay with them overnight, and they could contact the local mental health crisis team the following morning. The AMHP noted the crisis team may be able to support taking Mr C home the next day. In its response to the complaint, the Council said it had no further information about why Mr C did not stay overnight, as this was after the end of the AMHP’s involvement in Mr C’s care.
  3. During my investigation, I made enquiries of the Trust about what happened when Mr C was in the CDU following the end of the AMHP’s involvement. While the Trust’s discharge policy states the person and their family should be involved and informed about discharge decisions, it said that in Mr C’s case, the records state that on his first attendance, he wanted to discharge himself and asked for his family not to be informed. The Trust responded that it would always attempt to ensure a patient is discharged appropriately clothed and with a safe method of transport home. The Trust said its usual practice would be to keep patients overnight until public transport is running the next morning, and the cashiers’ office is open, if needed. However, the Trust said it could not hold a patient against their will if they are deemed to have capacity, and do not wish to wait for transport.
  4. As it is documented Mr C had capacity to make that decision, I have not found fault with the Trust or Livewell Southwest on this point. The Trust’s response that it cannot keep a patient in hospital if they are deemed to have capacity and do not wish to take on board advice about clothing or transport seems reasonable. The Trust discharge policy also states that staff should consider requesting follow-up in the community when people are discharged with a specific need. This was done in Mr C’s case as he was referred to the community mental health team.

Contact with family during first attendance

  1. Mr B complained that during the first attendance, more effort should have been made to try and contact someone who would have been able to look after Mr C and made sure he was safe to get home. Mr C’s father lived further away than Mr B. Although on the first occasion Mr C told the AMHP he did not want to speak to anyone from his family, Mr B said this should have been revisited before he was discharged, as Mr C was vulnerable.
  2. There is a note in the records to say the AMHP did try to double check with Mr C about whether he wanted his family informed. However, as Mr C was not answering questions, the AMHP noted they were “unable to go against [Mr C’s] wishes and discuss this further with his family”. Therefore, as the records indicate that the Council did try to check again with Mr C about contacting his family, I have not found fault on this point.
  3. Mr B also said he would have been able to give the AMHP helpful information about Mr C during his first attendance at hospital, as he lived close to Mr C, was in regular contact with him, and he knew his situation well. He said he spoke to the AMHP, but they did not take on board the information that he gave them. However, there is a note in the records of a discussion with Mr B. This indicates that the out of hours team did take note of the information he provided, so I have found no fault on this point.

Mobile phone and house keys

  1. Mr B said that prior to the first discharge from hospital, nobody checked whether Mr C had his house keys or mobile phone. The records show that staff were concerned that Mr C did not have his keys. However, because he had been found to have capacity to make decisions himself, he was advised to speak to his family to get keys for his flat, or to involve the police. Therefore, although staff could not speak to Mr B directly as Mr C had asked them not to contact his family, the records indicate staff did attempt to encourage him to talk to them. The notes also show that staff did check with Mr B about his house keys and phone. Therefore, I have not found fault on this point.
  2. Regarding Mr B’s complaint that the Council misunderstood the issue with Mr C’s house keys, the Council response says the police were informed and offered to support Mr C to help retrieve his keys. The Council said this was to support his safe discharge home. This response is supported by the information in the records. The Council apologised to Mr B for any misunderstanding about the keys. I do not consider I can add anything further on this point.

Second discharge from hospital

  1. Mr C attended hospital again the next day, and on this occasion, he said he did want his family to be contacted. The AMHP then contacted Mr C’s father, as he was named as the Nearest Relative.

Explanation for notifying relatives

  1. In its response to the complaint, the Council said it had notified Mr C’s father about the second assessment because under the Mental Health Act 1983 (the MHA), it was their duty to notify the nearest relative. It said the nearest relative was defined in priority order, with “the person’s father legally taking precedence over their mother”.
  2. Section 26 of the MHA defines the “nearest relative”. Where there are two nearest relatives in the same category (for example, parents), the oldest of the nearest relatives takes precedence. The records state that Mr C’s father was older than his mother, and this was the reason given in the records for the Council contacting him. Therefore, the records are in line with the definition in the MHA. However, the explanation given in the Council response is not fully accurate. The father does not automatically take precedence over the mother as nearest relative, but in Mr C’s case he did because he was the older of the two parents. The Council’s complaint response could have explained this more clearly and accurately, but I have not found fault in the Council’s actions at the time. The decision to contact Mr C’s father as nearest relative was in line with the relevant guidance, as supported by the information in the records.

Second discharge home

  1. Mr B complained that although transport was arranged for Mr C this time, he was discharged late at night and wearing hospital pyjamas. In response to the complaint, Livewell Southwest said Mr C accepted an offer of a taxi home.
  2. There are references within the records saying Mr C was wearing hospital pyjamas during this attendance, and although I have not seen any specific record stating that Mr C left wearing pyjamas, I have no reason to doubt Mr B’s recollection of this. However, I note that the records show taxi transport home was offered to Mr C and he accepted this. I recognise Mr B may have disagreed with Mr C being allowed to leave under these circumstances. However, the records say Mr C had capacity, wished to be discharged and accepted the arrangements offered at the time. Therefore, I have not found fault with Livewell Southwest for the discharge arrangements on this occasion.

Follow up support for Mr C following discharge

  1. During his first attendance at the Liaison Psychiatry Service, Mr C was referred to the community mental health team for follow-up the next day. This was so he could access support in the community, and for a review of his medication. There is a note to say this had been discussed with Mr C and he had agreed to engage with this. Mr B complained this arrangement was not sufficient to meet Mr C’s needs, and that the community team were not aware of the referral until Tuesday.
  2. The Livewell Southwest policy states that where someone is not detained under the MHA, the next step is to decide whether they should remain in hospital or be discharged and referred for community support. There is a note in the records (for both discharges) to say a referral for community support was made, and the reasons for this. As it is documented that Mr C had capacity to make decisions about his care and wanted to be discharged, and that he agreed with the referral at the time, I have not found fault on this point.

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Final decision

  1. I found no fault by the Council, Livewell Southwest and the Trust. I have completed my investigation on this basis.

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Investigator's decision on behalf of the Ombudsman

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