Summary: Worcestershire Health and Care NHS Trust’s community mental health team took too long to rearrange a cancelled appointment. Also, it did not return Mrs A’s call after she raised concerns about her son’s mental health. This caused Mrs A distress. The Ombudsmen consider Worcestershire County Council and the community mental health team’s lack of communication after April 2015 was fault. However, there was no impact on Mr B.

The complaint

1. Mrs A complains, on behalf of her late son (Mr B) about the actions of Worcestershire County Council’s (the Council) drug and alcohol services, and Worcestershire Health and Care NHS Trust’s (the Trust) community mental health team (CMHT).
2. Mrs A says the drug services did not tell the CMHT Mr B was reducing his addiction medication or that he then changed it to different one. Also, the CMHT did not tell the drug service Mr B was not taking his anti‑psychotic medication.
3. She says if both services communicated better, they may have checked Mr B more closely, and not decided to reduce his addiction medication.
4. Mrs A says the CMHT repeatedly cancelled appointments, and there was no consistency in care, or a clear treatment plan. Also, no one at the CMHT returned her call on 4 December 2015 when she had concerns about her son. The CMHT did not provide details for mental health support, or out of hours contacts. Mr B took his own life and was found dead by Mrs A’s husband two days later.
5. She says if a duty worker assessed Mr B on 4 December 2015, the outcome may have been different. She also suffered distress, panic attacks and sleeping problems. Mrs A also says her later husband suffered distress.
6. Mrs A also says the Trust’s decision to remove Mr B’s community psychiatric nurse (CPN) in 2013 may have contributed to his death. She says the CPN may have noticed Mr B’s worsening condition.
7. Mrs A would like the organisations to apologise, carry out service improvements and provide a financial remedy.

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What I have investigated

8. I have investigated Mrs A’s complaints about communication between the CMHT and substance misuse services, the CMHT’s cancellation of appointments and the events on 4 December 2015. The final section of this statement contains my reasons for not investigating the removal of the CPN in 2013.

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The Ombudsmen’s role and powers

9. The Ombudsmen have the power to jointly consider complaints about health and social care. Since April 2015, these complaints have been considered by a single team acting for both Ombudsmen. (Local Government Act 1974, section 33ZA,as amended, and Health Service Commissioners Act 1993, section 18ZA)
10. 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)
11. 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.
12. The Ombudsmen may investigate, and question the merits of, action taken in the exercise of clinical judgement.
13. The Ombudsmen cannot investigate late complaints unless they decide there are good reasons. Late complaints are when someone takes more than 12 months to complain to the Ombudsmen about something an organisation has done. (Local Government Act 1974, sections 26B and 34D, as amended, and Health Service Commissioners Act 1993, section 9(4).)
14. 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

15. I have considered the complaint information Mrs A has provided to me. I have asked the Council, CCG, Trust and Partnership Trust to comment on the complaint, and provide supporting documentation.
16. I have taken the relevant law and guidance into account. I sought independent clinical advice from a psychiatrist.
17. I have also written to Mrs A, the Council and the Trust with my draft decision and considered their comments.

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What I found

Key facts

18. Since 2013, Mr B was under the Council’s substance misuse team. The Council commissioned a company (Company 1) to deliver that service. Mr B was also under the Trust’s CMHT to treat his paranoid schizophrenia.
19. In January 2013, the CMHT cancelled an appointment for 16 January, but then saw him a week later. After June 2013, Mr B did not see the CMHT until March 2014. This was due to a combination of staff sickness, cancelled appointments and Mr B not attending.
20. Between December 2014 and March 2015, Mr B attended appointments with Company 1 and the CMHT. Both services communicated with each other about his progress and treatments.
21. In April 2015, the Council changed its substance misuse provider from Company 1 to Company 2. During that period, Mr B reluctantly but gradually reduced his methadone dosage. Company 2 encouraged him to interact with people more.
22. In August 2015 Mr B told the CMHT psychiatrist he had stopped taking his medication for schizophrenia because he did not believe he had schizophrenia.
23. In September 2015, Mrs A asked Mr B’s GP to seek a second opinion from the CMHT about Mr B’s diagnosis. Mrs A was not happy with the attitude of Mr B’s psychiatrist. Also, the psychiatrist did not agree Mr A’s lack of motivation was due to his deteriorating mental health, which Mr and Mrs A were concerned with. A month later, a different psychiatrist diagnosed Mr B with amotivational syndrome. People with amotivational syndrome lack drive and are demotivated.
24. On 1 December 2015, Company 2 told the CMHT it had discharged Mr B as he was no longer using alcohol or illegal drugs.
25. On 4 December 2015, Mrs A called the CMHT twice to raise concerns about Mr B’s mental health and asked that they contact him. A duty worker spoke to Mr B the same day, and he said he had sleeping problems. The duty worker recommended booking an appointment with his GP. No one from the CMHT updated Mrs A. Two days later, Mr B took his own life.
26. In February 2016, the Trust completed an investigation into Mr B’s death. It said it needed to improve parts of its service. However, it considered the fault would not have changed the outcome for Mr B.

Analysis

Communication about medication

27. In 2009 the Royal College of Psychiatrists produced its Good Psychiatric Practice guidelines. Specifically, paragraph 15 says: “A psychiatrist must communicate treatment decisions, changes in treatment plans and other necessary information to all relevant professionals and agencies, with due regard to confidentiality”.
28. I consider the CMHT and Company 1 communicated effectively between December 2014 and March 2015.
29. Company 1 case notes and CMHT’s outpatient letters show on 23 March 2015 it held a joint meeting with Mr B to discuss his care and treatment, including medication. They discussed Mr B’s care and treatment again in a meeting on 24 March, which Mr B did not attend. The CMHT copied a doctor from Company 1 into its outpatient letter to Mr B from that meeting.
30. Between December 2014 and March 2015, there was good communication between the CMHT and Company 1 regarding Mr B’s care and treatment, including his medication. I do not consider the CMHT or Company 1’s actions were fault.
31. When the Council changed its provider from Company 1 to Company 2, communication between the two services stopped. I cannot say why they stopped communicating with each other. While they were not communicating, both services were aware Mr B was reducing his methadone. This is clear in the Trust’s clinical notes from March 2015.
32. In August 2015, the CMHT did not tell Company 2 Mr B had stopped taking his schizophrenia medication for the previous six months. This was not in line with the relevant guidelines. However, Mr B told Company 2 the same information a month later. Therefore, Company 2 would have only been unaware he had not been taking that medication for just under a month. However, I do not consider there was an injustice to Mr B. Company 2 did not change its treatment plan for Mr B after September 2015. Also, Mr B’s condition did not deteriorate after that point.
33. Company 2 did not tell the CMHT it changed Mr B’s addiction medication in October 2015. This was not in line with the relevant guidelines. Again, I have not seen any evidence Mr B’s condition deteriorated after that point.
34. While communication between the CMHT and Company 2 stopped after April 2015, they prescribed drugs in line with their respective policies. This included the British National Formulary, the Maudsley Prescribing Guidelines and the ‘Choice and Medication’ website.
35. I consider the CMHT and Company 2’s lack of communication was fault. I have not found there was any impact to Mr B. Mrs A said if the services communicated better, they would not have reduced Mr B’s addiction medication. I do not agree. Most people reduce the dose they take with the aim to stop taking it altogether. This was the case also with Mr B. I do not consider the CMHT and Company 2’s lack of communication would have changed either of their respective treatment plans.
36. The Council has provided evidence that Company 2 and the CMHT have a memorandum of understanding. The Council said Company 2 meets with the CMHT regularly to discuss complex cases. Also, the CMHT have attended training sessions at Company 2. Overall, I am satisfied the Council has provided evidence to show how the CMHT and Company 2 effectively communicate with each other, and how it is working to avoid similar fault occurring.

Cancellation of appointments

37. After July 2014, it took the CMHT too long to rearrange Mr B’s cancelled appointment because it did not meet him again until March 2015. The Trust said this was due to staff sickness. I consider that delay was fault.
38. I understand how that delay would have been distressing for Mrs A. The Trust has recognised Mrs A’s distress and accepted this fault during its own investigation. The Trust added it was over reliant on temporary doctors, which led to a lack of consistency in Mr B’s care.
39. The Trust now has a written procedure for staff which tells them to reallocate appointments as soon as they have cancelled one. Also, it no longer uses temporary doctors. I consider the Trust has improved its service to avoid similar fault happening again to others. However, I feel the Trust needs to do more to remedy the distress Mrs A suffered.
40. From the Trust’s records, when the CMHT cancelled Mr B’s other appointments (after 2013), I consider it rearranged them quickly.

The CMHT’s communication on 4 December 2015

41. The CMHT should have provided an update to Mrs A after the duty worker contacted Mr B on 4 December 2015. I consider this was fault, which would have caused Mrs A distress.
42. I do not consider the Trust has fully remedied Mrs A’s distress. The Trust apologised for the distress caused to Mrs A. It has also ensured staff will make sure families of patients will be told what response they should expect from staff after raising concerns. However, I feel the Trust needs to do more to remedy the distress Mrs A suffered.
43. The duty worker provided Mr B with information about crisis support and out of hours contacts. Therefore, he was aware who he should contact for support. However, the duty worker should have completed a more robust assessment of Mr B on 4 December 2015. The duty worker did not consider his presentation in line with his care plan or risk assessments. This was fault but I cannot agree Mr B would not have committed suicide if the duty worker had completed a more robust assessment. However, I consider the Trust has learnt lessons from the fault.

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Recommendations

44. Within four weeks the Trust should pay Mrs A £200 in recognition of the distress she suffered.

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Final decision

45. I consider the lack of communication between CMHT and Company 2 was fault. However, I do not agree this impacted Mr B’s mental or physical condition.
46. I consider at times the CMHT took too long to rearrange appointments for Mr B after it cancelled them. Also, the CMHT should have called Mrs A back after she raised concerns about Mr B’s mental health. This caused Mrs A distress.

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Parts of the complaint I did not not investigate

47. Mrs A would like me to investigate the Trust's decision to remove her son’s CPN in 2013. She says Mr B had a good relationship with that CPN, who may have been able to notice Mr B’s deteriorating condition. I consider Mrs A and Mr B had the opportunity to raise this complaint earlier. Mrs A has not provided any exceptional reasons why we should look at the complaint about the CPN. Therefore, further to paragraph 13, I do not consider we should be investigating this part of her complaint.

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Investigator's decision on behalf of the Ombudsman