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Oxford Health NHS Foundation Trust (18 018 286a)

Category : Health > Mental health services

Decision : Upheld

Decision date : 20 Apr 2021

The Ombudsman's final decision:

Summary: We found fault with the support a Trust provided to a man with complex care needs and his parents. We also found fault by a Council in terms of the handling of the Mental Health Act Assessment process by an Approved Mental Health Practitioner acting on its behalf. The Council and Trust will apologise to the complainants and pay a financial sum in recognition of the distress caused to them by this fault. They will also take action to prevent similar problems occurring in future.

The complaint

  1. The complainants, who I will call Mr and Mrs G, are complaining about the care and support provided to their son, Mr H, by Buckinghamshire County Council (the Council) and Oxford Health NHS Foundation Trust (the Trust).
  2. Mr and Mrs G complain that:
  • Staff from the Trust and a Housing Association (both acting on behalf of the Council) failed to provide Mr H with social care support to meet his assessed eligible needs. Mr and Mrs G say this led Mr H to disengage from the professionals involved in his care.
  • The Trust failed to take action to support Mr H when his condition began to deteriorate.
  • Professionals broke into Mr H’s apartment unnecessarily to carry out a Mental Health Act Assessment.
  • When Mr H was evicted from his supported living property, the Trust (acting on behalf of the Council) failed to find suitable alternative accommodation for him.
  1. Mr and Mrs G say the failure of the organisations involved in Mr H’s care to support him left him distressed, withdrawn and homeless. They say this has placed immense pressure on Mr H and his family.
  2. Mr and Mrs G would like the organisations involved in Mr H’s care to ensure he has suitable accommodation and support. They would like Mr H to receive financial recompense and for action to be taken to ensure similar problems do not occur in future.

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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 (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. In reaching this draft view, I considered information provided by Mr and Mrs G and discussed the complaint with Mr G. I also considered comments and documentation from the Council and Trust, including copies of the clinical and social care records. I invited comments on my draft decision statement from Mr and Mrs G and the organisations they are complaining about and considered the responses I received.

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What I found

Relevant legislation and guidance

Mental Health Act 1983

  1. The Mental Health Act 1983 (the MHA) allows for someone who has a mental disorder and is putting their safety, or that of someone else, to be detained in hospital against their wishes. This is sometimes known as ‘being sectioned’.
  2. An application for detention may be made by an Approved Mental Health Professional (AMHP – an officer acting on behalf of the local authority) or the patient’s nearest relative. An application must be supported by two medical recommendations, one of which should be from a doctor who has been specially approved in MHA detentions.
  3. Section 135(1) of the MHA allows an AMHP to apply to the courts for a warrant to enter the private premises of a person with a mental disorder. This warrant gives the police the power to enter private premises for the purpose of removing a person with a mental disorder to a place of safety for a mental health assessment. This includes gaining entry to the premises by force if necessary. The police officer gaining entry must be accompanied by an AMHP and a doctor.
  4. The MHA is accompanied by the Mental Health Act 1983: Code of Practice (the Code of Practice). This provides statutory guidance for professionals on how to carry out their functions under the MHA.

Key facts

  1. Mr H has a diagnosis of Atypical Autism with obsessive-compulsive symptoms and social phobia secondary to this diagnosis.
  2. In 2013, Mr H moved into a supported living placement run by the Housing Association. This placement provided him with 12 hours of social care support per week. This included support to help Mr H leave the premises as he was often reluctant to do so.
  3. Mr H was also supported by the Trust’s Assertive Outreach Team (AOT) for his mental health needs and had an allocated care coordinator.
  4. In early 2015, Mr H’s care transferred from the AOT to the local Community Mental Health Team (CMHT). The Trust allocated him a new care coordinator.
  5. Mr H kept a life-size figure with a replica gun in his room. In May 2016, a passing member of the public noticed the figure and alerted the police. The police attended Mr H’s apartment. Mr H was agitated and aggressive and felt staff at the placement had called the police. As a result, Mr H largely disengaged from the support services on offer at the placement.
  6. In July 2016, the Housing Association issued Mr H with a written warning. This explained that Mr H was in breach of his support agreement and that he would need to resume engagement with support staff or face possible eviction.
  7. The situation did not improve, and the Housing Association convened a meeting in November 2016. The meeting heard that Mr H would be unable to remain in the supported living placement if he was unwilling to engage with the support on offer. Mr and Mrs G agreed to search for private rented accommodation in the community.
  8. Mr H continued to refuse support from both placement and Trust staff and the Housing Association issued a final written warning in May 2017.
  9. When Mr H’s engagement did not improve, the Housing Association served him with an eviction notice in August 2017.
  10. The matter subsequently progressed to the County Court in March 2018.
  11. In April 2018, a consultant psychiatrist from the CMHT visited Mr H at the placement to complete a review. However, Mr H would not admit her or engage fully with the assessment.
  12. Following discussion with the multidisciplinary team, the consultant psychiatrist concluded it would be necessary to complete a Mental Health Act Assessment for Mr H.
  13. The consultant psychiatrist referred the case to the local Approved Mental Health Act Professionals (AMHP) service. An AMHP obtained a warrant under Section 135(1) of the MHA to enter Mr H’s apartment for the purposes of completing an assessment. However, by the time the warrant was served in May 2018, Mr H had left the placement and was living with Mr and Mrs G.

Analysis

Disengagement and support

  1. Mr and Mrs G complain that the Trust and Housing Association (on behalf of the Council) failed to properly care for Mr H when he began to disengage from support and his condition deteriorated.
  2. The case records provided by the Housing Association show that, in 2015, Mr H was generally engaging well with support staff at the placement. Support workers prompted Mr H to access the community, accompanying him to the cinema and supermarket. They also prompted him to take his medication (an antidepressant).
  3. Mr H’s engagement with his care coordinator was more sporadic that year. He refused to meet with the care coordinator several times. However, the care coordinator completed two visits to Mr H during the early part of the year. This included a care review meeting. The care coordinator noted Mr H was “happy with the current arrangement and has been more open and engaging in activities he enjoys”.
  4. By early 2016, Mr H’s engagement with staff at the placement was becoming more limited. The Housing Association’s records show Mr H sometimes refused support or did not answer his door when staff called for him. Nevertheless, he still spoke to support staff regularly and was noted to be “in a positive state of mind”.
  5. Again, Mr H was less willing to engage with his care coordinator in early 2016. In January 2016, the care coordinator visited Mr H, but he did not answer the door. The care coordinator arranged a care plan review meeting for the following month, but this did not proceed.
  6. Following the police incident in May 2016, the situation deteriorated significantly. From that point, the case records show Mr H disengaged almost entirely from any contact with support workers. Mr H met with a support worker on 9 June 2016, who noted he was “very reluctant to talk about anything during the link session and seemed a bit down”. Mr H also told the support worker that he had stopped taking his medication.
  7. On 22 June 2016, Mr H attended a review meeting with his care coordinator and an officer from the placement. Mr G was also present. The notes of the meeting show the care coordinator explained to Mr H that he would need to start engaging with support staff or he would be in breach of his tenancy agreement. The care coordinator noted “[i]t was agreed that [Mr H] would start re-engaging with staff for his supported hours…[Mr H] was advised to start taking his medication and he agreed to do this.”
  8. Support workers spent some time with Mr H on 24 and 25 June 2016. He was noted to be very unhappy about the police incident but was described as “talkative and seemed positive.” However, Mr H generally refused to answer his door or speak to staff.
  9. When Mr H failed to attend a review meeting in early July 2016, his care coordinator visited him at the placement. Mr H did not answer his door. Staff at the placement advised the care coordinator that Mr H had secured his door from the inside.
  10. On 25 July 2016, Mr and Mrs G attended an outpatient appointment with Mr H’s care coordinator and consultant psychiatrist. Mr H waited outside and would not attend. The consultant psychiatrist was able to speak to Mr H briefly outside the meeting. She noted Mr H appeared to be protesting about the police incident in May 2016 and refused to restart his medicine. The consultant psychiatrist said she would arrange a further appointment and noted Mr H appeared to agree to attend this.
  11. Throughout August 2016, Mr H refused to engage with staff at the placement. However, staff occasionally witnessed Mr H with his family on the placement CCTV system.
  12. The consultant psychiatrist arranged a new appointment for 30 August 2016. Mr H did not attend.
  13. On 5 September 2016, Mrs G called the placement to report that Mr H had been feeling unwell with chest pains and had taken the train to visit her. This was followed by a message from Mr G on 7 September 2016 that explained Mr H had attended hospital and was taking antibiotics for a chest infection.
  14. Mr H returned to his apartment. Support staff continued to attend daily to provide social support. Mr H did not answer his door and staff had very little contact with him throughout September and October 2016. However, Mr H continued to see his family and staff maintained regular contact with Mr and Mrs G to check on his welfare.
  15. In their complaint correspondence, Mr and Mrs G said that Mr H’s disengagement from support was a gradual process and that professionals from the Trust and Housing Association missed opportunities to prevent this deterioration.
  16. The evidence I have seen suggests that Mr H was still engaging with support staff relatively well by early 2016. Staff accompanied him to the cinema, shopping and on walks and prompted him to take his medication. The notes of these support visits suggest Mr H was generally in a positive state of mind and happy to interact with staff. There were occasions during this period when Mr H did not answer the door for support visits. Nevertheless, there was not, in my view, a clear pattern of disengagement at that stage. Based on this evidence, I do not agree that the professionals supporting Mr H missed opportunities to prevent him disengaging from support.
  17. The police incident on 28 May 2016 appears to have prompted a rapid deterioration in the situation. This was clearly a very unfortunate incident, but not one for which the Council or Trust bear any responsibility.
  18. Initially, Mr H appears to have told placement staff that he would not engage with them as a means of protesting against the police involvement, which he believed had been initiated by staff. The notes of the meeting on 8 June 2016, which Mr H did not attend, record that Mr H “has indicated he will start talking to staff after 6 weeks.”
  19. Mr H’s care plan of August 2015 noted that “[w]hen [Mr H] first discharged himself from hospital [in 2013] and was non-compliant with a medication treatment plan, his symptoms worsened and irritability and aggressive behaviour increased as he struggled to manage his symptoms. Now [Mr H] is taking [his medication] daily…agitated behaviour has reduced.” This suggests Mr H’s decision to stop taking his medication (in early June 2016) may also have contributed to the deteriorating situation.
  20. The care records show staff from the Housing Association and Trust made continued attempts to engage with Mr H in the following months. This included prompts to restart his medication and attempted care meetings. However, the situation did not improve.
  21. The Mental Capacity Act 2005 makes clear that, simply because a person chooses to make an unwise decision, it should not be presumed that person does not have capacity to make that decision. I have seen no evidence to suggest Mr H lacked capacity to make decisions about his care and treatment. Ultimately, this meant he was free to decide not to engage with the professionals supporting him and to stop taking his medication.
  22. I recognise it is possible that a thorough review of Mr H’s care needs might have identified a more effective way of encouraging his engagement with support services. However, Mr H’s unwillingness to engage in any assessments or reviews meant it was not possible to explore this further.
  23. Taking everything into account, I consider the Trust and Housing Association (on behalf of the Council) made appropriate efforts to engage Mr H during the period to November 2016, though without success. I found no fault on this point.

Accommodation

  1. Mr and Mrs G complain that the Trust (acting on behalf of the Council) failed to find suitable alternative accommodation for Mr H after he was evicted from the supported living placement. They say the placements the Trust did identify were completely unsuitable for Mr H.
  2. On 28 November 2016, Mr and Mrs G attended a meeting at the placement with staff from the Trust and Housing Association, including Mr H’s care coordinator. Mr H did not attend. The meeting heard Mr H was no longer engaging with support and that he would be unable to remain in the placement. The notes of the meeting show Mr and Mrs G wanted Mr H to live in a nearby town closer to the family. The notes record “[f]amily agreed to start looking for accommodation in [the nearby town] and to act as guarantors for private rental.”
  3. On 22 December 2016, a housing officer from the CMHT spoke to Mr G. Mr G said he had identified some potential private rental accommodation but was unsure when Mr H would be leaving the supported living placement. The housing officer advised Mr G that Mr H’s care coordinator was on leave but would be in contact in the new year to arrange a meeting.
  4. I found no evidence to suggest the care coordinator contacted Mr and Mrs G as agreed. The next case note from the care coordinator is dated 30 March 2017 (over three months later). This notes that Mr H was still not engaging with support that the care coordinator would “[c]ontinue to try and engage [Mr H] and progress plans regarding accommodation [in the nearby town].”
  5. In April 2017, the Housing Association offered Mr H an independent living apartment. However, after consultation with Mr H, Mr and Mrs G declined this placement as they felt the area in which the placement was located would be unsuitable.
  6. The Housing Association issued Mr H with a final written warning the following month. This explained that Mr H would need to engage with his support plan or action would be taken to evict him within 14 days.
  7. Mr H’s care coordinator subsequently asked the Housing Association to put the threat of eviction on hold while further efforts were made to identify suitable accommodation for Mr H. The Housing Association agreed to a four-week extension. In a case note later in June 2017, the care coordinator noted that he would “[c]ontinue with pursuing a move from [the placement] to [the nearby town] near his mother who has been giving him support.”
  8. Around this time, the Trust’s placement team identified a potential shared placement for Mr H, but it was agreed this would not be suitable for him.
  9. I understand the CMHT then contacted the housing team of the neighbouring local authority to explore the possibility of securing accommodation for Mr H closer to Mr and Mrs G. However, that local authority declined to accept Mr H on the basis that he did not have a connection with the local area.
  10. In August 2017, the Trust’s placement team identified an alternative supported living provider. The case records suggest Mr H initially engaged well with an officer from the provider. However, he ultimately decided that he no longer wanted accommodation with a care component and was hoping to live independently in the community. As a result, the provider withdrew from the process.
  11. In early October 2017, a housing officer from the CMHT contacted a homelessness charity in the town in which Mr H was hoping to secure accommodation (Charity A). Charity A explained that Mr H would need to engage with its staff if they were to support him. By this stage, Mr H was not engaging with any of the professionals involved in his care. Charity A suggested an alternative homelessness charity in the same area as the placement in which Mr H was living (Charity B).
  12. The housing officer from the CMHT subsequently contacted Charity B, which agreed to support Mr H to search for accommodation in the local area.
  13. On 2 November 2017, Charity A confirmed it would be unable to support Mr H as he did not have a connection to that area.
  14. On 17 November 2017, the housing officer spoke to Mrs G. She explained that Mr and Mrs G would need to visit Charity B in person to discuss Mr H’s housing needs.
  15. However, the Council’s records reveal there was some confusion on this point as Mr G contacted Mr H’s care coordinator later that month to ask for an update. The care coordinator explained again that Mr and Mrs G would need to engage with Charity B for support. Mr G responded to say he had done so.
  16. I found no evidence in the Trust’s records of any further contact with Mr and Mrs G (or any other activity) until February 2018, when Mr G contacted the care coordinator to ask for a resolution to Mr H’s housing situation.
  17. On 22 March 2018, Mr and Mrs G attended a county court hearing regarding Mr H’s eviction. Mr H did not attend. The court would not allow Mr G to act as Mr H’s litigation friend as Mr H had not given his consent. The court adjourned to allow the Trust additional time to gather information about Mr H’s ability to participate in the legal proceedings.
  18. The following day, Mr H’s care coordinator visited him at the placement. Mr H would not see the care coordinator but spoke to him through the door of his apartment. The care coordinator noted that Mr H “was very clear that he wants to live away from everyone somewhere isolated”. The care coordinator invited Mr H to attend a professionals meeting to be held later that month.
  19. Mr H did not attend this meeting, though Mr and Mrs G were present. The notes of this meeting are brief, recording only that the care coordinator would visit Mr H again to obtain up-to-date information for the court.
  20. The care coordinator and consultant psychiatrist visited Mr H on 3 April 2018. Again, Mr H would not see them, but spoke to them through his door. The consultant psychiatrist noted Mr H was worried about the legal process but “[w]ould not confirm whether or not he wanted to have his father represent him as a litigation friend”. As Mr H was refusing to engage with assessments or reviews, the consultant psychiatrist concluded that a Mental Health Act Assessment would be necessary. I have commented on the handling of this process in the ‘Mental Health Act Assessment’ section of this decision statement.
  21. On 10 April 2018, Mr G contacted the care coordinator to report that the neighbouring council was willing to accept Mr H onto its housing allocations list. The care coordinator emailed the housing support officer to ask what further action the CMHT needed to take with regards to Mr H’s housing situation. I found no response to this email on file.
  22. On 16 April 2018, Mr G told the care coordinator that Charity A had now agreed to support Mr H to find accommodation closer to Mr and Mrs G. An officer from Charity A contacted the care coordinator on 23 April 2018 to explain that she would arrange to meet Mr H. She also asked the care coordinator to call her to discuss the case. It is unclear whether he did so.
  23. Around this time, Mr H moved out of the placement and began living with Mr and Mrs G.
  24. The case records show that, by November 2016, Mr H’s supported living placement was failing as he refused to engage with the support on offer. This was explained to Mr and Mrs G during a meeting that month.
  25. The evidence I have seen suggests the Trust was attempting to identify suitable accommodation for Mr H from this point. However, various factors delayed this process. Foremost amongst these was Mr H’s ongoing refusal to engage with the professionals supporting him. This meant prospective accommodation providers were unable to assess his needs. It also made it more difficult for professionals to obtain Mr H’s views on where he would like to live.
  26. The situation was further complicated by Mr H’s decision, in September 2017, that he no longer wanted to live in accommodation with a care component (such as supported living accommodation). This meant Mr H (or Mr and Mrs G on his behalf), needed to seek accommodation through mainstream housing services, rather than through the Trust’s placement team.
  27. Mr and Mrs G’s efforts to find Mr H accommodation near their home was further hampered by that local authority’s decision that it did not owe a housing duty to Mr H as he had no local connection to the area. This was understandably frustrating for Mr and Mrs G. However, neither the Trust nor the Council had any control over this decision.
  28. The housing support officer subsequently referred Mr and Mrs G to both Charity A and Charity B with a view to supporting them to secure suitable accommodation for Mr H.
  29. Taking everything into account, I am satisfied the Trust (acting on behalf of the Council) made appropriate efforts to find accommodation for Mr H, albeit these efforts were unsuccessful. I also consider the Trust to have acted appropriately in making referrals for Mr H to local housing charities. I found no fault in this regard.
  30. Nevertheless, I do have some areas of concern.
  31. As I have explained above, Mr H’s limited engagement with the professionals supporting him made it difficult to obtain his views on his accommodation situation. Despite this, I found no evidence to suggest the Trust offered to arrange an advocate to support Mr H with this process. This was fault.
  32. It is not possible to say whether Mr H would have engaged with an advocate even if the Trust had arranged one. However, the Trust’s failure to provide this support represented a missed opportunity for Mr H to make his views known.
  33. I also have some concerns about the Trust’s communication with Mr and Mrs G during this process.
  34. This was evidently a challenging situation given Mr H’s complex needs and the involvement of various agencies, including the neighbouring housing authority and two homelessness charities. The case records show that Mr and Mrs G were not always clear what was required of them in terms of securing suitable accommodation for Mr H.
  35. Mr H’s decision that he no longer wanted to live in supported accommodation represented a significant change in circumstances. The evidence strongly suggests that a multiagency meeting was needed to discuss Mr H’s accommodation situation at that stage. Despite this, I found no evidence of any further meetings in the records beyond the one in November 2016.
  36. I accept it is unlikely Mr H would have attended such a meeting in person. However, a meeting would have allowed the professionals working with Mr H to make clear to Mr and Mrs G what they would need to do to secure accommodation for Mr H and what support they could expect to receive.
  37. In my view, the failure to hold a meeting contributed to Mr and Mrs G’s confusion and caused them unnecessary confusion and distress.
  38. Furthermore, I identified some delays on the part of Trust officers with regards to their communication with Mr and Mrs G.
  39. In December 2016, the housing support officer told Mr G that the care coordinator would contact him to discuss Mr H’s housing situation. In fact, it was not until March 2017 (almost three months later) that he did so.
  40. Similarly, in November 2017, Mr G contacted the care coordinator with a further query. He did not receive a response until February 2018 (two months later).
  41. I found no adequate explanation for these delays. This was fault and caused Mr and Mrs G understandable frustration during what was already a challenging period.

Mental Health Act Assessment

  1. Mr and Mrs G complain that the Trust acted unnecessarily in forcing entry to Mr H’s apartment under Section 135(1) of the Mental Health Act. They say this only served to place Mr H under further duress.
  2. The Housing Association’s records show that, throughout the first half of 2017, support staff continued to attend Mr H’s apartment to offer him support. However, Mr H refused to answer the door or speak to staff.
  3. The Housing Association considered Mr H’s apartment to be a potential fire risk due to the amount of electrical equipment he was using. In early June 2017, a fire risk assessor attended to assess the premises. Mr H did not answer his door.
  4. Later that month, support staff called the police as they noticed Mr H had hung a burning saucepan out of his window. Both support staff and police officers attempted to gain entry to the apartment to check on Mr H’s welfare. Mr H would not admit them but was eventually persuaded to speak to the police. He would not show his face and wore a balaclava.
  5. Support staff continued to make efforts to contact Mr H in the later part of the year, but without success.
  6. In March 2018, support staff at the placement informed Mr H’s care coordinator that Mr H’s gas provider had cut off his supply as he had repeatedly refused to admit an engineer to complete a gas safety check.
  7. That month, another resident at the placement complained about banging noises coming from Mr H’s apartment. This led to an altercation between Mr H and support staff. Staff noted that Mr H would not admit them, but shouted abuse and threats through his door.
  8. Mr H’s care coordinator and consultant psychiatrist visited him on 3 April 2018 to complete a review. Mr H would not admit them or leave his apartment, although he did speak to them through the door. This meant the review was limited in scope. The consultant psychiatrist subsequently discussed Mr H’s case with the multidisciplinary team and concluded it would be appropriate to conduct a Mental Health Act Assessment.
  9. The case records show that, by April 2018, Mr H’s relationship with both support staff at the placement and the CMHT had broken down entirely. Mr H had not consistently engaged with the professionals supporting him since May 2016.
  10. The case records show the professionals supporting Mr H had further reasons to be concerned about his welfare. During the attempted review in April 2018, Mr H told the consultant psychiatrist he had not left his room since September 2017 and had now lost all his teeth. Based on this evidence, it is understandable the consultant psychiatrist considered Mr H to be at risk of self-neglect.
  11. In addition, Mr H had refused to allow gas and electrical engineers access to complete safety checks. This potentially placed other residents at risk.
  12. In my view, the evidence supports the consultant psychiatrist’s decision to pursue a Mental Health Act Assessment. This is because Mr H’s refusal to engage in any way with professionals meant it was necessary to use the powers granted by the Mental Health Act 1983 to conduct a compulsory assessment.
  13. As Mr H would not leave his apartment, the AMHP applied to the County Court for warrant under Section 135(1) of the MHA. This empowered the police to enter Mr H’s apartment for the purposes of transporting him to a place of safety so the assessment could go ahead. I note the Court was satisfied there were sufficient grounds on which to issue a warrant.
  14. The case records show arrangements for execution of the warrant were confirmed at around 12.00pm on 9 May 2018. The AMHP noted she had called Mr G to inform him but received no response and left a voicemail.
  15. The AMHP, consultant psychiatrist and police arrived at the placement at around 13.20pm. A police officer knocked on Mr H’s door and called out to him but received no response. The police arranged for equipment to be delivered to the placement to enable them to force entry to the apartment. In the meantime, a support worker from the placement attempted to call Mrs G. However, she received no answer and left a message.
  16. The police forced entry to the apartment at around 2.45pm. The AMHP noted that Mr H’s cupboards and fridge were bare and that he appeared to have moved out. As a result, the assessment did not proceed.
  17. Section 14.7 of the Code of Practice requires that, before deciding that admission to hospital under the MHA is necessary, consideration must be given to whether there are alternative means of providing the care and treatment the patient requires. This can include informal admission to hospital or treatment in the community. However, Mr H’s lack of engagement with the professionals supporting him meant these were not viable options.
  18. In the circumstances, I consider the decision to use powers granted by the MHA to complete a compulsory assessment for Mr H to have been made in accordance with the requirements of the Code of Practice. I found no fault in this regard.
  19. Section 14 of the Code of Practice sets out the AMHP’s responsibilities in the Mental Health Act Assessment process. This section makes clear the importance of effective communication with the patient’s nearest relative. The AMHP should ascertain the nearest relative’s views, explain why the assessment is considered necessary and inform them of their rights under the MHA.
  20. The consultant psychiatrist identified the need for a Mental Health Act Assessment in early April 2018. The Trust’s records show the AMHP service subsequently obtained the Section 135(1) warrant on 16 April 2018. A further note (dated 3 May 2018) recorded that the AMHP would “liaise with [the placement] and nearest relative/family”. Despite this, I found no evidence to suggest the AMHP, or any member of the CMHT, contacted Mr and Mrs G until shortly before the warrant was executed on 9 May 2018. When the professionals were unable to contact Mr and Mrs G, the warrant was executed without their input.
  21. In my view, the AMHP should have contacted Mr and Mrs G sooner than she did. The failure to do so meant they were not given the opportunity to provide their input into the assessment process. This represented fault by the Council, as the AMHP was acting on its behalf.
  22. The assessment ultimately did not proceed as Mr H was not present at the placement on that day. Nevertheless, the lack of consultation caused Mr and Mrs G understandable distress.

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Agreed actions

Trust

  1. Within one month of this decision statement, the Trust will:
  • Write to Mr H to apologise for the distress caused to him by its failure to provide him with an advocate to support him to put across his views about his care and accommodation.
  • The Trust will also pay Mr H £200 in recognition of the impact of this failure on him.
  • Offer Mr H a remote meeting to discuss his ongoing care and accommodation needs, with support from an advocate and/or Mr and Mrs G, if required.
  1. Within one month of this decision statement, the Trust will also write to Mr and Mrs G to apologise for the distress and uncertainty caused to them by:
  • Its failure to arrange a multiagency meeting in 2017 to discuss Mr H’s accommodation situation.
  • Its failure to respond in a timely manner to their correspondence and requests for assistance.
  • The Trust will also pay Mr and Mrs G £100 in recognition of the impact this had on them.
  1. Within three months of this decision statement, the Trust will write to the Ombudsmen to explain what action it will take to:
  • Ensure there is a clear process in place for arranging advocacy support for service users where appropriate. The Trust should also explain what action it will take to ensure relevant staff are familiar with this process.

Council

  1. Within one month of this decision statement, the Council will write to Mr and Mrs G to apologise for:
  • The distress caused to them by the AMHP’s failure to consult with them in a timely manner before executing the Section 135(1) warrant in May 2018.
  1. The Council will also pay Mr and Mrs G £100 in recognition of the impact this had on them.
  2. Within three months of this decision statement, the Council will write to the Ombudsmen to explain what action it will take to:
  • Ensure there is clear local guidance in place for AMHPs regarding the need to consult with Nearest Relatives as part of the Mental Health Act Assessment process, in accordance with the requirements of the Code of Practice. The Council will also explain what action it will take to ensure AMHPs are familiar with this guidance.

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Final decision

  1. I found fault by the Trust with regards to its failure to provide Mr H with an advocate to support him. I also found fault with the Trust’s communication with Mr and Mrs G during the search for alternative accommodation for Mr H.
  2. In addition, I found fault by the Council regarding the AMHP’s failure to consult with Mr and Mrs G in a timely manner.
  3. The actions the Council and Trust have now agreed to take represent a reasonable and proportionate remedy for the injustice caused to Mr H, and Mr and Mrs G, by the fault I identified.
  4. I have now completed my investigation on this basis.

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Investigator's decision on behalf of the Ombudsman

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