Summary: We consider an Approved Mental Health Professional and a Community Psychiatric Nurse appropriately supported Mr L before and after the decision to detain him under section 2 of the Mental Health Act.

The complaint

1. Ms K complains about a Mental Health Act assessment for her son, Mr L, on 4 March 2020. She says an Approved Mental Health Professional (the AMHP), a Community Psychiatric Nurse (the CPN) and a section 12 approved doctor did not support her son after the assessment. Later that day Mr L attempted suicide, which caused significant injuries, and his mental health has worsened. Ms K also says she suffered distress and anxiety due to events that day. She would like the organisations to ensure similar fault does not happen to others.

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What I have investigated

2. I have investigated the roles of the AMHP and CPN in Ms K’s complaint above. The final section of this statement contains my reason for not investigating the actions of the section 12 approved doctor.

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The Ombudsmen’s role and powers

3. 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 on behalf of both Ombudsmen. (Local Government Act 1974, section 33ZA, as amended, and Health Service Commissioners Act 1993, section 18ZA)
4. When investigating complaints, if there is a conflict of evidence, the Ombudsmen may make findings based on the balance of probabilities. This means that during an investigation, we will weigh up the available evidence and base our findings on what we think was more likely to have happened. 
5. The Health Service Ombudsman investigates complaints about ‘maladministration’ and ‘service failure’ in the delivery of health services by people and organisations specified in the Health Service Commissioners Act 1993. When doctors make recommendations under sections 2, 3 or 4 of the Mental Health Act 1983 (MHA), they are acting under powers which have been given to them under the MHA. They are acting as individuals and not on behalf of the NHS. This means we cannot investigate complaints about their actions and recommendations. (Health Service Commissioners Act 1993, sections 2, 2A, 2B and 3)
6. 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

7. I have considered information provided by Ms K, the Council and the Trust. I have also spoken with Ms K on the telephone. Ms K and those organisations had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

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What I found

Background

8. In late February 2020, Mr L’s ex-partner was concerned his mental health was deteriorating, so referred him to the Trust’s Home Treatment Team (HTT).
9. On 3 March, a Psychiatrist and the CPN for the HTT visited Mr L at Ms K’s home. They noted Mr K was slowly relapsing, had stopped taking his medication for paranoid schizophrenia and refuted his mental illness. They also completed a risk assessment. The HTT decided to:
• Carry out a Mental Health Act (MHA) assessment with the view to detain Mr L under section 2.
• Place Mr L on a bed list before the MHA assessment.
• Visit Mr L every day (in pairs).
10. The next morning, the HTT contacted a Bed Manager in Wolverhampton who placed Mr L on bed list.
11. At 2pm, the AMHP, the CPN and a section 12 approved doctor visited Mr L at home to complete the MHA assessment. Mr L did not engage and refuted his mental illness again. He told them he would kill himself if they tried to give him medication. They did not challenge Mr L as it would cause him further distress. Mr L refused an informal admission to hospital and closed the door.
12. The AMHP and section 12 approved doctor agreed to detain Mr L under section 2 of the MHA. However, the AMHP could not make the application until a bed was available in Wolverhampton. The AMHP said the HTT should refer Mr L’s application to the Council’s out of hours AMHP when a bed was available. The AMHP and CPN also agreed to arrange a private ambulance when necessary to transport Mr L to Wolverhampton.
13. Shortly after the MHA assessment, the CPN communicated that plan to Ms K. Ms K said Mr L had left the house. The CPN agreed to update Ms K when a bed was available, and asked Ms K to call her when Mr L returned home.
14. At 5pm, a different CPN told the AMHP that Mr L had jumped off a bridge and suffered broken limbs. A hospital had admitted him. The AMHP recommended that, when Mr L was medically fit, it should detain him under section 2 of the MHA and transfer him to the psychiatric unit in Wolverhampton.
15. In late March 2020, the hospital detained Mr L under section 2 and then section 3 of the MHA.

Relevant law and guidance

16. Under the Mental Health Act 1983, when someone has a mental disorder and is putting their safety or someone else’s at risk they can be detained in hospital against their wishes. This is sometimes known as ‘being sectioned’. Usually three professionals need to agree that the person needs to be detained in hospital. These are either an Approved Mental Health Professional (AMHP) or the nearest relative, plus a doctor who has been specially approved in Mental Health Act detentions (section 12) and another doctor. The AMHP is responsible for deciding whether to go ahead with the application to detain the person and for telling the person and their nearest relative about this. Admission should be in the best interests of the person and they should not be detained if there is a less restrictive alternative.
17. The purpose of detention under section 2 of the Mental Health Act 1983 is for assessment of a patient’s mental health and to provide any treatment they might need. Patients can be detained under section 2 for a maximum of 28 days.
18. The MHA Code of Practice states:
• Paragraph 4.75 - “If the doctors reach the opinion that the patient needs to be admitted to hospital, it is their responsibility to take the necessary steps to secure a suitable bed”.
• 14.80 – “Local authorities, providers, NHS commissioners, police forces and ambulance services should ensure that they have a clear joint policy for the safe and appropriate admission of people in their local area...”
• 14.81: “...NHS commissioners and providers should work together to take steps, with appropriate input from section 12 doctors and AMHPs, to place individuals as close as is reasonably possible to a location that the patient identifies they would like to be close to...This should take account of any risk assessment undertaken...”
• 14.89: “Providers should identify a bed manager...who will be responsible for finding a suitable bed as soon as possible and telling the applicant the name of the site...”.
19. The Council’s Mental Health Act Procedures state what AMHPs should do following an assessment under the MHA:
• While the Trust is responsible for assigning beds for patients at hospital, it is important that proper planning takes place. An application cannot be made until the Trust finds a bed.
• The Trust’s Bed Managers are responsible for sourcing beds.
• If the AMHP decides to make an application, but is aware that no bed is available, they should discuss the following with the patient, the doctor responsible for the patient care and other relevant parties:
1. The nature of any risks;
2. A plan to manage any risks;
3. The urgency for admission; and
4. The process for obtaining a bed.
• The AMHP should ensure they pass full information to the Council’s out of hours AMHP, who should keep the situation under close review.
• The use of private transport may be needed to transport patients to beds outside the area.

Analysis

20. I consider that, on 4 March 2020, all parties (except Mr L) agreed Mr L needed to be detained under section 2 at hospital for an assessment of his mental health. My investigation has not questioned how the AMHP decided that. Rather, it has focused on the support provided to Mr L on 3 and 4 March.
21. I have reviewed the relevant HTT and AMHP’s records after 3 March.
22. On 4 March, the AMHP could not complete the application to detain Mr L under section 2 because there were no beds for him. I have considered whether the HTT did enough to get Mr L on a bed.
23. I am satisfied the HTT proactively sought a bed for Mr L before the MHA assessment. The HTT showed good planning, which was in line with the MHA: Code of Practice and the Council’s local procedures.
24. The HTT told me it sought a bed in Wolverhampton, rather than Birmingham, because Mr L was known to the mental health services in that area. I understand Mr L did not state where he would prefer to be detained, because he refused to engage. Therefore, without Mr L’s views, I consider the HTT’s decision to move him to Wolverhampton was made without fault. The HTT and AMHP recognised Mr L was familiar with services in Wolverhampton. I accept that would have gone some way to reducing further distress to Mr L. The AMHP and HTT also recognised Mr L would need private transport to go to the bed in Wolverhampton. While that did not happen, it showed the AMHP and HTT appropriately considered the Council’s local policy.
25. Overall, I consider the AMHP and HTT worked well jointly to source a bed for Mr L in Wolverhampton.
26. I have also considered how the AMHP and Trust’s HTT planned to support Mr L before and after the MHA assessment.
27. On 3 March, the CPN assessed Mr L’s risk and noted under the ‘Suicide’ and ‘Self injury or Harm’ sections: “[Mr L] didn’t express any thoughts/plan however possible risks due to relapse in mental state”. The CPN also noted Mr L had “no obvious psychotic symptoms”. While Mr L was hostile to the HTT, it would continue visit Mr L daily (in pairs). The HTT has demonstrated it was trying to engage Mr L and trying to support him. I consider the HTT appropriately assessed Mr L’s risk of suicide and self-injury before when deciding how to support him.
28. After the MHA assessment, I am satisfied the AMHP and HTT acted appropriately to support Mr L. The best support for Mr L at that time was getting him to the bed in Wolverhampton. The delay getting Mr L on to a bed in Wolverhampton was out of the AMHP and HTT’s control. I consider that, on the balance of probabilities, if the HTT had offered more practical support to Mr L after the MHA assessment he would have refused it. Therefore, I do not consider the AMHP or HTT acted with fault on 4 March.
29. Even if I had found fault in this case, I would have found it difficult to link that to Ms K’s claimed injustice. The time between the MHA assessment and Mr L leaving home to attempt suicide was so short. I would most likely not have agreed that support after the MHA assessment would have led to a different outcome.

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Final decision

30. I consider the AMHP and HTT appropriately supported Mr L before and after the decision to detain him under section 2 of the Mental Health Act.

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Parts of the complaint that I did not investigate

31. I have not investigated the section 12 approved doctor who assessed Mr L on 4 March 2020 during the MHA assessment. That doctor was not acting on behalf of the NHS, rather as an individual under the MHA. Therefore, I cannot investigate his actions.

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Investigator's decision on behalf of the Ombudsman