Summary: Mr E has complained about the mental health and social care of his sister, Mrs F, by the Council and Trust. We find fault with the mental health and social care of Mrs F but not with her mental health assessment or the Trust’s complaint handling. The Trust and Council agreed to apologise to Mr E and take action to prevent similar problems in the future.

The complaint

1. Mr E has complained on behalf of his sister, Mrs F, in relation to her mental health and social care from October 2019 to April 2020. The Trust provided both mental health and social care, with social care being provided on behalf of the Council. Specifically Mr E complains:

• The Trust would not provide the family with any information or involve them in Mrs F’s care as she had withdrawn consent

• The Trust did not follow up a missed appointment in October 2019 despite signs of Mrs F’s deterioration

• The Trust and a care coordinator did not provide support to Mrs F regularly when she was in crisis which meant her mental health deteriorated and her house fell into disrepair

• The Trust did not involve Mrs F’s next of kin in her mental health assessment

• The Trust handled the complaint badly, first having someone investigate it who was involved in Mrs F’s care, then closing the complaint when Mr E wanted more answers and a meeting

2. Mr E said these issues led to a deterioration in Mrs F’s mental health and distress for him witnessing events. In addition he was frustrated when the Trust closed the complaint.
3. Mr E would like the Trust and Council to be held to account in the public domain and for it to implement service improvements.

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The Ombudsmen’s role and powers

4. 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)
5. 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).
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. As part of my investigation of this complaint I have considered evidence from Mr E, the Council and the Trust. I have also taken advice from an independent clinical adviser.

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What I found

Background

8. Section 75 of the NHS Act 2006 allows NHS organisations and councils to arrange to delegate their functions to one another. These arrangements are known as Section 75 Agreements and under them, NHS organisations can take on the provision of social work services which are normally the responsibility of councils. Subsection 5 of section 75 says the NHS and councils remain liable for the exercise of their own functions. In this case the Trust was carrying out social care functions on the behalf of the Council, but we would still hold the Council responsible for those functions.
9. Mrs F was experiencing mental health issues in October 2019 and these intensified until in April 2020 she was detained under the Mental Health Act 1983.
10. Mr E raised a complaint at that time with the Trust and received some responses from it before approaching the Ombudsmen in October 2020.

Communication

11. Mr E complained the Trust would not disclose any information or support the family as it said his sister had refused permission for them to be involved in her care. He said it was obvious his sister lacked capacity and so the family should have been involved and kept abreast of developments.
12. The Trust has told the Ombudsmen the assumption under the Mental Capacity Act 2005 is a patient has capacity until proven otherwise.
13. The Trust said Mrs F made it very clear in July 2019 she did not want her family involved in her care or any information shared, therefore making it difficult for staff to share any detailed information with family members.
14. However, the Trust admitted it should have had a conversation with the family at this time to create a plan for moving forward and explaining what could and could not be shared with them. In addition it said it should have put in place a plan whereby Mrs F’s social worker could respond to the family’s emails in a timely and suitable manner.
15. The Trust has acknowledged it was a fault on its part this did not happen and the family were left with no communication which led to frustration for them.
16. The Trust said it had made improvements to communication including workshops, and including this case as a case study in training materials.

Analysis

17. The actions taken by the Trust to address its fault in relation to communication are in line with National Institute for Health and Care Excellence (NICE) Guidelines CG136 Service User Experience in Adult Mental Health (paragraph 1.1.14) which states:

“As the involvement of families and carers can be quite complex, staff should receive training in the skills needed to negotiate and work with families and carers, and also in managing issues relating to information sharing and confidentiality.”

18. However, to fully address this fault the Trust needs to be more explicit in what training it carried out, how it is monitoring which patients have not agreed to have information shared with their families, whether the training is mandatory for all staff and how it monitors compliance with this training.

Lack of support and follow up provided to Mrs F

19. Mr E outlined his sister’s deterioration over the period October 2019 to April 2020. He highlighted occasions when she missed appointments but was not followed up by the Trust and this lack of follow up meant her mental health was allowed to deteriorate. In addition, he noted Mrs F’s care coordinator was off on leave and this led to a shortfall in support for his sister in this period. Mr E said his sister’s deterioration led to her house falling into disorder. In addition his sister did not appear to have a care plan.
20. The Trust identified that the Care Coordinator had not had clinical supervision. It also admitted several faults in Mrs F not having a care plan, not following up missed appointments and a lack of action on Mrs F’s case while the Care Coordinator was on leave.
21. As a result of this complaint the Trust said it taken action to address this in the service and to ensure all newly qualified staff are well supported through the systems and processes it has in the team.
22. The Trust said it was working on ways it could support newly qualified staff and how they can develop skills and respond to risk.
23. The Trust also put in actions such as senior managers checking someone’s caseload while they are on leave and ensuring staff follow the Service Users Did Not Attend Policy. In addition, the Trust agreed a protocol to monitor those who do not attend appointments.
24. With regard to Mrs F not having a care plan the Trust apologised for this omission and said it was working with staff to record care plans for all service users as an improvement action.

Analysis

25. Mrs F was clearly encountering several mental health issues in this period which culminated in her being detained for her own health. In addition, the lack of support provided by the Trust on several aspects of Mrs F’s care increased the risk of her suffering these difficulties. However, there are several other external factors which could also have hastened her deterioration. We cannot say the fault of the Trust caused Mrs F’s mental deterioration, but it was a missed opportunity to provide her with the care which could have reduced the risk of it happening. In addition, the lack of support caused distress for Mr E in seeing his sister deteriorating and not getting professional support.
26. The Trust needs to do more to address the faults identified as a result of this complaint.
27. In relation to the Care Coordinator not having sufficient clinical supervision, the Trust has outlined its action but not shown any evidence it has taken this action. The Trust has not shown how it was monitoring if members of the team are having monthly supervision and if it was auditing this.
28. With regard to its new protocol covering staff and patients in relation to sick leave, the Trust has not shown how this protocol was monitored and audited to show if it was working.
29. In relation to the lack of a care plan, the Trust has simply said it is working with staff. This is not adequate as setting up a care plan is normal practice with every mental health patient. The Trust has not shown how it is checking if patients have a care plan and how it is auditing and monitored this. In addition, these events took place over a year ago so this audit should already have been carried out.
30. Considering the above the Trust has not shown it has taken sufficient action to address the faults in its care and to ensure the faults do not happen to other patients.

Lack of involvement of next of kin in the Mental Health Act Assessment

31. Mr E complained that Mrs F’s next of kin, her son, was only contacted the day before the assessment was due to take place and the Trust did not involve him in the assessment on the day.
32. The Trust said on the morning of the assessment it contacted Mrs F’s son, explained the process and took his views regarding his mother’s mental health and made him aware of his rights.
33. I can see that Mrs F’s son was involved in the assessment and all parties agreed she should be detained. I do not find fault in this aspect of Mr E’s complaint.

Complaints handling

34. Mr E said when he first complained the investigation was carried out by the manager of the social workers and so lacked independence.
35. Mr E escalated the complaint to a more senior level at the Trust and received another response in November 2020. He said the process was going ok until December 2020 when the Trust refused to do any more and closed the case. Mr E was unhappy with this as he had originally wanted more answers and a meeting
36. The Trust said it was part of its complaints process that the manager of the team complained about investigates the complaint at the first stage. Then, as Mr E escalated his complaint, it was further investigated at executive level.
37. The Trust said it had investigated all Mr E’s concerns and held a meeting with him in September 2020 and so the investigation was complete at local level and it closed the case.
38. The Trust provided Mr E with two detailed and lengthy complaint responses and held a meeting with him. I have not found fault with the Trust bringing the matter to a close as his complaint was still essentially about failings in his sister’s mental health treatment for this period. As Mr E remained dissatisfied after having two written responses and a complaint meeting, it was appropriate for the Trust to close the complaint and for Mr E to approach the Ombudsmen if he wanted the complaint to be considered further. I have not found fault with the Trust in its complaint handling.

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Recommendations

39. I have found the faults in the mental health and social care of Mrs F led to a missed opportunity to prevent her deterioration and subsequent detention. In addition it caused distress to Mr E.
40. I recommend by 28 February 2022 the Trust and Council:

• Write to Mr E acknowledging and apologising for the faults in care that led to the impact on him and Mrs F outlined above

And by 25 April 2022 the Trust and Council:

• Produce an action plan fully addressing the faults in relation to communication training, clinical supervision, staff absence, and missed appointments. The action plan should include arrangements for auditing and monitoring the effectiveness of actions, to show evidence of improvement

41. The Action Plan should be shared with Mr E, the Ombudsmen, the Care Quality Commission and NHS Improvement.

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Final decision

42. I found fault in the mental health and social care of Mrs F but not with her mental health assessment or the Trust’s complaint handling.

Investigator’s decision on behalf of the Ombudsmen

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Investigator's decision on behalf of the Ombudsman