Trust agreed to assess psychological needs and to improve clinical documentation

What happened

Ms Y was detained under mental health legislation following an episode of illness related to her diagnosis of bipolar disorder. She was given permission to leave the ward on her own and was later found walking in the middle of a main road by police.

Ms Y's mother complained that her daughter had been put at risk by being allowed to leave the ward and also complained that she had recently had clinical psychology support withdrawn, possibly for financial reasons.

The Trust said that Ms Y's leave was reviewed and granted in line with Trust policy and procedures. It added that one purpose of leave was to assess the individual's progress as part of their recovery and if the leave did not go well, this was accepted as part of learning and positive risk taking.

The Trust said Ms Y had been assessed for psychological support and that it was found that she did not need psychological support from a clinical psychologist.

What we found

The decision to grant Ms Y leave was acceptable, as giving increasing periods of leave is important in testing a patient's recovery, and positive risk taking is sometimes required. However, this needs to be underpinned by adequate risk assessment. In this case there was little documentation to support decision making about leave and there was no evidence of any discussion about changes to risk that supported the decision to grant leave. This amounted to service failure and left Mrs Y concerned that her complaint was not properly dealt with as it was not based on the evidence available but about the reasonableness of her daughter's care.

There was no evidence to support the Trust's assertion that Ms Y had received an assessment that indicated that psychology support was not required.

Putting it right

The Trust took steps to address the accuracy of its clinical documentation and also agreed to provide Ms Y with a new assessment of her psychological needs.