Mrs C complained that she had not been able to access support when she had a mental health crisis and her key worker was on leave. The Trust carried out an internal investigation that was robust and acknowledged its failings. However, it did not fully implement its own recommendations.
What happened
Mrs C suffers from mental health problems and receives care from the Trust's community mental health team and a psychologist. At the end of 2011 Mrs C did not have a named care co-ordinator, and her psychologist was acting as her key worker. However, her psychologist went on leave unexpectedly. At the same time, Mrs C experienced a mental health crisis. She tried to access support through the Trust's out-of–hours service. Although she had some telephone discussions with Trust staff, they did not identify that her crisis was escalating and did not offer her a face-to-face appointment.
The Trust's own internal investigation identified that it had not provided appropriate care. It said that there was a failure in cover arrangements, that Mrs C did not have a named care co‑ordinator, and that her crisis plan had been copied from her old records from a previous trust. The Trust also said that its investigation found that Mrs C's crisis situation had escalated over a number of days, without being adequately addressed, and that she had not been offered face-to-face contact. It made recommendations for improvements in the community mental health team to address these issues.
What we found
The Trust's investigation was robust, identified the failings in Mrs C's care, and made reasonable recommendations aimed at addressing these failings. However, when we looked at how the Trust had implemented these recommendations, we found that it had not put sufficient improvements in place.
Putting it right
We asked the Trust to apologise to Mrs C and acknowledge that it had not yet put improvements in place to address its failings. We asked it to show that it has robust cover arrangements in place and implement a suitable procedure to flag repeated contact to the out-of-hours service and highlight any escalation of a crisis situation. We also asked it to show that it has implemented a robust procedure to assess the need for face-to-face contact.
Cornwall Partnership NHS Foundation Trust
UK
Not applicable
Apology
Recommendation to learn lessons or draw up an action plan