Failings in mental health assessment

What happened

In winter 2013 Mr Q took an overdose of painkillers combined with alcohol. He contacted a friend and was taken by ambulance to the first Trust. His mother joined him in hospital and was present at his initial assessment. That evening, Mr Q was assessed as having a suicide risk score of 8, which put him at high risk and probably requiring hospital admission. Mr Q had blood tests and, according to his mother, he was told by a doctor that he would be assessed by the mental health crisis team and monitored in hospital overnight. Mr Q was transferred from A&E to the acute assessment centre (AAC) where his mother said her contact details, including her mobile telephone number, were recorded.

Later that night, Mr Q was assessed by a mental health team from the second Trust. The mental health team recorded that, by the time of the assessment, Mr Q had no suicidal intent and that he had calmed down and sobered up. A psychotherapy referral was agreed. A suicide risk score of 5 was calculated, indicating he was possibly fit for discharge. According to nursing notes Mr Q 'had no mobile phone with him and no contact numbers available. He wanted to leave and walk to his friend who lives locally to get his car and his mobile phone'. Mr Q was discharged that evening to make his own way to a temporary residence for follow–up community care.

Mr Q's mother said that at around midnight she was called by Mr Q's father, who told her that Mr Q had been discharged against his will. He had no money, phone or transport, and had knocked on a stranger's door in order to telephone his father's house. His father's partner took the call. Mr Q had forgotten his mother's mobile number.

In early 2014, Mr Q's mother complained to the Trust on his behalf about his assessment and discharge. She said that he had been forced to leave hospital when he was vulnerable and at risk yet she had been reassured that he would be kept in overnight. She asked why nobody had called her to let her know.

The Trust said that they took appropriate physical and mental health assessments and these indicated that Mr Q had capacity and was fit for discharge. He had told the assessing mental health clinician that he would be staying with a friend when he left hospital, and nursing records confirmed that he wanted to leave and walk to a friend's house nearby. He had been told that he could stay in hospital overnight if he wished. The Trust explained that Mr Q's contact and next of kin details had not been updated. It apologised for this failing.

Mr Q denied that he was discharged willingly.

What we found

We found no failings in relation to the discharge decision. However, we found failings in Mr Q's mental health assessment by South Staffordshire and Shropshire Healthcare NHS Foundation Trust. The documentation does not provide evidence of a detailed assessment and therefore the decision that Mr Q was psychologically fit for discharge was not based on adequate evidence.

We were unable to conclude that Mr Q was psychologically unfit for discharge. His return for follow–up treatment a few days later supported the view that he did not need to stay in hospital. However, Mr Q and his Family were not reassured that the discharge decision was as thorough as it should have been.

Putting it right

Staffordshire and Shropshire Healthcare NHS Foundation Trust wrote to Mr Q acknowledging the failings identified by our investigation and apologised for the impact these had on him. It also explained to Mr Q what action it had taken to address the failings we identified.