Health and social care organisation did not appropriately plan care and failed to respond to a deterioration in a man's mental health

What happened

Mr B had Asperger's syndrome and bipolar disorder. He lived in supported housing since 2012. He had a history of mental health and was receiving support from the mental health services for several years. At the beginning of 2013 Mr B's mental health deteriorated. During this time he left hospital and was later detained by the police.In spring of that year, he damaged property, and staff at the supported housing project called the police. After a short period at the police station, he was transferred to a psychiatric unit. Mr B asked to leave hospital within a few hours of arrival. He was not detained under the Mental Health Act 1983 at that time. Mr B left the ward and was found in the community. The police took him back to the psychiatric unit and he was then detained under the Mental Health Act 1983.

What we found

The care planning fell short of national standards, which require care reviews to involve all professionals working with the patient. The health and social care organisation accepted that there was an undue clinical focus in Mr B's early care plans. However, in relation to Mr B's Asperger's syndrome the care planning was appropriate because the health and social care organisation identified Mrs B's specialist needs. The health and social care organisation acted in accordance with the Autism Act 2009 in commissioning a new specialist support service.

The health and social care organisation missed clear signs in relation to Mr B's deterioration in his mental health. This caused Mr B considerable distress.

Putting it right

The health and social care organisation acknowledged the faults we identified and apologised to Mrs A and Mr B. It also paid £1,000 to Mr B and £500 to Mrs A to reflect their distress.

The health and social care organisation produced an action plan to address the faults identified and minimise the risk of recurrence.