Discharge from mental health services or transfers of care usually involves multiple teams and professionals. This means decision-making can be incredibly complex and challenging.
Effective communication between professionals who understand the aims and potential risks of discharge is vital to make assessments and planning as comprehensive as possible. Poor joint-working across clinical professionals, and between physical and mental health expert teams, results in quick readmission. This shortfall is especially severe in the case of eating disorders where cross-team, and sometimes cross-trust, management is vital.
Failure to carry out a Mental Capacity Act (MCA) assessment before discharge
The complaint
Mr S was admitted to an acute Trust hospital with leg swelling and shortness of breath. He was diagnosed with heart failure but experienced periods of mental ill health during his stay in hospital. Deprivation of liberty safeguards (where you are closely supervised and not free to go anywhere without permission) were issued to keep him safe and stop him leaving hospital.
A mental health team, from the local Foundation Trust which provided mental health services, assessed Mr S and noted he was sometimes disorientated and confused. Medical ward staff also reported that he had shown symptoms of a psychotic episode (psychosis is when you perceive or interpret reality in a very different way from people around you).
On another occasion where Mr S showed unusual behaviour, it was felt that a review by a consultant psychiatrist was needed so that a management plan could be put in place. The psychiatrist reported that Mr S’s condition was mainly due to delirium (sudden confusion), along with heart and liver failure.
Two days later, the mental health Trust liaison assessment team reported that Mr S was now in a bright mood, orientated to time and place, and considered mentally and medically fit for discharge. He was discharged home.
Mr S was not able to take his medication correctly and was readmitted to hospital. Sadly, he had a fatal cardiac arrest (when the heart stops pumping blood around the body) eight days later. His family disputed whether he had been mentally fit for discharge.
What we found
We found that although a pre-discharge assessment had been completed, which was in line with the mental health Trust’s policy, this was not comprehensive enough. A more detailed MCA should have taken place because staff had noted concerns about Mr S’s behaviour. We found evidence that a psychiatrist had recommended an MCA, but this was not followed up.
The MCA would have allowed the team to make a more informed decision about Mr S’s discharge. The lack of MCA was not in line with the Mental Capacity Code of Practice. It was a failing as the assessment process was not as robust as it should have been.
Putting things right
We recommended that the Trust should acknowledge its failings in care and apologise for the impact on Mr S’s family, who will never know if the discharge decision and outcome could have been different.
Poor joint-working led to multiple transfers of care and emergency hospital readmissions
The complaint
Ms I began to experience severe anxiety around food and drink. She was admitted to the hospital’s emergency department due to her reduced eating, drinking and weight loss.
A gastroenterology team (specialists in the digestive system) led the investigations initially and involved a mental health team at a different Trust to explore Ms I’s severe anxiety symptoms. The mental health team visited regularly while she was in hospital.
Due to Ms I’s reduced food intake, the Trust fitted a feeding tube. It felt that her inability to eat and drink was likely caused by a psychological issue and needed mental health treatment. The tube was then removed and Ms I’s care was transferred to a crisis home under the supervision of the mental health team.
In the proposal to discharge, the mental health team noted that Ms I coped well with the feeding tube and raised concerns that if it was removed, a quick readmission to hospital would be likely. The Trust’s reason for removing the tube was valid but it should have taken on board the mental health team’s recommendation to continue providing nutritional support. Just two days later, Ms I was readmitted due to dehydration and the feeding tube was reinserted.
Three months later, Ms I was admitted to a mental health inpatient unit. The following month, a diagnosis of avoidant/restrictive food intake disorder (ARFID) was made.
A feeding tube blockage led to an emergency admission and a subsequent transition of care to the mental health inpatient unit without replacing the tube. Two days later, the Trust readmitted Ms I because she had not eaten or drank anything. The tube was reinserted after two more days.
What we found
We found that, although it was right not to immediately replace a feeding tube to see if Ms I could tolerate food and drink, the gastroenterology team should have followed advice from the mental health team around the need to provide nutritional support. This was particularly important when it was clear Ms I was unable to eat or drink properly herself.
Repeatedly being left without food and medication during these periods traumatised Ms I, increased her anxiety and caused significant distress to her wider family. More likely than not, had the feeding tubes been replaced sooner, at least some of the succession of readmissions to hospital could have been prevented.
There are no established NICE guidelines for managing ARFID as it is a relatively newly recognised eating disorder. But this should not have stopped the gastroenterology team and mental health team from working together to agree a joint feeding and treatment plan, and listening and working together more effectively to provide better care for Ms I.
Putting things right
We recommended that the Trust apologise to Ms I and her family and make a payment to recognise the impact of its failings. We also recommended that the Trust should show us and Ms I what action it has taken to make sure its review of practices for patients at risk of malnutrition and under the care of a mental health professional addressed the failings we identified.