One of the central parts of the previous NHS Care Programme Approach (the standard for coordinating care around the needs of mental health service users), which was in place until September 2019, was having a written care plan that is jointly agreed with members of the multidisciplinary team, GP, individual patient, carers and any other relevant agencies.
This plays an important role in transitions of care from inpatient to community settings. Care plans should include:
- contact details for the care coordinator
- arrangements for the individual’s mental and physical health care
- any factors that suggest an individual is becoming unwell and what to do if this happens.
Poor record-keeping can directly affect patient safety. Care plans that are missing or not managed well can have significant negative consequences for care, at that time and in the future. Poor management of care plans also affects family, carer and patient involvement in planning for discharge.
When complaints about care are made, poor records can worsen the distress for complainants and their families. They can be left not knowing how decisions were made and whether a different outcome could have been possible. Without adequate records, we can also be prevented from getting answers to our questions and making sure accountability and learning can take place.
Poor record-keeping around discharge planning and sign-off
The complaint
Mr L was admitted several times to a mental health assessment unit, an extension of a Trust’s emergency department, after repeated attempts to take his own life. Each time he was discharged after psychological and risk assessments were done.
Sadly, after a third admission and discharge, a family member found Mr L had died at his home.
What we found
To provide appropriate discharge planning, either a multidisciplinary team or consultant psychiatrist should be involved in discharge decision-making. The Trust said the multidisciplinary team was involved, but we saw no evidence of this in the records.
We found that the Trust did not update Mr L’s medical records in line with its own policy. This represented a service failure. Although we did not find that this failure affected Mr L’s health or wellbeing, it caused unnecessary distress to his family as it created uncertainty about the quality and safety of the care he received in the lead-up to his death. We were also left unable to give a firmer view on the sign-off process of Mr L’s final discharge.
Putting things right
We recommended that the Trust should apologise to Mr L’s family for its failings in record-keeping, which denied them the right to fully understand what had happened to their loved one.
We also recommended that the Trust should provide Mr L’s family and us with evidence of how it will make sure staff complete patient records in line with its records management policy.