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Maintaining momentum: driving improvements in mental health care

The complaints we see: communication

Communication is critical to good care in all health settings, and particularly so in mental health services, where an individual’s decision making and understanding may be impaired. The NHS Constitution pledges to ‘make decisions in a clear and transparent way, so that patients and the public can understand how services are planned and delivered’.

The two complaints below show the potentially harmful impact of poor communication with patients. In both cases, the complainants were caused considerable distress because actions by the people caring for them were not explained to them. This lack of communication meant the actions that followed were disproportionate and unreasonable, and the injustice avoidable.

Equally important is communication between services. In mental health care, there is often interaction between services, including GP, acute physical health providers and social services. We often see poor communication and a lack of co-ordination between services – including on risk, need, treatment plans and discharge – and this can have a massive impact on patients and their families.

Mr P

What happened

Mr P was detained in hospital under section 2 of the Mental Health Act 1983, for assessment and treatment. Section 2 is for people whose mental health has not previously been assessed in hospital. A nurse visited Mr P to explain his rights while detained, but recorded that he was not able to understand them at that time. Mr P then started refusing his oral medication and a doctor authorised the forcible administration of the medication by injection.

What we found

Although there was an initial attempt to explain Mr P’s rights to him, further attempts should have been made at regular intervals. We found the Trust did not inform Mr P of his rights as a detained patient, or the Trust’s powers to force medication, as required by the Mental Health Act Code of Practice. This meant that he did not fully understand the consequences of his decision.

Furthermore, the decision to forcibly administer Mr P’s medication was carried out without a full assessment by a doctor or adequate information about his physical health. There was no discussion between medical staff and Mr P about his proposed treatment and possible alternatives. Mr P therefore was not given the opportunity to reconsider withholding his consent. Because the Trust did not communicate with Mr P in the way it should have, it did not minimise the need for force, meaning the level of restraint used was excessive.


Mr P was also denied a blanket for sleeping and was regularly woken at night by staff shining a light in his face. This was a serious failing of nursing care and has had a lasting effect on Mr P. The ward routine was dominated by the needs of smokers while Mr P, a non-smoker, was denied access to the fresh air. He was prevented from leaving a room when a false fire alarm went off, even though he was on the ward as a voluntary patient at that time.

Our recommendations

We recommended the Trust apologise to Mr P, and pay £2,000 in recognition of the distress, anxiety, discomfort and frustration he experienced. We also asked the Trust to develop an action plan to ensure they had
learned from their mistakes. This showed the Trust had:

  • Provided training for staff on giving information on their rights to detained patients.
  • Revised and updated a Rapid Tranquillisation Policy to provide guidance on best practice on treatment in an emergency.
  • Provided training for doctors and nurses emphasising the importance of physical evaluation before administering medication in an emergency.

Ms R

What happened

Ms R had a past diagnosis of bipolar disorder, having suffered a manic episode after an earlier miscarriage. She suffered further manic episodes in the following years and took medication to help manage her condition.

Ms R became pregnant again and, during her pregnancy, sought support from the Trust. Because of her history of bipolar disorder, the Trust decided that Ms R was at high risk of relapse and placed her on the vulnerable list for admission to the mother and baby unit.

She was visited a number of times by the Rapid Assessment, Interface and Discharge (RAID) team. When she gave birth, her baby was taken from her while she received a full assessment under the provisions of the Mental Health Act 1983. She was later reunited with her baby.

What we found

The Trust engaged well with Ms R during her pregnancy and took appropriate steps to support her. However, following the birth of her baby, Ms R told staff that she did not want to see her community psychiatric nurse or the Home Treatment Team when she returned home. She was reviewed by a psychiatrist who was concerned about the potential for a relapse, and arranged for a full assessment under the Mental Health Act 1983. At this
point, Ms R’s baby was taken away as staff were concerned about how she would react to the assessment and any risk to her baby.

We found that the Trust did not carry out an assessment of the risk Ms R posed to her baby before the decision was made to separate them. A full risk assessment should have been carried out and documented.
Furthermore, the decision seemed at odds with earlier statements that she had been bonding well with her baby and there were no other indications of risk.

Compounding this poor decision making was a lack of communication with Ms R. At no point was the reason for removing her baby explained to her. The decision to remove a baby from its mother is a significant one and
doing so without explanation would have been hugely distressing. It was not in accordance with established good practice. Additionally, Ms R was not informed about the frequency of visits from the RAID team while she was in hospital.
As a result, Ms R lost her appetite, which prevented her from breastfeeding, suffered sleepless nights and became increasingly stressed. She also became worried about having another baby.

Our recommendations

We recommended the Trust acknowledge and apologise for the failings we found, as well as pay Ms R a total of £500 in recognition of the upset and distress caused. We also recommended the Trust prepare an action plan to prevent repetition of the failings.

This action plan demonstrated the Trust had:

  • Emphasised to staff the need to be clear with patients on care plans and decisions, ensuring discussions and decisions are documented and a copy given to the patient.
  • Provided additional training for RAID teams on safeguarding and reminded them of risk assessment requirements.
  • Discussed the complaint at the Trust’s Governance Committee meeting and communicated key messages to all services.