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Maintaining momentum: driving improvements in mental health care

The complaints we see: risk assessment and safety

Risk assessment in mental health settings is crucial for understanding patient needs and ensuring the safety both of the individual and of others. Decisions around risk need to be based on knowledge of the individual, their social context and experience, relevant research evidence and clinical judgement.

The complaints we see related to risk assessment and patient safety reinforce concerns expressed by the CQC about patient safety. This includes unsafe staffing levels and poor reporting practices and systems, which can mean that risk assessments are not seen by all staff involved in a patient’s care and, consequently, inappropriate decisions are taken.

The cases below are examples of the impact of poor risk assessment – caused by poor knowledge of illness and the individual context – and the consequences of an unsafe care environment. They are representative of the failings we see in relation to risk assessments, where either a too stringent or too lax approach results in an injustice to the individual and their freedom or safety is compromised.

Mr D

What happened

Mr D had a history of mental ill health, and had recently been an inpatient with the Trust. He had a history of risky behaviour and excessive alcohol intake, and had previously self-harmed. Following his discharge from hospital, he was being cared for by the Trust’s Acute Home Treatment Team (AHTT).

Mr D contacted the AHTT crisis line ten days after his discharge from hospital. He reported having consumed a large amount of alcohol and that he had cut himself. The AHTT asked if he needed an ambulance, and advised him to get some sleep as he was due to be seen the following day.

A short time later, Mr D called the crisis line again, asking, ‘What should I do?’ The AHTT reiterated their previous advice. Mr D suggested he might take an overdose, before denying this and ending the call. Mr D went on to take an insulin overdose and started a fire in his flat. He was later jailed for three years for this offence.

What we found

We found the Trust had not put effective plans in place to manage Mr D’s risk after his discharge from hospital. Mr D’s recent inpatient stay meant he was at heightened risk of suicide. The Trust should have produced an action plan to manage this risk, in accordance with Preventing suicide: A toolkit for mental health services,but did not.

The Trust had assessed Mr D’s risk while he was an inpatient and identified alcohol as a risk factor. The Crisis Resolution Home Treatment Plan referred to alcohol misuse as a risk. However, it had not formally assessed the risks to his safety, or provided guidance for staff to manage and support him, in the event of alcohol misuse in the period following his discharge from hospital. This meant that the decisions taken when Mr D contacted the crisis line were unreasonable.

Mr D had consumed a large amount of alcohol and said he had cut himself. He hinted at further attempts to harm himself. Alcohol was one of the main risks to Mr D, and can also mean that a person lacks the capacity to make decisions about their own welfare. Given this, the AHTT should have assessed his mental capacity to make decisions, in line with the Mental Health Act Code of Practice. It should not have relied on his own assessment that he did not need medical assistance or that he would not attempt further self-harm.

The Home Treatment Plan also suggested that a welfare check was considered appropriate in certain circumstances. We found that the risk factors in Mr D’s case should have triggered a visit either from the AHTT or the police.

Mr D contacted the AHTT at a time of crisis. He had recently been an inpatient with the Trust, had consumed a large amount of alcohol, and had a history of self-harm and attempts to take his own life. These risks were not fully acknowledged or planned for by the Trust.

This was compounded by poor and inconsistent decision making around Mr D’s capacity to assess his own condition and decisions. Staff therefore did not judge his risk appropriately and take action to keep him safe.

The Trust missed opportunities to support Mr D effectively when he contacted them in crisis. Had appropriate action been identified and taken, there may have been a different outcome for Mr D, his further self-harm might have been prevented and he might have avoided prosecution.

Our recommendations

We recommended the Trust write to Mr D to acknowledge and apologise for these failings and the distress these mistakes caused. We also recommended the Trust review its policies and procedures around risk assessment by the AHTT, welfare checks for people in crisis, and managing patients with dynamic risk factors.

We recommended the Trust produce an action plan on the back of these reviews, detailing what had been learnt from the complaint and the action taken to prevent repetition.

The Trust’s action plan showed it had:

  • Established a process to ensure all patients have an initial assessment to help identify a dual diagnosis (mental illness and substance misuse), which is then updated on the first home visit. This action helps identify the additional risks for people with dual diagnosis and the actions to be taken to mitigate and respond to these risks.
  • Implemented ‘safety plans’ as part of the risk assessment process, developed with patients and available online. This ensures all staff are able to access and refer to this information when contacted by a person in crisis.
  • Reinforced the policy for ‘safe and well’ checks to all AHTT staff and developed a collaborative standard operating procedure with local police for these checks.
  • Shared learning from the complaint with AHTT staff, and held a reflective learning session to ensure all staff are aware of the appropriate policies and guidance for when they are contacted by a person in crisis.

Mr L

What happened

Mr L was a young person with autism and mental health issues. Following a gradual deterioration in his mental health, he was referred to a centre for severe mental illness as a voluntary inpatient. He was discharged a month later.

Some months later, Mr L was detained for a month under section 2 of the Mental Health Act 1983. He was discharged, and then readmitted the next day. Finally, he was moved to a permanent residential placement. Following this move he was diagnosed with bipolar disorder.

During Mr L’s first voluntary stay at the centre, he was assaulted by another patient, causing a deep cut to his lip which required stitches and several loose teeth which needed a form of splint to be attached to prevent further movement.

The Trust agreed to a care plan for Mr L to support both him and his family following his discharge, but this was never implemented. Mr L’s mother, Ms Y, complained about the care provided to Mr L.

What we found

Mr L was a very vulnerable young person who, as his own risk assessment noted, was susceptible to being bullied.

The Trust was also aware of the risk posed by the patient who went on to assault Mr L and they had increased staffing levels to mitigate the danger. However, we found that the risk assessment for the second patient was completed three days after his admission and two days after the assault. This was not in line with good practice.

We found that some of the staff had worked double shifts, again falling foul of good practice because of the risk of tiredness. There was a lack of specific experience of child mental health or learning disability.

We found that, while the Trust was aware of the risk posed by the other patient, it did not follow good practice in assessing that risk and it did not ensure staffing arrangements were adequate to mitigate the risk posed to others. The assault was avoidable.

We also found that, despite the Trust agreeing to a care package to support Mr L on his discharge, this mental health and social care support, which he and his family needed, did not take place.

Our recommendations

We recommended the Trust acknowledge and apologise for the failings we identified, and pay Mr L £1,000 and Ms Y £500 for the injury and distress caused. We also recommended the Trust produce an action plan.

The Trust’s action plan showed it had:

  • Introduced daily multi-disciplinary team (MDT) handover meetings on wards to enable early risk identification and a checklist to ensure risk assessments are completed within 24 hours of admission, together with ongoing audits to ensure compliance.
  • Provided training to staff working in child and adolescent services, with an overview of the key issues related to inpatient services, such as child and family development and behavioural skills specific to child and adolescent services.
  • Held meetings between the inpatient and community teams to agree ownership of care plans on discharge.