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< | Event july 2003 Inquiry Panel report ECRI; Corner [ italics are editor emphasis ]
September 2003 Internal Review
one piece of the guidance to the Panel
In practice with Root Cause Analysis procedures, and in order to
psychiatrist opinion was that MC was suffering from On Section 2, following police intervention, self harm and non compliance with OP appts and medication.recorded MC was admitted to the Ferndale Unit, Merseycare NHS Trust via the Accident and Emergency department. MC had indicated he could hear the neighbours talking about him through the walls of his property and he was taken into police custody after an apparent attempt to remove a kitchen knife and move towards the neighbours' house. MC's Consultant Psychiatrist presented a report to the Mental Health Review Tribunal. He was of the opinion that MC was suffering from a psychotic illness which required further assessment and treatment. He acknowledged that the incident leading to MC's admission was a very serious one and that there will be a risk to himself and other people if he were to be discharged prematurely. 28th August 2002. The Mental Health Review Tribunal’s decision was that MC was not to be discharged. This decision records no discharge “in the interests of his own mental health and the protection of others”. It was deemed MC was suffering from schizophrenia with a continuing evidence of psychosis and a lack of insight into his condition. He was thought not stable enough for discharge. Following the decision MC was subdued but settled with no obvious abnormal perceptions. He agreed that he should stop cannabis as this clearly added to his paranoia but continued to believe that his neighbours were talking about him but admitted that this feature had become to bother him less. He was allowed to have Section 17 leave for the weekend and one hour of unsupervised leave on the grounds. 2nd September 2002. His weekend leave was uneventful with no problems reported. He did not experience any problems with his neighbours and began to question whether or not he had actually heard any voices at all. He was granted more weekend leave and six hours leave per day. . 10th September 2002. MC returned from leave with no reported problems. He appeared compliant with his medication ( which ?) and denied using cannabis. He indicated he was keen to be discharged. 11th September 2002. MC was re-graded from Section 2 Mental Health Act (1983) to informal status. He was discharged from hospital with no psychotic phenomena and a good insight into his illness. A member of his own family phoned shortly afterwards to express concerns that he was not fit to be discharged. He was referred to the Crises Management Team of Mental Health Services and for review in outpatients. 23rd September 2002. MC was contacted { ! }by the Crisis Management team. He reported feeling much the same and denied any suicidal thoughts and indicated that a prescription was waiting for his anti-psychotic medication at his GP's surgery. 24th September 2002. The Crises Management Team contacted MCs Consultant Psychiatrist. They discussed recent events and MCs family's concerns regarding the need for Community Psychiatric Nurse visits and an urgent outpatient appointment. It was noted that his consultant would liaise with the CPNs and arrange for an outpatient appointment. 7th October 2002. MC was assessed by a Senior House Officer in Psychiatry outpatients. Since his discharge from the Ferndale Unit it was noted he had stopped taking his prescribed Olanzapine and resumed significant consumption of alcohol and cannabis. The paranoid thoughts and auditory hallucinations had returned. It was noted that he had started hearing voicesagain indicating that the neighbours were talking about him, despite the fact he had moved into a new flat. He mentioned hehad threatened a neighbour with a knife who had called the police who gave him a verbal warning. He had moved back home because he was feeling lonely and had restarted his Olanzapine. However, he thought his paranoid thoughts had remained. He was prescribed Venlafaxine 75mg od. His General Practitioner was requested to prescribe these as required. It was planned to review him in four weeks time. A risk assessment conducted indicated a categorised risk to himself and others as 'low' with a 'moderate' risk of neglect 18th April 2003. MC had failed to attend a scheduled outpatient appointments. His case was to be discussed. Panel lists matters that concern it. The lack of an implemented Care Programme Approach (CPA) process following MC's discharge into the community subsequent to his in-patient stay in August 2002. This finding should be considered in conjunction with the existence of published national guidance on the implementation of CPA and the published Effective Care Co-ordination (ECC) process within the Trust. A reliance by Trust services placed on MC, immediately following his in patient stay, and in the absence of formalised community support, to be able to self report any deterioration in his own mental health Following discharge from his in-patient stay a subsequent lack of assertive follow up by mental health services after a number of non-attendances for pre-planned out-patient appointments. The lack of availability of clinical information to the Community Mental Health Team and the Accident and Emergency Department during key periods of contact with MC. The method of communicating the Care Plan and Risk Assessment to the wider multi-disciplinary Team. The effectiveness of multi-disciplinary working and associated distribution of MC's clinical care documentation, including communication with MC's General Practice The assessment skills and in particular, supervision of junior medical staff assisting with the management of mental health service users. The overall lack of formal community support provided to MC following discharge into a community setting The lack of availability of clinical information to the Community Mental Health Team and the Accident and Emergency Department during key periods of contact with MC The lack of a formalised CPA is seen as a significant feature in the care of MC. As required by the National Service Framework for Mental Health, [ vide infra ] (and indeed the Trusts own policy in existence at the time of these events) service users admitted to hospital with a severe and enduring mental illness are to have their aftercare systematically managed and supervised using the Care Programme Approach (CPA). It is noted that Mersey Care NHS Trust published an Effective Care Coordination Process (ECC) in March 2002 that described the need to integrate CPA with Care Management including the need to provide integrated health and social cares needs assessment and the identification of a Care Coordinator. . A further audit should also be considered relating to the involvement and contributions of relatives of service users who are subject to detention under the Mental Health Act (1983). A Worthing Risk Indicator Assessment was conducted on the day of this admission on the 18th August 2002. This is a well validated and recognised approach to risk assessment. This risk assessment showed MC was a moderate to severe risk to both himself and to others. The assessment of the risk of harm to others was partly based on the following historical information: Age 18 yrs he stated that he enjoyed reading books about murder and would do anything to go to prison even if it meant killing someone. He admitted to alcohol abuse and to mugging and stealing to obtain money. ??In August 2002 (aged 24 years) he was increasingly paranoid; he was hearing voices and was regularly using cannabis. ??On 18 August 2002 he was held in police custody after an attempt to harm his neighbour with a kitchen knife. They were asked to visit by MC's Consultant as MC had failed to attend a follow up outpatient appointment and the objective was to re-engage with MC in order to support him. When visited, MC did not want further involvement by the CPN service and no further proactive follow up action was taken and no further follow up request was received from MC's Consultant. This issue reflects the failure to follow formal, established, Trust ECC/CPA processes. The Crisis Management Team followed up MC via telephone on five separate occasions following discharge from A&E and CPN involvement and the families concerns were discussed. No follow up assertive action by the CPN's could be identified. It is known that staff resources were reduced at that point but it is also possible they were never informed of the need for their further involvement. During July 2003, MC was arrested for murder. Panel findings and advice MC was admitted under Section 2 of the Mental Health Act (1983) on the 18th August and discharged on the 11th September 2003. MC's Consultant Psychiatrist, who was responsible for his care whilst an inpatient, did not implement or activate the CPA/ECC process, according to existing Trust policy, or as required by nationally recognised guidance at the time of his discharge from hospital into the community on 11 September 2002. This was considered by the RCA team to be the root cause of this incident. The psychiatric SHO was on a 6 months GP rotation (a training position) and had been in post for less than 2 months in September 2002. The SHO was relatively inexperienced in psychiatry. Following discharge from his in-patient stay there is no evidence that MC's supervising Consultant checked the discharge letter for accuracy or reviewed the risk assessment provided by the SHO. This was a contributory factor. The psychiatric outpatient SHO did not correctly assess the risk presented by MCs paranoid ideation, non-compliance with prescribed oral medication treatment and illicit drug abuse in outpatients on the 7 October 2002. The SHO allowed MC to remain in the community without active community support being available. This was a contributory factor. .MC's Consultant did not directly supervise the SHO in the outpatient management of MC and the SHO did not appear to discuss the case with the Consultant. This was a contributory factor. The psychiatric SHO allowed consecutive non-attendances at outpatients by MC to occur and no assertive outreach process appears to have been considered. The SHO did not seek advice about this non-compliance from the team Consultant. This was a contributory factor. . The CPN's tasked with monitoring MCs care (on the one identifiable occasion) in the community were not provided with the inpatient risk assessment and a discharge care plan by the inpatient team. This was a contributory factor. .The CPN's tasked with monitoring MCs care in the community did not proactively request information from the inpatient team prior to visiting MC, including the inpatient risk assessment and the care plan. This was a contributory factor. The supervising consultant's patients were distributed across four separate wards during MC's in-patient stay. This may have hampered communications and, additionally, there was a reported lack of community nursing staff. Community staff, as a result of these re-sourcing difficulties, reported not have the time to attend ward rounds. This was a contributory factor. It is noted that the community services have now restructured within a new Community Mental Health Team and staffing levels have improved. Due to the lack of an implemented CPA process for MC there was no on-going formal follow up in a community setting after he was discharged from hospital. This is where MC's clinical problems manifested themselves and the chronology illustrates that substance misuse, alcohol consumption and a lack of compliance with prescribed medication played a significant part in his illness. Other than one informal CPN visit following discharge no formal community CPN support was in place. This was a significant contributory factor as no monitoring of medication compliance or specialised mental health state examination was available following MC's discharge from a controlled, monitored in-patient setting. A liaison psychiatric referral policy or care pathway for use by A&E medical staff should be developed A system for quickly flagging and updating risk information on psychiatric patients under community care, and assessed as emergency cases in A&E, should be developed and deployed . In relation to any service user subject to in-patient care under the Mental Health Act (1983), it is essential to ensure that all correspondence, including that relating to the decision of Mental Health Tribunals and failure to attend routine out-patient appointments, be copied to the General Practitioner in order to advise them on the status and care requirements of the service user. The Primary Care Trust should emphasise to General Practitioners the importance of providing feedback should any concerns be perceived on the clinical status of service users who are known to be in contact with mental health care services Where CPN's attend a service user in the community following discharge from hospital they should be empowered with the full clinical history in order to further establish an accurate assessment of their mental health. The Report does not describe the panel members. It does add the chapter 4 NSF recommendations as context Back to front page back to Independent Inquiry Listing
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