Mrs B complained about the discharge planning in respect of her daughter, Miss A. The investigation considered whether the discharge planning prior to Miss A’s discharge on 23 January 2023 was appropriate and met her needs. The investigation specifically considered whether an updated risk assessment and care and treatment plan (“CTP”) were required prior to discharge and whether there were controlled measures in place to ensure mitigation of the risks identified.
Miss A had been re-admitted to hospital on 21 January 2023 following an overdose. The planning in the lead up to her previous discharge in December 2022 was clinically appropriate. The Wales Applied Risk Research Network (“WARRN”) formulation-based assessment and CTP undertaken on 22 December was comprehensive, extensive and in line with national guidance. These assessments and plans were of a high standard.
The WARRN was updated on 2 occasions during the appropriately short re-admission in January. Whilst the CTP was not updated by the Community Mental Health Team (“CMHT”) prior to discharge, the December 2022 version of the CTP covered a wide range of scenarios and recommendations on how to deal with them.
There was a risk that Miss A would attempt to self-harm post discharge. However, a certain degree of risk is commonly accepted to allow patients to live in the community and avoid long term hospital admission. The management plan to mitigate the risk of self-harm/suicide by locking Miss A’s medication in a cabinet was clinically appropriate and in line with national guidance. Unfortunately, the medication cabinet was not robust enough to withstand force, but this was not the fault of the Health Board. The complaint was not upheld.