Autistic patient trapped in hospital ward for four months due to system failures

The patients – who were both autistic and had learning disabilities, with special educational needs – were admitted to Maidstone and Tunbridge Wells Trust last year after attending emergency departments more than 10 times within a two-month period.

They were left on a paediatric ward – one of the patients for four months – as this was the “only available place of safety as opposed to the optimum setting to meet their needs,” according to Kent and Medway Integrated Care Board’s “learning review” of children and young people with complex needs, which the two cases prompted. 

The review, which HSJ obtained under a Freedom of Information request, revealed several problems with joint working, despite a multidisciplinary team meeting regularly to discuss the young patients’ needs. These problems included:

• Not all the organisations involved had the same information about the young people’s family background, meaning motivations were misunderstood when disagreements about what to do arose. There was no shared record accessible by all MDT members, which led to conflicted messaging with no “single understanding”; 
• Different organisations carried out multiple assessments “with little opportunity for alignments of findings”. When the young people were found not to meet thresholds for some services, this led to delays in waiting for another assessment. The MDT felt not all assessments were robust and decision-making was made more complex when the families sought assessments from independent providers;
• Pathways were unclear with MDT members not knowing what other organisations could offer or their own roles and responsibilities. Thresholds to services “appear to function as a barrier to access” in both established services such as health and social care and the newly formed mental health collaborative;
• The MDT did not have an identified lead to chair it and, when professional disagreement occurred or an issue required escalation, this was escalated through individual agencies. This contributed to the families “play[ing] one professional off against another, seeding both delay and uncertainty”; and 
• The MDT reported not having a diagnosis or assessment made access to services more difficult with varying professional opinions on whether the young people were presenting with health, mental health, trauma, social care or educational issues.

The review made several recommendations including early identification of complex cases with a single case manager assigned, shared information and risk registers, and a review of CAMHS provision. 

A spokesperson for NHS Kent and Medway and the wider system said: “We are committed to providing the best for all our young people, including those with complex mental health needs who often need very specialist care.

“This review, which we commissioned with Kent County Council, has helped identify areas we can improve – something we always want to do. We have already made some changes, such as improving processes, enhancing services and creating additional support.”

Since the review, a new escalation process has been introduced, urgent mental health risk assessments in the community have been enhanced and a three-month pilot of a self-harm service has been implemented at Tunbridge Wells Hospital, part of MTW.