Health board criticised for failing to provide medical records detailing shocking treatment of suicidal teenager

The father of a teenager whose multiple suicide attempts raised concerns about the quality of treatment at a mental health unit says he is deeply concerned at the failure of a health board to provide him with his daughter’s medical records.

In a special report, published in June 2023, Nation.Cymru gave voice to widespread unease held by service users and their families about the Hafan y Coed mental health unit at Llandough Hospital, run by Cardiff and Vale University Health Board. The article followed a protest outside the hospital undertaken by around 30 relatives of patients.

A review was commissioned into the care provided by Hafan y Coed to Anya Del Amo, now 19, after an incident when she was handcuffed.

Shortcomings

The review identified 30 shortcomings relating to the way she was treated while an in-patient at the unit:

1. Cedar ward CAMHS [Child and Adolescence Mental Health Services] policy states that “the young person is under constant observation in the presence of adults (constant observation may not be required in their individual bedroom following the appropriate risk assessment, however, a member of staff should be allocated outside in the event the young person wishes to leave their room and enter the adult communal area). Staffing for CAMHS close observations will be additional to Cedar ward’s usual/safe staffing levels..On review of the notes, it is documented on several occasions that staff were unfamiliar with the CAMHS policy and staff appeared to be unable to identify escalating risk and rationalise it in the context of the policy.

Ms Del Amo’s was engaging in escalating high risk behaviours and staff whilst immediately dealing with the risk i.e. cutting off ligatures, they permitted Ms Del Amo back into her room with the door closed and did not directly observe her. This appeared to escalate high risk behaviours which resulted in repeated episodes of restraint. This further exacerbated Ms Del Amo’s risk of deliberate self-harm becoming more dangerous and difficult to support on Cedar ward.

2.The transfer to Alder ward could have been better supported if Ms Del Amo had been offered time and medication (if appropriate) until there was a degree of cooperation from her that made the transfer safe for everyone. Staff would have had to support Ms Del Amo in a confined space (the lift) with high levels of resistance thus increasing the potential risk for injury.

3.There is no CCTV footage of the incident in the corridor (this is confirmed by security). 4. Whilst on Alder 2, Ms Del Amo was being supported with a 5:1 ratio of staff. It is unclear how staff were supporting her. There was little consistency of staff due to a high percentage of staff being bank and agency and they were unfamiliar with Ms Del Amo, her needs, complexities and risks.

5.There are significant incidents of restraint. Staff were compelled to react to Ms Del Amo’s self-harming behaviours to prevent her from self-injurious behaviours. Nursing staff have little experience of working with adolescents particularly in an adult acute setting, thus perpetuating the need for restraint as a preventative measure to mitigate self-harming behaviours..

6.Agency nurses were required to engage in repeated episodes of restraint despite not being SIMA trained in UHB approved techniques. This was often unavoidable due to the significant staffing challenges Alder was experiencing and the level of distressing challenging behaviour displayed by Ms Del Amo.

7.Adult in-patient staff have no training on how to support complex, speciality CAMHS patients.

8.There is currently no UHB policy on the use of restrictive interventions for CAMHS patients. 9.It is unclear if necessary reporting documentation and/ or a risk assessment was completed to reflect the admission of a CAMHS patient to Alder ward.

10. There is no segregation governance policy on Alder 2 to rationalise its use, an inclusion/exclusion criterion and monitoring of patients. Alder 2 was utilised as it was the only option to support Ms Del Amo away from adult patients to maintain her safety and dignity.

11.At the time, certain assessment documentation was not updated to reflect changing risk and or to include clinical incidents.

12.Not all incidents were reported in line with policy

13. The handing in of visitor’s belongings to be stored in the lockers in the lobby before entering the ward was not adhered to which resulted in Mr Del Amo’s repeatedly bringing in items that were restricted.

14. The use of restrictive interventions to minimise challenging behaviour was not included in risk assessments and or care plans. Restrictive interventions were being utilised to manage high risk behaviours. however, the care plans did not address Ms Del Amo’s specific complex care needs, identify particular triggers for challenging behaviour, or detail adaptive strategies to support Ms Del Amo safely. There was an absence of a robust risk management plan until her recent review.

15.A Positive Behaviour Support (PBS) approach to care was difficult to formulate due to the restrictive environment and absence of therapeutic opportunities to aid recovery. Inconsistencies with staff further compromised a coherent approach and the development of a therapeutic rapport.

16. Mr Del Amo’s involvement often left staff feeling very vulnerable. Staff were exposed to numerous threats of litigation, filmed and photographed without their consent and intimidated when trying to provide care to an adolescent with very complex needs and challenging behaviour.

17.The use of mechanical restraints was in breach of SIMA guidance and Welsh government guidance (Reducing Restrictive Practice).

18.A best Interest meeting was convened and acted upon without a mental capacity assessment to inform decision making.

19.Ms Del Amo was not in attendance to the Best Interest meeting.

20.SSC transport does not have an operational policy to include the recording/reporting of the use of handcuffs.

21.Police were not notified of any incidents.

22.Staff were subject to repeated assaults and consequently were injured trying to support Ms Del Amo.

23.There is no current plan in place by Cwm Taf UHB to transfer CAMH’s patients via secure transport.

24.Ms Del Amo’s care and treatment was shared with her father’s advocate prior to a mental capacity test being completed relating to Ms Del Amo’s consent to share information.

25.Restrictive practice such as removal of personal items was implemented without any clearly documented rationale for the decision making. This was not care planned which left staff unsure which items were prohibited and or restricted.

26.The team offered an unusually flexible approach in such a restrictive environment to accommodate Ms Del Amo’s needs and requests by her father. This, however, caused further conflict between Ms Del Amo’s father and staff making staff vulnerable to further threats of litigation and blame.

27.During Ms Del Amo’s time on Alder 2, she was supported on varying levels of observations. The recording of these observations was poor with staff only documenting their first names or nicknames making it difficult to determine who was supporting Ms Del Amo at any given time. No addressographs were fixed to the observation charts and there are large gaps in recording and incomplete observation sheets.

28.Several times Ms Del Amo was injured due to headbanging. These incidents were not documented on a body map nor is there any evidence of neurological observation assessment documentation as per UHB policy in her medical notes, it is recorded that she refused neurological observations in case notes.

29.There is no clear documented evidence that mental capacity assessments were completed for any of the medical interventions and surgeries to remove the ingested items. A best interest meeting was arranged and documentation completed to detail the outcome/decision of the meeting (05/10/2022) but Ms Del Amo was not involved in the assessment nor was it documented that a capacity assessment was completed regarding her ability to consent to treatment and to be transferred to UHW.

30.During her time on Alder 2, Ms Del Amo was on fluctuating levels of observations. It is difficult to ascertain how staff were supporting her and how she was able to conceal and swallow items on several occasions.

‘Distress’

The review concluded: “Following careful consideration by the health board’s Redress Team in June 2024, it was concluded that although the above failings in care were identified during the course of the incident investigation, the health board does not consider that any of these failings will have directly caused, or materially contributed to, any harm to your daughter.

“… I would also like to extend my sincere apologies for your and your daughter’s experience and for the distress this will have caused you both.”

Ms Del Amo’s father Scott Del Amo insists that he has not behaved in a threatening way. He told Nation.Cymru: “I was firm when raising concerns with staff at Hafan y Coed about how Anya was treated, but I certainly didn’t behave in an aggressive manner.

“Clearly the failures outlined in the review are very disturbing. We don’t accept that they caused Anya no harm.

“We want to see her medical records to cross-check them against the review findings as we consider whether to bring a lawsuit against the health board. I’ve been asking for them for a very long time. Senior managers have made repeated promises that the records would be handed over by particular dates, but they’ve failed to meet the deadlines.”

Ms Del Amo subsequently left Hafan y Coed and received treatment at as an in-patient at a residential NHS mental health unit called Springbank in Cambridge, where she made considerable progress. She now has a baby, Anya, who is four and a half months old.

Delay

A spokesperson for Cardiff and Vale University Health Board, said: “We would like to apologise for the delay in providing the medical records requested, we acknowledge that this has taken significantly longer than we would expect.

“The teams involved are working to provide the medical records and will be in contact with Mr Del Amo directly when they are available.”