Summary: Miss X complained about the actions of London Borough of Tower Hamlets (the Council’s) adult social care and substance misuse services and East London NHS Foundation Trust (the Trust’s) mental health and autism diagnosis services. The Ombudsmen have upheld some of Miss X’s complaints against both the Council and the Trust. The Council and the Trust have accepted our recommendations for apologies, financial remedies and service improvements. We have therefore completed our investigation.

The complaint

1. Miss X complains on behalf of herself and her brother, Mr X, about the actions of London Borough of Tower Hamlets (the Council) and East London NHS Foundation Trust (the Trust).
2. Miss X complains the Council’s adult social care services failed to properly communicate, assess and provide support for Mr X, and for Miss X as a carer for Mr X and her father.
3. Miss X also complains a substance misuse service, for which the Council is ultimately responsible, acted with fault by:
• delaying acting on a referral when Mr X was in crisis in September 2015;
• discharging Mr X to the Community Mental Health Team (CMHT) in late 2015/early 2016;
• failing to provide support for Mr X’s mental health needs; and
• failing to arrange drug rehabilitation treatment.
4. Miss X also complains the Trust acted with fault because of:
• poor care and support to Mr X by CMHT, including the actions of specific staff;
• failure to provide support (including psychology services) for Mr X’s mental health needs;
• flaws in Autism assessment;
• putting inaccurate information on Mr X’s medical records;
• decisions not to admit Mr X as an inpatient when he went to A&E in November 2016 and January 2017;
• flaws in responding to Miss X’s complaints about these matters.
5. Miss X says that this has resulted in lack of correct assessments, treatment and services for Mr X, leading to distress and time and trouble. She says the matters she complains of have had an impact on her work and health and forced her to be a carer for her brother. Mr X and Miss X are seeking a financial remedy and would like appropriate services and support in place.

Back to top

What I have investigated

6. I have investigated the complaint as it relates to matters which occurred from the 1 January 2016 to 13 April 2018. I have set out my reasons for not investigating the rest of the complaint at the end of this statement.

Back to top

The Ombudsmen’s role and powers

7. The Ombudsmen have the power to jointly consider complaints about health and social care. Since April 2015, these complaints have been considered by a single team acting on behalf of both Ombudsmen. (Local Government Act 1974, section 33ZA, as amended, and Health Service Commissioners Act 1993, section 18ZA)
8. If the Ombudsmen are satisfied with the actions or proposed actions of the bodies that are the subject of the complaint, they can complete their investigation and issue a decision statement. (Health Service Commissioners Act 1993, section 18ZA and Local Government Act 1974, section 30(1B) and 34H(i), as amended)
9. The Ombudsmen cannot investigate late complaints unless they decide there are good reasons. Late complaints are when someone takes more than 12 months to complain to the Ombudsmen about something an organisation has done. (Local Government Act 1974, sections 26B and 34D, as amended, and Health Service Commissioners Act 1993, section 9(4).)

Back to top

How I considered this complaint

10. The Health and Social Care Act 2012 amended the National Health Service Act 2006, placing a duty on local authorities to improve the health of people in their area. This includes the commissioning of drug and alcohol misuse services. This means the Council is ultimately accountable for the drug and alcohol services that treated Mr X in 2016-2018, even though they were run by the Trust. Before October 2016, the service was called Tower Hamlets Specialist Addictions Unit (THSAU). From 1 November 2016, the service has been called RESET. For simplicity, I will refer to the service as RESET throughout this decision statement.
11. As part of the evidence I have taken into account when investigating this complaint, I have considered:
• information Miss X has provided in writing and by telephone;
• information the Council and Trust have provided in writing and by telephone;
• advice from an adult general psychiatrist who has a special interest in adult Autism and is independent of the Trust;
• advice from a registered mental health nurse and NHS commissioning manager with experience of nursing patients with co-existing mental health and substance misuse problems;
• advice from a consultant psychiatrist with experience of working within hospital and community multidisciplinary psychiatric services.
12. Miss X first complained to the Ombudsmen in September 2017, so her complaints that predate September 2016 are ‘late’. I have decided there are good reasons for us to investigate what happened from January 2016 because Miss X has provided a reasonable explanation for her delay in coming to the Ombudsmen. This investigation covers the period January 2016 to April 2018.
13. Miss X, the Council and the Trust have had an opportunity to comment on a draft version of this decision. I have taken their comments into account before reaching a final decision.

Back to top

What I found

Background

14. Mr X has various diagnoses including a personality disorder, and a mental and behavioural disorder due to drug use. He has a long history of drug use.
15. Between January and September 2016, Mr X was under the care of the Trust’s CMHT.
16. Mr X was under the care of RESET between September 2016 and March 2018.
17. Mr X was admitted to a psychiatric hospital in September, October and November 2016 and January 2017.
18. Miss X complained to the Trust in December 2016.
19. The Trust assessed Mr X for Autism Spectrum Condition (ASC) in February 2017 and concluded he did not have ASC.
20. The Council and Trust replied to Miss X’s complaint in March 2017.
21. Mr X received support from the Council’s reablement service between June and August 2017 to prompt him to take care of himself.
22. RESET discharged Mr X in April 2018.

The Council – social care assessment and support for Mr X

Relevant law

23. Sections 9 and 10 of the Care Act 2014 require local authorities to carry out an assessment for any adult with an appearance of need for care and support. They must provide an assessment to all people regardless of their finances or whether the local authority thinks an individual has eligible needs. The assessment must be of the adult’s needs and how they impact on their wellbeing and the results they want to achieve. It must also involve the individual and where suitable their carer or any other person they might want involved.
24. Councils must carry out the assessment over a suitable and reasonable timescale considering the urgency of needs and any variation in those needs. Local authorities should tell the individual when their assessment will take place and keep the person informed throughout the assessment.
25. Where local authorities decide a person has any eligible needs, they must meet these needs.
26. The Care Act 2014 says local authorities must provide a care and support plan (or a support plan for a carer). The care and support plan should consider what the person has, what they want to achieve, what they can do by themselves or with existing support and what care and support may be available in the local area. When preparing a care and support plan the local authority must involve any carer the adult has. The local authority must keep the care and support plan under review. If it considers the person’s circumstances have changed in a way that affects the care and support plan, the local authority must do a new needs assessment and revise the care and support plan accordingly.
27. Local authorities can ‘contract out’ assessment, care planning and care provision to other organisations, such as NHS Trusts or commercial companies. However, a council remains responsible and accountable for the actions of the organisation acting on its behalf.

Key events

28. A local housing association support service says in a letter of August 2016 that it had recently applied to the Council for Mr X to be allocated a carer to help with his day to day activities.
29. On 2 September 2016, Miss X sent in a self-assessment form to the Council’s adult social care team, asking for social care support for her and Mr X. The Council sent the form on to the Trust’s CMHT as it considered all Mr X’s issues were to do with mental health.
30. In late November 2016, the fire brigade and police made referrals to the Council’s social care team because of concerns about Mr X. The Council decided to take no further action because the concerns were related to his mental health.
31. Miss X’s December 2016 letter of complaint was addressed, among others, to the Council’s head of social care. In that letter, Miss X describes Mr X’s difficulties at the time. She also states:
• Mr X wanted a social worker and support for his social care needs;
• she made a referral to the Council’s adult social services department in July 2016 but was told the Council had not received it;
• the Council forwarded a second referral of September 2016 to the CMHT and told her she would have to chase CMHT herself. When she did so, CHMT told her they had never received the referral from the Council;
• the Council had repeatedly refused to provide support for Mr X and told her that CMHT was the appropriate service for Mr X but refused to put this in writing and had told her to complain about CMHT; and
• the police and fire department had made referrals for social care support for Mr X.
32. In January 2017, a housing officer made a referral to the Council’s adult social care team asking for a social care assessment.
33. In February 2017, the Council decided the main issues for Mr X were around mental health needs and that no other care or support needs were identified. It therefore asked the Trust to assess his social care needs.
34. The Trust’s assessment included the following conclusions.
1. Mr X’s “needs are likely to fluctuate, dependent on whether he has taken any illicit substances. When he has taken these he becomes vary … paranoid, does not sleep or manage his health, safety and wellbeing.”
2. Mr X’s difficulties sometimes prevented him leaving his house and using public transport, although he could make his own way to some appointments.
3. Mr X was eligible for support to help him meet the following outcomes:
• making use of necessary facilities or services in the local community;
• developing and maintaining family or other personal relationships; and
• accessing and engaging in work, training, education or volunteering.
35. The assessment also said that:
• Miss X provided a lot of support to Mr X with administrative tasks, taking him shopping and to appointments, and acting as his advocate and support. She felt unable to continue to provide this level of support;
• it was unclear what prevented him from performing some tasks for himself;
• Miss X had been offered a carer’s assessment but had declined it as she wanted to resolve Mr X’s care needs before looking at her own.
36. The assessment concluded that the needs could be met by referrals to a floating support [support when required] service and to the Council’s reablement service. The Trust social worker also commissioned an occupational therapy (OT) assessment. The social worker typed the assessment in March 2017 and forwarded it to the Council’s social care team in April 2017.
37. The Trust carried out an OT assessment at the beginning of April 2017 and sent a copy to the social care team at the end of the month. In summary, the OT report concluded that Mr X’s home environment, basic ability and understanding were adequate, but his ability to carry out daily tasks had decreased noticeably, probably due to developing a significant dependence on Miss X. The assessor also considered Mr X’s physical health problems, cognitive difficulties and drug use affected his ability to look after himself, but he was working meaningfully with RESET. The OT assessment noted that Mr X and Miss X did not believe that he could cope without daily support from carers, should Miss X stop providing the level of support Mr X was used to receiving from her.
38. The OT report considered Mr X faced some challenges with most activities of daily living and significant challenges with finances. The report concluded Mr X needed practical support with:
• finances and dealing with correspondence;
• personal care, meal preparation and eating, daily domestic tasks and shopping;
• social inclusion, leisure and tasks in the community such as going to appointments;
• practising motor skills;
• developing a routine and goal-setting;
• coping mechanisms and anxiety management; and
• substance misuse.
39. I have seen no evidence the Council or Trust produced a corresponding care and support plan for Mr X at this time.
40. The social care team then organised a reablement care package. The Council’s records show reablement officers were available to start providing support from 19 May 2017. Mr X and Miss X asked for the support to be put on hold while Mr X was in hospital in May and until a roster of carers and support goals were agreed, which happened in late June 2017.
41. The Council says that in May 2017, Miss X stated she was no longer a carer for Mr X. I have not seen documentary evidence to support this. However, if this did happen, information that Miss X was no longer Mr X’s carer should have prompted a review of his needs, given that a recent (February-April 2017) assessment said that Mr X had a significant dependence on his sister.
42. Mr X received support from the reablement service between June and August 2017 to prompt him to take care of himself. The agreed service consisted of daily 1.5-hour visits to:
• promote routines in personal care, shopping and community access; and
• develop meal preparation skills.
43. The OT and Reablement service planner met with Mr X in August 2017 to review the effect of the reablement service he had received so far. The feedback from the reablement officers who worked with Mr X was that:
• his participation and motivation fluctuated daily; and
• he had not made any progress towards independence due to fluctuating mood, motivation and levels of paranoia.
44. At the meeting, the officers told Mr X and Miss X that Mr X’s support from the reablement service was a short-term intervention and would end soon. Mr X and Miss X were dissatisfied with this happening without a guarantee of ongoing care support for Mr X. Miss X questioned the usefulness of a referral to floating support as this had been unsuccessful in the past. While agreeing with the end of reablement and referring Mr X to a floating support service at the time, the OT considered Mr X would need “a long period of engagement [with a service] to improve his functionality”.
45. Following the meeting of August 2017, the CMHT agreed to fund a temporary support package for three days a week, two hours a session, until the independent living community support (ILCS) service could start providing a floating support service. The request for the temporary support package said that Mr X “won’t be able to cope by himself without external support”.
46. The floating support of six hours a week started at the end of October 2017. The temporary support package ended at the beginning of December 2017. Mr X received support similar to what had been provided through reablement, to help him look after himself and his home, and to go out into the community.
47. The Council also funded a weekly gardening session for Mr X between September and November 2017. The CMHT, on behalf of the Council, issued a support plan for the gardening session, but not the other support Mr X had from ILCS.
48. The Trust, on behalf of the Council, re-assessed Mr X’s care needs after the floating support started. It started the assessment at the end of October 2017 and signed it off in December 2017. The re-assessment said that:
• the reablement, temporary carers and ILCS service had helped Mr X make some recovery, including “improved engagement levels, increased community access, mini-routine, apparent improved wellbeing and increase in his generic motivation”;
• Mr X’s social anxiety limited his ability to access a gardening group and as a result he was unable to develop personal relationships or access work, education or volunteering;
• Mr X should continue to work with ILCS for six hours a week, using two of those hours for support to attend a weekly community gardening session.
49. In December 2017, the Trust (acting on behalf of the Council) issued a support plan for Mr X. This stated the Council would fund a weekly two-hour gardening session to help him access the community. The gardening session started in June 2018; a start date agreed with Miss X. The support plan does not include any help from ILCS.

My analysis

50. The Council says it did not assess Mr X’s social care needs during this period because it did not consider he had any unmet social care needs as he was:
• getting services from the CMHT or RESET;
• the subject of a discussion by an antisocial behaviour panel; and
• in prison or hospital for short periods in 2016.
51. As Miss X was asking for social care support for Mr X, and the fire brigade and police had raised concerns with social services:
• the Council should not have assumed Mr X had no unmet social care needs without conducting a proper assessment; and
• the approaches regarding social care to the Council and CMHT between July 2016 and January 2017 should have prompted an assessment of Mr X’s social care needs, unless he refused.
52. I consider that there was an unjustified delay in completing Mr X’s social care needs assessment between July 2016 and April 2017. This was fault for which the Council is accountable. The fault contributed to the delay in Mr X receiving support for his social care needs. It also led to unnecessary time and trouble for Miss X who had to chase the Council and CMHT to get the assessment completed. I have made a recommendation below for the Council to address their injustice and improve services.
53. There was no fault in the actual assessment of Mr X’s social care needs completed between February and April 2017. However, once there was an assessment of Mr X’s social care needs, the Council should have ensured there was a care and support plan setting out how it would meet his eligible needs and shared this with him. I have not seen any evidence it did this. This was fault. It meant that Mr X and Miss X did not have a clear document showing them how the Council was going to meet Mr X’s eligible needs, contributing to their confusion and feeling that Mr X’s needs were not being met. I have made recommendations below for the Council to address their injustice and improve services.
54. Once the assessment was completed, the CMHT, on behalf of the Council, put in place a short term reablement service. The reablement service saw Mr X on
    2 June 2017 but did not agree a set of goals with Mr X until the end of June 2017. I consider that this was fault, which contributed to the delay in the service starting. I have made a recommendation below for the Council to address Mr X’s injustice and improve services.
55. The reablement service was available to Mr X, when he would engage with it, between 26 June and 19 August 2017. Reablement officers visited him to provide support and help him learn skills so he could be less dependent on Miss X. Reablement services are time limited and there was no fault in ending this in August 2017.
56. However, the Council should have ensured it or CMHT wrote down and reviewed Mr X’s care plan and reassessed his needs, if it considered his circumstances had changed so significantly that he needed reduced support, in the form of a floating support service and a gardening course. There is no documentary evidence of a care plan, review or reassessment of Mr X’s needs when the daily 1.5-hour reablement visits stopped in August 2017. This was fault. Mr X continued to get two-hour visits from the temporary care agency until the beginning of December and received another six hours a week support from ILCS from October 2017. I therefore consider it more likely than not that a review at this point would not have led to a different outcome for Mr X.
57. Records indicate CMHT started reassessing Mr X’s social care needs in October and completed the reassessment in December 2017. The Council issued a care plan, but this did not reflect the full extent of the ILCS support he was receiving, only the two-hourly gardening session. This was fault, which has added to Mr X and Miss X’s confusion about the level of social care and support he should have been getting.
58. The delay since December 2017 in arranging the weekly gardening session was not fault. This is because the Council arranged it for June 2018 at Miss X’s request.
59. I have made a recommendation below for the Council to look at its review and reassessment processes to ensure others are not affected by similar flaws.

The Council – support for Miss X as a carer

Relevant law and guidance

60. Where an individual provides or intends to provide care for another adult and it appears the carer may have any needs for support, local authorities must carry out a carer’s assessment. (Care Act 2014, section 10)
61. Carers’ assessments must seek to find out not only the carer’s needs for support, but also the sustainability of the caring role itself. This includes the practical and emotional support the carer provides to the adult. Where the local authority is carrying out a carer’s assessment, it must include in its assessment a consideration of the carer’s potential future needs for support. Factored into this must be a consideration of whether the carer is, and will continue to be, able and willing to care for the adult needing care. (Care and Support Statutory Guidance 2014)
62. A carer may choose to refuse to have an assessment. In these circumstances local authorities do not have to carry out an assessment.

Key events and my analysis

63. Miss X says that, in the period this investigation is looking at, she was a carer for
    Mr X and for their late father, Mr Z. Mr Z was elderly, had a mental illness and used a wheelchair.
64. Miss X asked for social care support in a self-assessment form she sent the Council in September 2016. Miss X stated in her complaint letter of December 2016 that she was Mr X’s carer and would like a carer’s assessment. She also stated that she was sick and could not act as his carer any longer.
65. The Trust’s social care records say that it offered Miss X a carer’s assessment in December 2016 but that she refused.
66. The Council says that in May 2017, Miss X stated she was no longer a carer for Mr X. I have not seen documentary evidence to support this. Even if Miss X was not Mr X’s carer at that time, she says she was also a carer for their father, Mr Z. I have seen no evidence to show the Council took Miss X’s caring responsibilities for Mr Z into account at the time.
67. In July 2017, following a request by Miss X, records show the reablement service told the CMHT OT that Miss X was entitled to a carer’s assessment. The Council says that in July 2017, Miss X was advised of the support available to her via the recovery college for carers. However, the Council did not ensure she had a carer’s assessment.
68. Miss X asked for an update on her carer’s assessment at a meeting with the CMHT OT and Reablement service planner on 9 August 2017. She also chased this up with a CMHT community services manager on 18 August 2017.
69. On 15 September 2017, CMHT referred Miss X to a carers’ charity for support and advocacy. However, the Council did not ensure she had a carer’s assessment.
70. The Trust carried out its own version of a carer’s assessment on 11 October 2017. This said Miss X was eligible for support. On the information I have seen, the Trust used this assessment to determine whether Miss X qualified for a carer’s assessment and support from the Council. This is because the form states, “Assessor: If you have identified eligible needs that may be supported by the Local Authority please refer to the Local Authority’s guidance on eligibility and, if necessary, complete their local Carers Assessment form”. In this section, the Trust stated that Miss X “has been referred to The Carers Assessment for a Local Authority Assessment”.
71. Miss X and her advocate say they asked for a carer’s assessment in November 2017 and chased this repeatedly but were pushed back and forth between the Council and CMHT.
72. In March 2018, Miss X’s advocate complained to the Council on Miss X’s behalf and asked for a carer’s assessment. The Council made some initial enquiries which it referred to as “triage”. In April, the Council asked the Trust to carry out a carer’s assessment and told Miss X that there was a waiting list for this.
73. I consider there was fault in the following:
• the Council failed to assess Miss X’s needs as her father’s and brother’s carer in response to requests of September 2016, July 2017, August 2017, and November 2017;
• the Council delayed dealing with Miss X’s request for a carer’s assessment of March 2018;
• the Council and Trust ‘pre-assessed’ Miss X for eligibility for carer’s assessments through the Council’s “triage” system or the Trust’s carers’ assessments which refer people for additional Council carer’s assessments.
74. The faults caused Miss X unnecessary time, trouble and stress in getting a carer’s assessment. The ‘pre-assessment’ has also added to Miss X’s confusion and the delay she has experienced. We cannot now quantify how much support, if any, she is likely to have received. However, she has missed out on several opportunities to have a carer’s assessment and potentially, services. I have made a recommendation below for the Council to remedy Miss X’s injustice and to review its process for carers’ assessments.

The Council – drug rehabilitation services

Discharge in early 2016 and delay acting on a referral

75. Miss X says that RESET discharged Mr X in early 2016. I have seen no evidence that this happened. This investigation does not cover the period before January 2016 for the reasons given at the end of this decision statement.
76. CMHT referred Mr X to RESET on 5 September 2016, but RESET did not act on this referral because of an administrative error. Mr X’s GP referred him to RESET on 26 September and RESET acted on this referral. The Trust has apologised for the mistakes that led to a delay in Mr X being seen by RESET for about 4 weeks. It says it has spoken with the person responsible for the error and put in place a new process which should prevent a similar mistake from happening again. I am satisfied that the Trust has already taken appropriate action to resolve this matter on behalf of the Council.

Support for mental health needs

77. Mr X was under the care of RESET between late September 2016 and March 2018. Part of RESET’s role was to monitor Mr X’s mental health, and to ask his GP to refer him to the CMHT if RESET considered this appropriate.
78. In September and November 2016, and January 2017, Mr X was admitted to hospital because of drug induced psychosis. Psychosis is a mental health problem that causes people to perceive or interpret things differently from those around them. This may involve delusions (strong beliefs that are not shared by others). RESET wrote a letter to support the hospital admission of January 2017. On all three occasions, Mr X was discharged from hospital after a few days with a plan for weekly follow up by the RESET recovery worker.
79. RESET’s clinical notes and correspondence show that RESET saw Mr X approximately once a week:
• October 2016 to February 2017;
• May to June 2017;
• between the end of August and the beginning of September 2017; and
• in November 2017.
80. While RESET did not always see Mr X every week, there were good reasons for this. I have therefore found no fault in how often RESET saw Mr X.
81. Mr X’s 2017 RESET treatment plan included a mental health assessment completed on 12 January 2017 and a review in three months. I have seen evidence that RESET psychiatrists reviewed Mr X’s mental health in November 2016, twice in January 2017, and once in September 2017. Mr X also declined to meet a RESET psychiatrist in June 2017.
82. During our investigation, the Council was for a time unable to provide RESET’s clinical notes between February 2017 and March 2018. The Council’s lack of access to these clinical notes was fault. While this has not caused Mr X an injustice, I have made recommendations to the Council to ensure similar problems do not affect others. The Council has since been able to access and share these records with us. The available records show that Mr X was offered regular appointments.
83. I consider that RESET acted without fault in keeping Mr X’s mental health under regular review by:
• offering him regular appointments with his keyworker;
• carrying out a mental health assessment and four reviews by a psychiatrist between January and September 2017; and
• supporting a hospital admission in January 2017.
84. Mr X signed a RESET treatment agreement in October 2016. This indicates he was aware and agreed that his treatment may be reviewed and ended if:
• he missed appointments consistently; or
• he behaved in a threatening or abusive way.
85. Mr X would regularly voice conspiracy theories in his appointments at RESET. At times, records indicate he used language that most would consider racist and offensive and that he shared his beliefs with other service users and reception staff. In August 2017, RESET asked Mr X to sign a bespoke treatment agreement which stated he would refrain from expressing these views at RESET. Miss X considers this was a flawed approach which deprived Mr X of an outlet to voice his persecutory beliefs.
86. The available records indicate that:
• until August 2017, RESET would challenge inappropriate comments Mr X made in appointments and try to re-focus him on discussing his recovery;
• in the weeks leading up to August 2017, Mr X’s language relating to his persecutory beliefs became increasingly offensive and he behaved intrusively towards staff and other service users;
• RESET took into account Miss X’s concerns about Mr X needing an outlet to voice his beliefs before deciding to ask him to sign a new treatment agreement; and
• while asking Mr X to sign this agreement, RESET also offered him a review by a psychiatrist.
87. I consider that RESET took appropriate steps to consider Mr X’s needs and acted without fault in asking him to refrain from discussing his persecutory beliefs.
88. NICE guideline NG58 “Coexisting severe mental illness and substance misuse: community health and social care services” was published in November 2016. It says, “Ensure secondary care mental health services…Do not exclude people with severe mental illness because of their substance misuse.” The Department of Health and Social Care’s guidance, “Drug misuse and dependence: UK guidance on clinical management”, says: “in general, the coexistence of a drug problem should not be a reason for denying service users access to the recommended treatment usually provided by mental health services”.
89. RESET explained to Mr X that it would consider referring him to the personality disorder (PD) service if he could show continued abstinence from drugs. In October 2017 RESET clarified that this meant he should be free of drugs for three months. RESET told Mr X that the treatment from the PD service can be difficult and stressful for patients, which is why the PD service would not accept a referral if Mr X was using drugs.
90. However, there is no record that the PD service told RESET that it would reject a referral without a long period of abstinence. The PD service’s criteria for accepting referrals say that candidates who use drugs may not be suitable for the service, but drug use would not necessarily exclude them. The PD service’s criteria also say that all referrals must be made with the agreement of a patient’s consultant psychiatrist. This means RESET did not have to refer Mr X to the PD service unless his RESET consultant psychiatrist decided this was appropriate.
91. The available information indicates the PD service did not refuse to accept a referral for Mr X because of his drug use. Rather, RESET could have referred him there but decided not to, because of his drug use. It would have been more accurate for RESET to have told Mr X this was the case at the time.
92. While RESET could have referred Mr X to the PD service, the PD service may not have accepted the referral without evidence Mr X was abstaining from drugs. This is because drug use can make it difficult for patients to engage with the service and because Mr X had apparently delusional beliefs, which were potentially linked to drug use and for which he did not want to try medication. When Mr X was referred to the PD service in June 2018 after he left RESET’s care, he was abstinent from drugs. However, the PD service assessed him and decided it would not be able to offer him the support he needed. This adds weight to RESET’s decision not to refer Mr X to the PD service between September 2016 and March 2018.
93. In September 2017, RESET told Mr X it would consider Miss X’s request for it to provide Mr X with “psychology input” while waiting for a re-referral to the PD service. RESET’s records indicate that its psychologist offered Mr X an appointment in November 2017. Mr and Miss X cancelled psychology appointments in December 2017 due to ill health. The psychologist met Mr X in January 2018 and had a preliminary discussion with him before booking a psychology assessment for the following week. Mr X later cancelled this appointment. Soon after, RESET decided that Mr X had successfully reduced his drug use to a level where he did so only occasionally, through choice rather than compulsion. RESET therefore decided that it was no longer the most appropriate service for Mr X. It decided to discharge and refer him to CMHT for further input with his mental health. As RESET was going to discharge Mr X, and Mr X had cancelled several psychology appointments between December and February 2017, RESET decided not to offer him another psychology appointment. I consider that there was no fault in the way RESET dealt with Mr X’s request for psychology.

Delay in arranging residential rehabilitation treatment

94. Mr X’s RESET treatment plan included working towards residential rehabilitation treatment. On 4 April 2017, RESET applied to the Council’s residential treatment panel for treatment for Mr X. The application said (in summary) that:
• Mr X had managed to reduce drug use, and had last used drugs in February;
• Mr X was unwilling to use medication to stabilise his mood;
• Mr X had numerous mental health issues including persecutory and anti-Semitic beliefs;
• Mr X was socially isolated and had a conviction for stalking;
• Mr X had shown exemplary engagement with RESET since October 2016 and was engaging well with peers in his pre-detox group;
• despite working well with RESET, he had had occasional drug binges resulting in hospital admissions;
• weekly sessions with RESET were not enough for abstinence which was essential for Mr X to access more mental health treatment;
• Mr X could not attend community groups due to social awkwardness and persecutory beliefs;
• Mr X would need a psychiatric evaluation before going into residential treatment; and
• there was a risk that Mr X’s persecutory anti-Semitic beliefs would affect other residents and compromise his stay in residential treatment.
95. The panel considered the application twice but reached no decision. On 6 April 2017 it asked RESET for more information on the units that would accept Mr X for treatment given the risks. It also asked if Mr X would consider taking anti-psychotic medication (medication to help relieve the symptoms of psychosis). Miss X did some research and provided details of five residential treatment centres she said would accept Mr X in full knowledge of his history. RESET sent the panel all the information it had asked for. On 20 April the panel deferred its decision again because it wanted a formal offending history and risk assessment from the probation service, and a recommendation from Mr X’s RESET keyworker for the most suitable treatment provider.
96. Between April and November 2017, all except one of the providers approached by RESET declined to provide residential treatment for Mr X. One private provider told RESET that it may be able to provide residential rehabilitation, but did not answer all of RESET’s questions about suitability.
97. The Council says that substance misuse residential rehabilitation units:
• occasionally manage people with complex needs in addition to drug addiction, for example mental health issues such as anxiety or depression, with very few units willing to work with psychosis;
• usually do not accept people with a history of violence for residential treatment;
• provide planned, not emergency, treatment; and
• focus on group work and living together.
98. The Council says that:
• Mr X’s attendance at RESET “continued to be marked by racism, obscenities, threats to staff including death threats to keyworker”;
• his keyworker was changed to a senior mental health nurse; and
• RESET assessed the threats as not being due to psychosis and considered Mr X was aware of his behaviour.
99. The Council says Mr X continued to see RESET but “presented aggressively” and refused further mental health assessments. The residential treatment panel’s decision remained deferred and awaited resubmission by RESET. The Council says RESET did not pursue residential rehabilitation for Mr X because of the “complexity… [of his] …presentation”.
100. I have seen evidence that RESET raised concerns about Mr X’s behaviour with Mr X and Miss X in meetings and in writing since 30 June 2017.
101. NG58 says people should not be excluded from appropriate substance misuse services because of a diagnosis of psychosis. However, whether a residential substance misuse treatment is suitable for a patient is a matter of clinical judgement (“Drug misuse and dependence: UK guidance on clinical management”).
102. While there are gaps in the Council’s record keeping, the available records indicate the providers and the Council considered that residential treatment would not be suitable for Mr X in 2017, because his condition and associated behaviour were likely to make it difficult for him to cope with the work required and to disrupt other residents and their recovery. By early 2018, RESET decided to discharge Mr X from its service because he had successfully reduced his drug use. It therefore did not pursue residential rehabilitation further.
103. I have found no fault in the decision not to pursue residential treatment because the Council can provide a reasoned explanation for how it reached that decision. However, the Council did not ensure that Mr X got a clear explanation of what happened with his residential treatment application. I consider this was fault. The Council says that it has now changed how it deals with applications to ensure everyone whose application the panel adjourns gets a letter explaining why.
104. I have made a recommendation below for the Council to apologise to Mr X and to provide us with evidence of how it has improved its handling of applications for residential treatment.

The Trust – care and treatment from CMHT

105. Miss X complains about poor care and support by CMHT, including the actions of dual diagnosis workers during their appointments with Mr X. She says that CMHT failed to provide support for Mr X’s mental health needs and delayed referring him to a personality disorder (PD) service.

What happened

106. During the period this investigation covers (January 2016 to April 2018), Mr X was under the care of CMHT between January and September 2016.
107. Following a referral from RESET, CMHT wrote to Mr X in January 2016 to offer him an appointment with a keyworker, Ms Y. CMHT saw Mr X twice in January 2016. Mr X was remanded in prison between February and April 2016.
108. CMHT saw Mr X twice in April 2016, including a review by a consultant psychiatrist, who saw Mr X at the Dual Diagnosis clinic. The plan was to continue appointments with his keyworker to reinforce abstinence from drugs, possibly attending Narcotics Anonymous, continue with probation, physical exam and blood tests by GP, with a further review in a month. The psychiatrist sent a copy of the appointment summary letter to the PD service to ask if they would consider a re-referral for Mr X. CMHT did not make a formal referral to the PD service at the time because it considered Mr X first needed to show a period of abstinence from drugs.
109. CMHT saw Mr X twice in May 2016, and offered him an appointment in June which he did not attend. CMHT cancelled an appointment in July 2016 as Ms Y was off work. CMHT offered Mr X an appointment in August 2016 but he cancelled this on the day due to feeling unwell.
110. In July 2016, Miss X asked Mr X’s keyworker for a referral to the PD service. The Trust says it did not refer Mr X then because he had refused his last urine drug screen so his abstinence from drugs could not be guaranteed.
111. CMHT saw Mr X again for a review in early September 2016. Following the appointment, CMHT wrote to Mr X’s GP to advise them that a psychiatrist and keyworker had seen Mr X and discussed:
• Mr X’s recent crisis following drug and alcohol use;
• that Mr X could not access the PD service due to drug misuse, but a referral could be re-considered should he become abstinent;
• Mr X’s engagement with CMHT has been sporadic;
• Mr X has refused drug screening and medication; and
• the psychiatrist and keyworker considered CMHT had little further to offer Mr X, so will be discharging him and referring him to RESET.
112. The Trust says it did not refer Mr X to the PD service in September 2016 because of continuing uncertainty over his abstinence from drugs. The Trust says it told
     Mr X regularly that it would only refer him to the PD service following a period of abstinence from drugs.
113. The Trust says that the keyworker either gave Mr X details of his next appointment during a session and that he wrote these down, or that CMHT would call Mr X to advise him of his next appointment.
114. The Trust says it was not the keyworker’s role to decide whether Mr X needed a social worker or a referral for an Autism assessment. It says Mr X’s consultant was responsible for these decisions and the consultant did not consider Mr X needed social work support. The Trust apologised to Miss X in its letter of March 2017 for not clarifying this and for not telling Miss X who she should contact for taking her requests further. The Trust says the keyworker’s role was to support
     Mr X in minimising harm from drug misuse and to reduce his drug misuse, rather than help him with focusing on daily tasks.
115. On 3 January 2017, Mr X’s GP wrote to CMHT asking for a second opinion regarding CMHT’s decision to discharge Mr X from its ongoing support. A consultant psychiatrist (Dr R) sent a second opinion letter on 16 February 2017, having reviewed Mr X’s records. Dr R:
• reviewed Mr X’s diagnosis and whether he should continue to receive services from the CMHT;
• considered Mr X did not meet the criteria for CMHT, nor did he require CMHT treatment or monitoring;
• said that CMHT should keep a close link with Mr X’s GP and offer an assessment if the GP asked for one.
116. Mr X’s GP made referrals to CMHT on 4 August and 6 September 2017. Another consultant psychiatrist (Dr D) decided on 29 August and 7 September 2017 that there was no role for CMHT and that Mr X should stay under the care of RESET.

My analysis

117. I have found no evidence of fault in the way CMHT staff behaved during appointments with Mr X, for example using their telephone. I consider that CMHT provided appropriate appointment information to Mr X. Miss X and other organisations referred Mr X for social care support and Mr X’s GP referred him for an Autism assessment, so there was no fault in CMHT not referring him as well.
118. Other than one cancelled appointment in July 2016, CMHT offered Mr X regular monthly or fortnightly appointments between January and September 2016. CMHT also:
• assessed Mr X’s mental health needs and suggested a trial of antipsychotic medication;
• arranged a mental health review at home when there were concerns about his behaviour;
• provided advice about what to do in a crisis;
• regularly enquired about substance misuse and asked for urine drug tests as evidence of abstinence; and
• monitored Mr X’s mental state regularly.
119. I therefore consider there was no fault in CMHT’s care and treatment of Mr X between January and September 2016.
120. Mr X and Miss X made several requests for CMHT to refer Mr X to a specific PD service. Records indicate that CMHT told Mr X the PD service would not accept a referral until he could show he was drug-free for a long but unspecified period of time. However, there is no record the PD service told CMHT that it would not accept a referral without a long period of abstinence. The PD service’s criteria for accepting referrals say that candidates who use drugs may not be suitable for the service, but drug use would not necessarily exclude them from assessment or consultation.
121. The PD service’s criteria also say that all referrals must be made with the agreement of a patient’s consultant psychiatrist.
122. The information I have seen indicates that CMHT could have referred Mr X to the PD service but had decided not to, because of his drug use. It would have been more accurate for CMHT to have told Mr X this was the case at the time. In response to our enquiries, the Trust has added that a referral to the PD service was also not appropriate at the time because Mr X would not take anti-psychotic medication and had been abusive towards staff.
123. While CMHT could have referred Mr X to the PD service, the Trust has given cogent reasons for its decision not to make the referral. At the time, Mr X had used drugs recently and frequently and had voiced delusional beliefs, for which he did not want to try medication. It is therefore likely that the PD service would not have accepted a referral at the time. Therefore, I consider there was no fault in CMHT’s decision not to refer Mr X to the PD service between January and September 2016.
124. National guidance applicable between January and September 2016 (the National Service Framework for Mental Health 1999) says people with coexisting drug addiction and mental illness can receive either primary (GP) or secondary (specialist) care. The Trust’s internal policy also says that CMHT may discharge a patient to their GP and/or other services when a consultant or “senior clinician” considers this appropriate. When CMHT decided to discharge Mr X from its care in September 2016, it considered:
• Mr X has consistently refused to trial medication and drug screening;
• CMHT had little further to offer Mr X; and
• Mr X could access the care he needed through his GP and RESET.
125. CMHT explained its decision to Mr X in person and by letter. It also wrote to his GP and referred him to RESET. As part of its discharge letter it explained Mr X should attend Accident & Emergency if he experienced a crisis.
126. CMHT acted in accordance with national guidance and local policy and considered the relevant issues when deciding to discharge Mr X from its care in September 2016. I have found no fault in the way CMHT reached its decision or communicated it to Mr X.
127. Mr X’s GP sought a ‘second opinion’ of CMHT’s decision to discharge Mr X. The Trust asked its clinical director for adult mental health services, a senior experienced doctor, to provide this. The doctor reviewed the available records and concluded that Mr X did not meet the criteria for further CMHT involvement at the time, but that CMHT should offer him a further assessment if his GP asked for one. I have found no fault in the second opinion.
128. However, Mr X’s GP did ask for further assessments in August and September 2017. This was about a year after Mr X’s discharge from CMHT and about six months since a psychiatrist had written to CMHT with his concerns that Mr X had exhibited symptoms which could be drug-induced psychosis or schizophrenia at an Autism assessment. Mr X had also been detained under Section 2 of the Mental Health Act 1983 in May 2017. CMHT refused the GP’s referral without providing a reason other than referring to the second opinion letter, which predated the Autism assessor’s concerns, and the Section 2 detention. The Trust has not explained how and why it decided to refuse the GP referrals, despite:
• the second opinion letter of 16 February 2017 stating a further assessment should be offered; and
• the Autism assessor’s concerns of March 2017 and the Section 2 detention of May 2017 adding further weight to the GP referrals.
129. The Trust acted with fault in refusing the GP referrals for CMHT assessment in light of the events of March and May 2017, without a clear explanation of its reasons for doing so against the advice of its clinical director.
130. However, between September 2016 and March 2018, Mr X was under the care of RESET where he had regular appointments with keyworkers and access to a psychiatrist, who monitored his mental state and discussed his drug use. Soon after RESET discharged Mr X in 2018, CMHT again took on responsibility for his care and treatment. It is unlikely that Mr X would have been accepted for treatment by CMHT and RESET at the same time. Therefore, while Mr X would have been left with doubts about having missed out on a chance to return to CMHT’s care sooner, I consider that Mr X did not lose out on services as a result fault in the way the Trust dealt with the GP referrals of August and September 2017.

The Trust – decisions not to admit Mr X to hospital

131. Miss X complains about decisions not to transfer Mr X from A&E to a psychiatric unit in November 2016 and January 2017.
132. On 18 November 2016, Mr X was brought by police and paramedics to RESET following a crisis. The doctor who first saw him and spoke to police and paramedics described him as being “floridly psychotic” and advised the police and paramedics to take him to A&E for a psychiatric assessment. Mr X was unwell enough for the police to consider detaining him under section 136 of the Mental Health Act 1983. Mr X was seen by the Trust’s psychiatrist when he got A&E. The doctor who saw him spoke to Mr X, the police officers who brought him to A&E, and Miss X. Having done so, the doctor admitted Mr X to a psychiatric ward under the care of Dr G. Mr X stayed on the ward as a voluntary patient. He left and returned to the ward several times during his admission. His mental state improved significantly. This could have been because while he was in hospital, he was not using drugs and had taken antipsychotic medication. Mr X was discharged on 24 November 2016.
133. Mr X returned to the ward on 26 November 2016. The Trust’s case notes say he appeared paranoid and was carrying a piece of wood with nails in it. The note says staff advised him to go to A&E and that they called the police, who had earlier attended an incident at his home. Mr X’s neighbour took him to A&E, but Mr X left because there was a long waiting time. When Mr X went to his father’s house, Miss X called the police and an ambulance, who took him to A&E. A psychiatric doctor (Dr C) acting on behalf of the Trust saw Mr X in the early evening. Dr C’s impression was that Mr X had psychosis in the context of drug use. Dr C’s plan was to admit Mr X to a psychiatric ward as an informal patient and to liaise with RESET. Dr G, who had been responsible for Mr X’s care on the psychiatric ward a few days earlier, contacted Dr C’s team stating that Mr X should not be admitted to hospital and that he did not need inpatient care. Dr G told Dr C she considered that Mr X’s problems were drug induced and that he did not benefit from being on the psychiatric ward. Dr C decided not to admit Mr X to hospital as a result of Dr G’s advice. Later that evening, Mr X was discharged from A&E with an updated plan for him to engage with RESET and for police to manage any criminal behaviour.
134. On 1 January 2017, the police brought Mr X to A&E after he had reported feeling paranoid and having been on a drugs binge. A doctor from the Trust’s psychiatric liaison team assessed Mr X and gave him medication to treat anxiety. The doctor re-assessed Mr X an hour after giving him the medication and considered he was well enough to be discharged. The doctor also referred to Dr G’s advice of 26 November 2016 and discussed the situation with Mr X and Miss X before discharging Mr X.
135. Mr X attended A&E again the next day. Another doctor assessed him and concluded that he had psychotic symptoms due to drugs. The doctor also considered there was a risk Mr X could be violent towards others and was himself vulnerable to being attacked because of his provocative behaviour. The assessing doctor discharged Mr X from A&E after referring to Dr G’s advice of
     26 November 2016.
136. Mr X was admitted to hospital the next day, after attending RESET whilst experiencing a mental health crisis. His RESET keyworker had written a letter supporting hospital admission. Mr X’s mental state improved after two days and he was discharged six days later.
137. Miss X reports that while Mr X was experiencing crises between late November 2016 and early January 2017:
• he experienced significant distress as a result of being refused inpatient treatment; and
• she experienced threatening behaviour and damage to property by Mr X, as well as increasing demands from him for support at times when she felt at risk from him. She was distressed and exhausted because of this.
138. Where a person attends A&E in a state of distress, the decision whether to admit them to hospital should be based on a doctor’s clinical judgement following an assessment of the patient and relevant risks at the time. It should not be based on the views of a doctor who has not seen the patient at the time. Dr G had not assessed Mr X in person on 26 November 2016 or 1 and 2 January 2017. The evidence was that Mr X had benefited from his hospital admission earlier in November 2016 because his mental state had improved considerably by the end of the admission. The Trust’s decisions not to admit Mr X to hospital on 26 November 2016, 1 and 2 January 2017 were influenced significantly by advice from a doctor who had not assessed him in person on the days he had attended A&E. This was fault. As a result, Mr X missed out on the opportunity for hospital admissions which may have benefited him at the time. He and his sister suffered significant avoidable distress as a result.
139. I have made a recommendation below for the Trust to remedy the injustice to
     Mr X and Miss X and to review its practice to prevent similar problems happening again.

The Trust – Autism assessment

Background summary

140. Autism is a developmental condition which affects the way a person interacts and communicates with others and perceives and makes sense of the world. The way that autism is expressed can differ with the presence of other conditions.
141. In June 2016, the Trust wrote to Mr X’s GP to advise Mr X had been added to the waiting list for an autism assessment. The Trust wrote to Mr X in November to apologise for the delay in assessment and to tell him he would receive an appointment in the New Year.
142. In February 2017, the Trust carried out an assessment and a diagnostic interview with Mr X over two days about a fortnight apart. The assessment, carried out first, looked at Mr X’s history. The assessor decided not to carry out an activity called “Autism Diagnostic Observation Schedule Module 4” (an assessment used to observe social behaviour and communication). The assessor considered it would be inappropriate because of Mr X’s possibly intoxicated and delusional state at the time.
143. The report of the assessment, written in March 2017, concluded that the psychiatrist and OT assessing Mr X did not consider Mr X had an Autism Spectrum Disorder (ASD) although his drug use, psychotic symptoms and difficulties in getting a neurodevelopmental history meant that the assessment was not as rigorous as they would like.
144. The Trust declined Mr X’s request for a second assessment because it considered:
• he demonstrated social and communication skills which ruled out an ASD; and
• the influence of drugs or psychosis is likely to worsen such skills, so assessing Mr X again when he is not under the influence of drugs or psychosis is unlikely to lead to a diagnosis of an ASD.

My analysis

145. Mr X waited about eight months for an ASD assessment. The NHS aims for adults to have ASD assessments within three months of referral. However, this is not a requirement. I consider that the period between referral and assessment in February 2017 was not so long as to amount to fault.
146. NICE has published a clinical guideline 142, Autism spectrum disorder in adults: diagnosis and management (2012) (CG142). CG142 says adult autism assessments should:
• be done by a team of trained and competent professionals;
• where possible, get information about behaviour and early development from an ‘informant’ such as a family member;
• assess autistic traits and sensitivities (sometimes called signs and symptoms); and
• consider using a formal assessment tool if the assessment is more complex.
147. There was no fault in the way the Trust carried out the assessment because:
• the process was in accordance with CG142;
• the assessors considered whether Mr X’s beliefs could be intense autistic beliefs. However, they concluded they were delusional beliefs instead, based on the information available at the time; and
• the assessors have explained why they did not consider Mr X was autistic.
148. The diagnosis of autism is a matter of professional opinion, based on the information available at the time. There is no fault in the way the assessors reached their opinion, or in the opinion itself.
149. In June 2017, Miss X disagreed with the outcome of the assessment and asked for a fresh one. The Trust refused because it was satisfied that Mr X showed social communication skills during assessment which ruled out autism. The Trust considers that intoxication may mask those skills but is unlikely to create them.
150. CG142 says that a second opinion or referral to another team should be considered where:
• there is disagreement about the diagnosis;
• the person has a complex coexisting condition such as a severe mental disorder.
151. In this case, the assessment report said the assessment was not done with the rigour the assessors would prefer because of Mr X’s possibly intoxicated and delusional state at the time. It also said that in this case, “the differentiation… between drug induced psychosis as opposed to schizophrenia is not entirely clear”.
152. There was fault in the Trust’s decision to refuse a fresh assessment or second opinion because:
• while the original assessment was not flawed, it was complicated by a potential coexisting condition and possible intoxication and did not include a module the assessors would normally complete;
• Mr X and Miss X disagree with the outcome of the assessment and have not had an opportunity to read and comment on the detailed assessment report; and
• the Trust has not provided a clear explanation as to why it considers the symptoms and behaviour Mr X had during the assessment, and in particular intoxication, would not mask autism.
153. I consider that this has led Mr X to miss out on a fresh assessment or second opinion with either a different outcome or a more definitive explanation as to why he is not autistic. I have made a recommendation below for the Trust to remedy Mr X’s injustice.

The Trust – complaint handling

154. Miss X complained in December 2016. The Trust responded on 9 March 2017. The response included the following comments:
• Ms Y referred Mr X to RESET on 5 September 2016. However, there was an administrative error which meant the RESET did not act on the referral until 26 September 2016. The Trust apologised for this delay.
• Mr X attended the accident and emergency department and a decision was made to admit Mr X. However, the decision was reversed after speaking with Mr X’s psychiatrist. The Trust apologised for the confusion caused by the change of decision.
155. The Trust’s response includes apologies for:
• the distress to Miss X and Mr X resulting from Mr X’s care and treatment by the CMHT and RESET;
• the delay in the complaint response.
156. On 30 June 2017, the Trust held a meeting to discuss Miss X’s ongoing concerns.
157. On 13 October 2017, the Trust wrote to Miss X with an update on the action points from the meeting of 30 June. It confirmed that it had had removed some references to Mr X being violent and racist from the minutes of the meeting of 30 June as requested by Miss X. In response to our enquiries, the Trust has also agreed to add Mr X and Miss X’s comments to any records they believe are inaccurate.
158. I consider that the time the Trust took to respond to Miss K’s complaints was not fault. This is because the complaints were complex and required the Trust to coordinate responses from several teams within the Trust and Council. The Trust has apologised to Miss X for the delays in complaint handling. Even if we had found fault, the Ombudsmen would not ask for more as a remedy for the problems caused by the delay.
159. I have found no evidence of fault in any other elements of the Trust’s complaint handling.

Back to top

Agreed actions

160. The Council will, within a month of the date of my final decision, write to Mr X and Miss X to apologise for each of the faults identified in this decision and the effect of the faults on Mr X and Miss X.
161. The Council will, within two months of the date of my final decision:
1. ensure any ongoing care and support plans for Mr X and Miss X are up to date;
2. pay Mr X £750 in recognition of the avoidable delay in receiving an assessment of social care needs and the social care support he needed;
3. pay Miss X £400 in recognition of:
• the avoidable time and trouble she had to go to, in order to ensure she and
  Mr X received social care assessments and support; and
• her lost opportunity to receive support as a carer.
162. Some of the faults we have identified in services the Council is accountable for happened a long time ago. We recognise that practice and policy may have changed and improved since then. The Council should, within three months of the date of my final decision, send evidence to the Ombudsmen of the steps already taken, or of an action plan for changes, to prevent a recurrence of the faults we have identified with:
• delays in social care assessments and carers’ assessments;
• failing to provide an accurate care plan;
• agreeing reablement goals;
• failing to arrange timely care plan reviews or reassessments of care needs;
• the Council not having access to records of the drug treatment services it commissioned;
• communicating with service users about decisions to adjourn or no longer pursue applications for residential rehab treatment.
163. The Trust will, within a month of the date of my final decision, write to Mr X and Miss X to apologise for each of the faults identified in this decision and the effect of the faults on Mr X and Miss X.
164. The Trust will, within a month of the date of my final decision, either:
• provide a clear and comprehensive explanation to Mr X (or Miss X on his behalf) of its reasons for refusing a second autism assessment. This should include a clear explanation why the Trust considers that intoxication may mask social communication skills but is unlikely to create them; or
• provide a second opinion on the autism assessment; or
• place Mr X on the waiting list for a fresh assessment with different assessors.
165. The Trust will, within two months of the date of my final decision:
• pay £500 to Mr X in recognition of the missed opportunities for hospital admissions in late 2016/early 2017 and the resulting avoidable distress;
• pay £500 to Miss X in recognition of the avoidable distress she suffered as a result of the missed opportunities for Mr X to be admitted to hospital; and
• discuss our decision with the clinicians involved in the matters complained of so they can reflect on it as part of their supervision.
166. The faults we have identified in the way the Trust dealt with Mr X’s requests for admission to hospital happened three years ago. We recognise that practice and policy may have changed and improved since then. The Trust should, within three months of the date of my final decision, review its current practice and policy and send the Ombudsmen:
• either evidence of the measures that are already in place to prevent similar faults happening again; or
• an action plan for changes to prevent a recurrence of the faults we have identified.
167. The Trust will also send a copy of any action plan to the complainant, the Care Quality Commission and NHS Improvement.

Back to top

Final decision

168. The Ombudsmen have upheld some of Miss X’s complaints about the Council’s and Trust’s adult social care, substance misuse and mental health services. The Council and Trust have agreed to implement my recommendations. I have therefore completed my investigation.

Back to top

Parts of the complaint that I did not investigate

169. I have not investigated events that pre-date 2016. Miss X first approached the Trust in December 2016. She does not appear to have done so before this date, although she was aware of the matters causing her concern at the time. Therefore, I cannot see a good reason to investigate matters that occurred more than 12 months earlier.

Back to top

Investigator's decision on behalf of the Ombudsman