The investigation

The complaint

5. Mr and Mrs X complain on behalf of themselves and their daughter, Miss X. They complain about the actions of:

• London Borough of Croydon (the Council);

• South London and Maudsley NHS Foundation Trust (the Trust); and

• NHS South West London Clinical Commissioning Group (the CCG).

6. Mr and Mrs X complain about the following.

A failure of the Trust to refer for supported living accommodation

7. Mr and Mrs X complain the Trust did not refer Miss X for supported living accommodation, as agreed with a Child and Adolescent Mental Health Service (CAMHS) in 2017. The complainants said this led to Miss X missing an opportunity to live independently with suitable support.

A failure of the Trust to place important documents on Miss X’s files

8. Mr and Mrs X complain the Trust failed to place important documents on Miss X’s clinical files, after it agreed to do this in 2017 as part of an earlier investigation by the Ombudsmen. The complainants are concerned this may have an impact on future health and social care decisions.

A failure of the Trust to adequately protect Miss X from known risks

9. Mr and Mrs X complain about actions the Trust took when providing aftercare under section 117 of the Mental Health Act 1983 on behalf of the Council and CCG. They complain the Trust did not provide Miss X with a crisis plan, or give Mr and Mrs X enough support in managing her risks. Mr and Mrs X say the Trust,

CCG and Council have a flawed policy of not sharing information with carers without a patient’s consent, even when there is a risk of danger to the patient or others. The complainants say this meant:

• Miss X faced unnecessary risk and suffered avoidable distress; and

Mr and Mrs X found managing Miss X’s risks difficult and stressful because of inadequate information and support.

• A failure of all organisations to provide timely and accurate information

10. Mr and Mrs X complain the Council, Trust and CCG failed to ensure they and Miss X got timely and accurate access to information relating to Miss X’s section 117 aftercare. They say that because of this:

• they have not had all the information they need to understand whether the aftercare is adequate and to make timely requests for extra services that may be of use to Miss X;

• Miss X has missed an opportunity to have more control over her section 117 aftercare through a Personal Health Budget;

• they have all suffered financial losses because Miss X missed out on claiming benefits; and

• Mr and Mrs X have been put to avoidable time and trouble.

• A failure by the organisations to provide information about alternative services

11. Mr and Mrs X say:

• a local personality disorder service was unsuitable for Miss X;

• they did not get information about local community alternatives to this service until they complained to the CCG in 2019;

• the CCG’s complaint response gave details of two services that Miss X would have engaged with and benefited from, if the Trust had offered them; and

• the Trust has still not discussed these with Miss X or referred her to them, so she has not been able to access them.

A failure by the Trust to provide family therapy

12. Mr and Mrs X complain the Trust failed to provide family therapy as part of Miss X’s section 117 aftercare. Mr and Mrs X said this made it more difficult for the family to understand and manage Miss X’s risks.

A failure by the Trust to manage a referral to a hospital effectively

13. Mr and Mrs X complain the Trust:

• did not tell the family about hospital A;

• delayed referring Miss X there between February and June 2018; and

• misinformed the family about the process.

14. They say this led to an avoidable delay in Miss X accessing suitable mental health care.

A failure by the Council to support Mr and Mrs X as carers

15. Mr and Mrs X complain the Council’s support for them as Miss X’s carers is inadequate. They said this made it more difficult for them to fulfil their caring role.

Inappropriate comments in a report by the Trust in June 2018

16. Mr and Mrs X said the Trust made negative unsubstantiated comments about them in a report, causing them distress.

Care provided to Miss X by another NHS Trust

17. Mr and Mrs X complain about a placement Miss X had at a hospital run by another NHS Trust.

Desired outcomes

18. The complainants would like the following outcomes, should an investigation by the Ombudsmen uphold their complaints.

• The Council, Trust and CCG to improve their approach to managing people with a personality disorder safely in the community.

• All three organisations to acknowledge where there have been flaws and apologise for their impact on the complainants, including individual apologies to Miss X.

• Financial redress to recognise avoidable distress, private therapy costs and the financial impact of Miss X’s lost opportunity to claim benefits earlier.

Legal and administrative background

19. 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.)

20. 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).) Mr and Mrs X were aware of some issues they complained about more than 12 months before complaining to the Ombudsmen. However, they have provided good reasons for not complaining to us earlier. We have therefore exercised the discretion available to us to investigate what happened between May 2017 and the end of January 2020.

21. When investigating complaints, if there is a conflict of evidence, the Ombudsmen may make findings based on the balance of probabilities. This means that during an investigation, we will weigh up the available evidence and base our findings on what we think was more likely to have happened.

22. The Ombudsmen provide a free service, but must use public money carefully. They may decide not to start or continue with an investigation if they believe they cannot achieve the outcome someone wants. (Health Service Commissioners Act 1993, section 3(2) and Local Government Act 1974, section 24A(6), as amended.)

23. The Ombudsmen investigate complaints about ‘maladministration’ and ‘service failure’. In this report, we have used the word ‘fault’ to refer to these. We must also consider whether any fault has had an adverse impact on, or caused hardship to, the person making the complaint. We refer to this as ‘injustice’. If there has been fault which has caused an injustice, we may suggest a remedy.

(Health Service Commissioners Act 1993, section 3(1) and Local Government Act 1974, sections 26(1) and 26A(1), as amended.)

24. The Ombudsmen may investigate, and question the merits of, action taken in the exercise of clinical judgement.

What we have investigated

25. We have investigated the complaints summarised at paragraphs 7 – 15 above. We have explained at the end of this report why we have not investigated the complaints summarised in paragraphs 16 and 17.

How we considered this complaint

26. We produced this report after examining relevant documents and interviewing the complainants.

27. We considered the following as part of our investigation:

• information the complainants have provided by telephone and in writing. This includes records of an assessment of Miss X’s eligibility for a Personal Independence Payment (PIP) and the resulting award certificate;

• written information and documents from the Council, Trust and CCG, including health records from the period of the complaint;

• advice from a mental health nurse and a psychiatrist with extensive experience of mental health services who have no connection to the matters complained of; and

• relevant law and guidance, which we refer to under each complaint heading where we have relied on it.

28. We gave the complainants, the Council, the Trust and the CCG a confidential draft of this report and invited their comments. We took the comments received into account before finalising the report.

What we found

29. Miss X was taken into care aged five and had a series of placements until Mr and Mrs X adopted her as an older child. She is now a young adult.

A – supported living referral

30. Supported living is an alternative to residential care or living with family that enables adults with disabilities to live in their own home, with the help they need to be independent. When a person moves into independent living accommodation, they usually sign a tenancy agreement for their own house or flat. People have security of tenure and cannot be moved against their will without a breach of tenancy. Accommodation could be part of an independent living community or a stand-alone property owned and managed by the local authority or an independent provider.

31. The complainants say the Trust did not refer Miss X for supported living accommodation, as agreed with the Trust’s CAMHS service. Miss X says she consented to the referral many times and was told her parents would have to make her homeless for it to be considered. She says the lack of referral meant she missed the opportunity to live independently with suitable support. The complainants are all clear that Mr and Mrs X were at no point asking, or forcing, Miss X to leave the family home. While Mr and Mrs X were happy for her to continue living there, Miss X at the time felt that living away from home would help improve her relationship with her parents. Her parents say they would have supported her in that decision but were not pressing for supported accommodation. In commenting on a draft version of this report, Miss X told us she considers that, if it was not for her parents, she would not be alive today, let alone be on a successful pathway to starting university.

2017

32. In response to our enquiries, the Trust has told us:

• CAMHS agreed to apply for supported living in 2017, when Miss X’s care was transferring from CAMHS to adult services;

• there is no record that CAMHS or adult services completed the referral; and

• there is no reason in Miss X’s records explaining why neither CAMHS nor adult services completed the referral.

33. The failure to refer Miss X for supported living accommodation in 2017 was fault by the Trust.

2018

34. The Homelessness Reduction Act 2017 took effect in April 2018. Therefore, the Council and Trust agreed a new process for the Trust to use when referring people for supported living accommodation. The Council decided that from April 2018, it would only provide supported living accommodation to people it accepts are homeless, or to those who can move from high cost residential care funded by the Council. The Council is entitled to allocate supported living accommodation in this way. However, it needs to consider properly whether the applicant is homeless, including the following questions.

• Is accommodation available to the person?

• Do they have a legal right to occupy the accommodation?

Is it reasonable for them to continue to occupy it?

• This means that, even if a person has accommodation they are allowed to stay in, they can be considered homeless if it is not reasonable for them to carry on living there.

35. After discussing Miss X’s needs with a Council housing officer, the Trust emailed a supported living referral to the Council in April 2018. The Trust followed this up in May 2018. The Trust’s referral did not follow the new process. However, it gave a detailed summary of Miss X’s mental health and social history and why it may not be reasonable for her to continue living with her parents. There is no evidence the Council responded. This is fault. Further, there is no evidence the Trust followed this up, and this is also fault.

2019

36. On 15 January 2019, the Trust told Mrs X that she and Mr X would have to state in writing that Miss X cannot live with them, “for Housing to do anything”. This advice was wrong because it did not explain that a person can be considered homeless if it is not reasonable for them to stay in their present accommodation. It is more likely than not the Trust’s advice to Mr and Mrs X was based on advice from the Council. This was fault by both the Council and the Trust.

37. Miss X’s parents refused to write a letter stating she could no longer live with them. This is understandable in light of Miss X’s health and past experiences

including those relating to abandonment. There was no further progress for the rest of 2019. Had the Trust and Council not given the wrong advice, it is possible there could have been some progress.

2020

38. The Trust contacted the Council about supported accommodation again in February 2020. The Trust’s records say that a Council supported housing officer told Miss X’s care coordinator the Council would not accept a referral for supported accommodation unless Miss X was “registered as homeless”. As in early 2019, this was not in line with the Homelessness Reduction Act. There is no evidence the Council explained to the Trust that Miss X could be considered homeless, without the need for her parents to ask her to leave home, if her situation meant it was not reasonable for her to continue living with them. This was fault.

Summary of findings relating to complaint A

39. We have found the following faults:

• the Trust failed to refer Miss X for supported living accommodation in 2017 after it recognised the need for a referral;

• the Council failed to act on the Trust’s referrals of April and May 2018;

• the Trust failed to follow up its referrals of April and May 2018;

• the Council and Trust collectively failed to provide accurate advice during 2018 and 2019; and

• the Council’s and Trust’s faults led to missed opportunities for the Council to consider referrals under the system in place before April 2018, as well as under the new process.

40. Because of these faults:

• Miss X missed an opportunity to have her eligibility for supported living considered under the systems in place before and after April 2018;

• Miss X did not have accurate information about accessing supported living accommodation; and

• Mr and Mrs X suffered distress because of the advice that they should state in writing that Miss X could no longer live with them.

  41. We cannot say, even on balance of probability, whether Miss X would have moved into supported accommodation between 2017 and 2020 had there been no fault. This is because:

• the Council may not have accepted a referral in 2017 or referrals with homelessness applications since 2018; and

• we do not know whether Miss X would have accepted and stayed in any placement offered to her.

42. However, Miss X has missed out on several opportunities to have her need for supported living accommodation properly considered. Further, this has left her with uncertainty about whether she may have missed out on accommodation with support. We cannot say whether supported accommodation would have led to a tangible improvement in Miss X's health. However, her belief that it may have done is not unreasonable and so, she has been left with understandable uncertainty about whether, without these collective failings, she would now be in better health.

43. We have recommended remedies and service improvements at the end of this report.

B – placing documents on clinical files

44. The complainants say the Trust has failed to place important documents on Miss X’s clinical files. They are concerned that any future reviews of Miss X’s mental health history will be based on incomplete information, which may have an impact on future health and social care decisions.

45. The Trust agreed to add documents provided by Mr and Mrs X to Miss X’s clinical files in November 2017. At the time, the Ombudsmen were considering a different complaint from her and her parents. The Trust has provided evidence that it added a large number of documents on the same day it told us it would do so, in November 2017. However, it cannot find evidence of nine of the documents Mr and Mrs X provided, including one which Mr and Mrs X consider to be particularly important.

46. In failing to add all the documents Mr and Mrs X provided, the Trust has not completed a commitment it made to the Ombudsmen. This is fault.

47. This fault led to avoidable distress for all three complainants, caused by their worry about practitioners having incomplete and misleading information. It also caused Mr and Mrs X avoidable time and trouble in trying to resolve the matter.

48. We have recommended remedies at the end of this report.

C – crisis plan, support to Mr and Mrs X for managing Miss X’s risks, not sharing information with Mr and Mrs X

49. The complainants say that:

• when providing section 117 aftercare on behalf of the Council and CCG, the Trust did not provide Miss X with a crisis plan or adequate support to Mr and Mrs X in managing her risks; and

• the organisations have a flawed policy of not sharing information with carers unless the patient agrees, even when there is a risk of danger to the patient or others.

50. They say this has caused the following problems.

• Miss X has been placed at unnecessary risk and suffered avoidable distress, including repeated detentions by the police under section 136 of the Mental Health Act 1983.

• Mr and Mrs X have found managing Miss X’s risks difficult and stressful because of inadequate information and support.

Crisis planning

51. The Care Programme Approach (CPA) is the process by which mental health services assess a patient’s needs, plan how to meet them and ensure they are met. Under ‘Refocusing the Care Programme Approach’ published by the Department of Health in 2008 (CPA Guidelines), people under the CPA should have:

• a comprehensive needs assessment;

• a risk assessment and risk management plan;

• explicit crisis and contingency plans; and

• a process for reviewing their needs and care plans regularly and at least once a year.

52. Trusts should offer copies of the plans to the service users and, if appropriate, their carers.

53. In 2009 The Department of Health issued guidelines called ‘Best Practice in Managing Risk Principles and Evidence for Best Practice in the Assessment and Management of Risk to Self and Others in Mental Health Services’ (Risk Guidelines). These say that the risk management plan should be made in collaboration with the service user and carers. It should include:

• a summary of all risks identified;

• situations in which the risks might happen; and

• actions to be taken by professionals and the service user in response to crisis.

54. The police can use section 136 of the Mental Health Act 1983 to take a person to a ‘place of safety’, if they think the person has a mental illness and needs ‘care or control’. A place of safety is usually a hospital.

55. Miss X’s condition means there are times her behaviour puts her at risk. Her risky behaviour in 2017 and 2018 was at times extreme and there were occasions where it put her at risk of accidental death.

56. The Trust says it completed Miss X’s Care and Risk management plan following its own guidance around service users on CPA who receive section 117 aftercare. However:

• the Trust has not provided a copy of the Care and Risk management plan it refers to; and

• the evidence the Trust has given us indicates it did not produce its own guidance on section 117 aftercare until October 2018, about 17 months after the start of the period this complaint relates to.

57. The Trust completed more than 30 documents it refers to variously as ‘risk assessments’ and ‘risk crisis plans’ for Miss X between May 2017 and January 2020. There is no evidence the Trust developed these in collaboration with Miss X. The Trust also prepared care plans in 2018, 2019 and 2020. These care plans:

• include some information about crisis and contingency plans; and

• were sent as letters to Miss X’s GP practice. The letters state that copies have been sent to Miss X.

58. Most of the crisis arrangements in these documents involved contacting the emergency services or the Trust’s crisis telephone line. There were some individual arrangements in light of specific incidents or hospital admissions. The Trust has told us that most of its crisis planning was reactive rather than preventative.

59. The Trust says it tried to complete a Recovery and Support Plan twice in July 2017 and once as part of Miss X’s CPA review in April 2018. It says Miss X “did not fully engage in this formal approach to care and crisis planning”. The Trust says that Miss X has not had a CPA review since April 2018, but she has a care plan dated 25 November 2019, which she and her care coordinator have agreed. The Trust also says it completed an agreed individualised care plan for Miss X in January 2020, which includes crisis and contingency planning. It has no record of whether it has shared this with Miss X’s family.

60. The Trust has no record of sharing written copies of Miss X’s risk assessments and resulting crisis plans with Miss X. This lack of records supports the complainants’ account that they did not receive written copies of these documents. We therefore consider it more likely than not, that the Trust failed to share these documents with Miss X.

61. There is evidence the Trust carried out risk assessments and some crisis planning for Miss X. However, it acted with fault in:

• having no records to show how it worked collaboratively with Miss X as part of its risk assessment and management;

• failing to hold CPA reviews at least annually; and

• not sharing copies of all relevant documents with Miss X.

62. We will address the overall injustice to Miss X and her parents at the end of section C.

Sharing information with Mr and Mrs X

63. The Trust says that, since 2017, it has worked with Miss X as an adult who is able to make decisions about her treatment and care. It also says that Miss X’s care coordinator:

• frequently reviewed and checked Miss X’s wishes about confidentiality;

• offered her family opportunities to communicate with him by telephone and email about a range of issues, separately from his contact with Miss X;

• was aware of the risks and explored with Miss X how to communicate these to her family when the risks reached a point he believed her parents would need to be informed; and

• clearly told Miss X and her family that he would disclose information to her family against Miss X’s wishes when he judged it necessary.

64. The Trust has told us that information sharing with Mr and Mrs X has been inconsistent, but this is because it had to respect Miss X’s varying wishes about the degree of information she was willing to share with them.

65. The evidence we have seen supports the Trust’s account of sharing information with Miss X’s parents.

• The Trust involved Miss X’s family in crisis planning conversations in July and August 2017.

• Miss X experienced several mental health crises in May 2018 and when seeing professionals about some of these she declined to share information with her family. In late May and June 2018, Miss X had further crises where she allowed professionals to involve her family in conversations about discharge and crisis planning.

• In September 2018, Miss X agreed that the Trust could only share limited information with her family. The Trust informed Mr and Mrs X of a serious risk incident that happened that month.

• The Trust communicated with Mr and Mrs X in October 2018 by email about Miss X’s current difficulties and medication.

• Miss X did not want her family informed about crises she experienced in January, February, October and November 2019, but agreed for her parents to be involved in arranging a planned hospital stay and for them to be informed about a planned appointment in November 2019.

• In December 2019, the Trust contacted Miss X’s family and her GP following events which may have carried a risk to Miss X.

66. In summary, there were times when Miss X asked the Trust not to share information with her parents, and the Trust respected her wishes. This was in line with the Royal College of Psychiatrists guidelines called ‘Good Psychiatric Practice Confidentiality and Information Sharing’ (3rd edition), published in 2017 as well as Triangle of Care guidance. Both guidelines state that, in general, information should only be shared with the patient’s consent. There were occasions when the Trust put Miss X’s safety first and shared information without her consent. Again, this was in line with relevant guidance and not fault. I have found no fault with the organisations’ policies around information sharing.

67. While we have not found fault with the Trust’s general approach, we have found fault in two specific events.

• Miss X gave permission for the Trust to share a copy of her CPA record of 18 April 2018 with her family. There is no evidence the Trust sent them a copy. This was fault.

• On 6 February 2019 Miss X disclosed information to the Trust which indicated a potential risk to her parents. We have found no evidence the Trust explored this further with Miss X or the wider team involved in her care, or informed Mr and Mrs X. This was fault. Fortunately, there is no indication that Mr and Mrs X suffered any harm as a result.

Support to Mr and Mrs X in managing Miss X’s risks

68. The Risk Guidelines say carers should be:

• offered an assessment; and “helped to develop a plan for meeting their own specific needs”.

69. The Risk Guidelines also say that carers “should receive enough information in a comprehensible format to enable them to provide the necessary care”.

70. The Carers Trust published guidance in 2013 called “The Triangle of Care, Carers Included: A Guide to Best Practice in Mental Health Care in England” (Triangle of Care guidance). The Trust references this guidance in its family and carers strategy 2015-2019. The guidance makes a distinction between:

• engaging with carers (such as providing them with general information, including support available to them as carers); and giving carers confidential information about the patient.

71. The Trust has told us that information sharing with Mr and Mrs X has been inconsistent, but this is because it had to respect Miss X’s varying wishes about the degree of information she was willing to share with them.

72. While the Trust engaged with Mr and Mrs X, it did not give them enough information about services and support available specifically to them. The Trust has acknowledged that it recorded much of Miss X’s family’s involvement in risk and care planning within its daily records rather than within any formal review process. These were faults. The Trust has apologised for the “gap in any consistent formal involvement and recording of the level of involvement of [Mr and Mrs X in Miss X’s] risk assessment and crisis planning”.

Summary of fault and injustice relating to crisis planning and information sharing

73. The Trust acted with fault because of:

• flawed record keeping;

• not working collaboratively with Miss X;

• failing to carry out CPA reviews at least annually;

• not sharing written records of crisis and risk management plans with Miss X; and

• failing to address the risk to Mr and Mrs X in February 2019. There was no injustice from this last point.

74. The Trust could not share confidential information with Mr and Mrs X without Miss X’s consent. The Trust failing to share records with Miss X meant she lost the opportunity to choose to share them with her parents. While we cannot say whether she would have chosen to share them at the time, Mr and Mrs X will be left with uncertainty over the benefits of this, had she done so. This is an injustice to them.

75. The records we have seen indicate the police detained Miss X in a place of safety eight times between 2017 and 2019. These will have been distressing incidents for Miss X and her family. The records also show Miss X was distressed for long periods between 2017 and the end of 2019, and there were instances where she suffered harm or was at serious risk of physical harm. We cannot say, even on balance of probability, that Miss X would have suffered less distress and risk of harm if there had been no fault in the Trust’s crisis planning. However, she and her parents are left with a distressing uncertainty about this.

76. We have recommended remedies and service improvements at the end of this report.

D – timely and accurate information about Miss X’s section 117 aftercare

77. The complainants say that the Trust, Council and CCG failed to ensure they were given timely and accurate information about Miss X’s section 117 aftercare, specifically:

• Miss X’s section 117 aftercare plan and review documents;

• the possibility of a Personal Health Budget (PHB) for Miss X;

• how the CCG will meet its statutory duty;

• the process for requesting funding for alternative provision; and

• that Miss X could apply for a PIP.

78. They say this has caused them the following problems.

• They have not had all the information they need, to understand whether Miss X’s provision is adequate and to make timely requests for additional services that may be of use to her.

• Miss X has missed out on an opportunity to have more control over her section 117 aftercare through a PHB.

• They have suffered a financial loss: Miss X did because she missed out on claiming for benefits that she was entitled to, and her parents did because they supported her financially in this period.

• Mr and Mrs X have had to go to the avoidable time and trouble of complaining before being given some of the information they wanted.

79. Under the Mental Health Act 1983, when someone has a mental disorder and is putting their safety or someone else’s at risk they can be detained in hospital against their wishes. This is sometimes known as ‘being sectioned’. Section 3 of the Mental Health Act is for the purpose of providing treatment. People who are discharged from section 3 will not have to pay for any aftercare they will need. This is known as section 117 aftercare. Section 117 aftercare services must:

• meet a need arising from or related to the mental disorder for which the person was detained; and

• aim to reduce the risk of the person's mental condition worsening and the person returning to hospital for the treatment of the mental disorder.

80. The "Mental Health Act 1983: Code of Practice" (the Code) is statutory guidance. This means that councils and CCGs must follow it, unless there are good reasons not to. The Code says section 117 aftercare can include supported accommodation. Aftercare services continue for as long as the person needs them.

81. Councils and CCGs must keep a record of the people for whom they provide aftercare services and what those services are.

82. The Code says that aftercare planning needs to start as soon as a person is admitted to hospital and should be done within the Care Programme Approach (CPA). CCGs and councils “should take reasonable steps” to ensure aftercare services are in place in good time for discharge. The care plan should specify that the person is entitled to section 117 aftercare and state which services will be provided under section 117.

83. CCGs and councils may engage other organisations, such as NHS trusts, to carry out their section 117 duties. However, they cannot delegate their legal accountability to providers. Councils and CCGs retain responsibility for the quality of any section 117 services they commission. If there are faults in how a section 117 service was commissioned or with the oversight of a service, the Ombudsmen may find fault with the relevant council and/or CCG.

Section 117 aftercare plan and review documents

84. Miss X was detained under section 3 of the Mental Health Act in 2015, before she reached 18. Although she moved between hospitals, the Trust’s CAMHS was involved in Miss X’s care. In spring 2017, just before her 18th birthday, the Trust transferred her to an adult ward in one of its hospitals.

85. The Trust, CCG and Council did not have a policy and procedure for section 117 aftercare until October 2018.

86. The Council has told us that it and the Trust carry out periodic audits of the section 117 services the Trust provides on the Council’s behalf.

87. While Miss X was still in hospital, the Trust discussed her care in a team meeting on 4 May 2017. The record from that meeting says “Move-on plans from [ward] needed”. The care coordinator met Miss X on 8 May 2017 and discussed her appeal to the Mental Health Tribunal. A record from the same day says, “following discharge [care coordinator] to book joint appointment with consultant”. This means the Trust was aware from early May 2017, at the latest, that Miss X could soon be discharged from section 3 detention.

88. A Mental Health Tribunal heard Miss X’s appeal against her section 3 detention on 24 May 2017. The judge adjourned the tribunal until 21 July 2017 to allow time for a robust discharge care plan to be put in place. The judge issued a detailed decision statement which included the following comment:

“if a robust care package was in place…[Miss X] could potentially [judge’s emphasis] be discharged to her parents’ home. However, the tribunal had scant evidence of a robust care plan”.

89. When adjourning the tribunal, the judge asked the Trust to produce an addendum report to address the lack of a robust care package.

90. Notes of a ward round meeting of 21 June 2017 between Miss X, her parents, a consultant psychiatrist, two nurses and a doctor state that the psychiatrist decided to discharge Miss X from section 3 detention. Miss X agreed to stay as an informal patient for the time being. The ward formed a loose plan which included the need to look for possible community groups and to continue discharge planning at another meeting. There is no mention of section 117 aftercare and Miss X’s care coordinator was not at the meeting.

91. There is no evidence the Council, or the Trust on behalf of the CCG, complied with their duties under the Mental Health Act and Code to ensure Miss X’s section 117 aftercare was planned before the Trust discharged Miss X from section 3 detention in June 2017. This was fault by all three organisations.

92. The Trust wrote to Miss X on 23 June 2017 to confirm that her section 3 detention ended on 21 June 2017. The letter says she is entitled to free aftercare services provided by the “Trust and the local Social Services Authority, in co-operation with any other relevant agencies”. The letter does not set out which services are part of Miss X’s section 117 aftercare plan, nor does it explain who the local social services authority is. This was contrary to the Care Programme Approach and therefore fault.

93. There was another ward round meeting on 26 June 2017. Present were Miss X, her parents, a consultant psychiatrist, another doctor, a nurse and Miss X’s care coordinator. The record of this meeting does not mention section 117 aftercare and notes the following care plan:

• Miss X will be discharged from hospital on the same day;

• if Miss X has difficulty coping with day to day activities then medication can be considered if Miss X agrees; and the care coordinator “will follow up in the community”.

94. The Trust, CCG and Council have no records of:

• an original section 117 aftercare plan, which should have been prepared in consultation with Miss X (and if appropriate her parents) in advance of her discharge from section 3 detention in June 2017;

• any other care plan which specifies which services Miss X should be receiving as section 117 aftercare; or

• sharing Miss X’s aftercare plans with her.

95. The Trust and Council have shown us copies of care plans for Miss X, but none of them specify the services Miss X should be receiving as section 117 aftercare.

96. The lack of section 117 aftercare planning and general poor record-keeping around section 117 aftercare is fault by all three organisations. Despite there being no record of what constituted Miss X’s section 117 aftercare plan since 2017, neither the Council’s nor Trust’s audits, nor the local complaints procedures, have identified and rectified this. This is even more concerning because Miss X’s parents have been raising concerns about her section 117 aftercare since she became entitled to it.

97. We will address the injustice to the complainants at the end of section D.

Possibility of a Personal Health Budget (PHB)

98. A Personal Health Budget (PHB) is an amount of money that an NHS organisation would normally spend providing or arranging someone’s care which the person can spend in a more flexible way to meet their identified need.

99. Since 2014, people eligible for certain health services have had a legal right to request a PHB. In December 2019, this right was extended to people eligible for section 117 aftercare. CCGs have legal duties to:

• ensure they have systems and processes in place to arrange for the provision of PHBs;

• publicise and promote the availability of PHBs;

• provide information, advice and support to help people to decide whether to request a PHB;

• consider individual requests for PHBs; and

• grant a request unless doing so would not be appropriate in the individual’s circumstances.

100. The relevant legislation and guidance are:

• The National Health Service (Direct Payments) Regulations 2013;

• The National Health Service Commissioning Board and Clinical Commissioning Groups (Responsibilities and Standing Rules) (Amendment) Regulations 2013;

• The National Health Service Commissioning Board and Clinical Commissioning Groups (Responsibilities and Standing Rules) (Amendment) (No. 3) Regulations 2014;

• The National Health Service Commissioning Board and Clinical Commissioning Groups (Responsibilities and Standing Rules) (Amendment) (No. 2) Regulations 2019 [the 2019 Regulations]; and

• “Guidance on the legal rights to have personal health budgets and personal wheelchair budgets”, December 2019.

101. The Trust told us in 2020, nearly a year after the 2019 Regulations came into force, that it could not discuss the possibility of using a PHB with Miss X because PHBs were not available to service users with mental health needs in the area Miss X lives in. This is fault by the CCG, which has been under a legal duty since December 2019 to ensure PHBs and information about them are available to people eligible for section 117 aftercare. As a result, Miss X has lost out on the opportunity to request a PHB since December 2019. We cannot say, even on balance of probability, whether a PHB would have been agreed for any or all services Miss X requested. However, the missed opportunity to exercise her legal right to request a PHB, and the uncertainty about whether she could have had greater control and flexibility in her aftercare is a significant injustice. This was also a missed opportunity to identify that Miss X did not have a section 117 aftercare plan.

102. The CCG told us that:

• it was developing a pilot to introduce PHBs for section 117 aftercare which was intended to go live in April 2020, but it put this on hold due to the COVID-19 pandemic;

• it re-started developing the pilot in 2021; and

• until it develops a more robust process, it considers individual requests for PHBs through a panel.

103. In response to draft versions of this report, the Council and CCG gave us the following extra information:

• the CCG does not have a specific panel that considers PHB requests;

• instead, the CCG uses a “Tertiary Panel” to support specific requests for therapies or care to meet mental health needs that it cannot provide through its commissioned services;

• the Council operates a separate panel which considers requests for allocation of section 117 personal budgets (different from PHBs);

• the CCG does not participate in the Council’s panel or fund any of the provision it agrees because it uses the “Tertiary Panel” instead; and

• together with the Council and Trust, the CCG is establishing a pilot project to test and learn the best approach to administer PHBs. This will start in July 2022 with 10 people. The CCG says it will expand the project following feedback and evaluation.

104. We understand that the COVID-19 pandemic has had a significant detrimental effect on NHS services. However, the CCG should have made PHBs and information about them available by law in December 2019, before the pandemic started. Not doing this is a service failure.

105. We are very concerned that the CCG has failed to comply with its legal duties on PHBs for people eligible for section 117 aftercare since December 2019. This is likely to have caused an injustice to others in its area. Any restrictions on providing PHBs, including limiting the number of people that can access them, need to be in line with relevant law, guidance and general good administrative practice. We have recommended service improvements to address this.

Process for requesting funding for alternative provision

106. The CCG and Trust have told us that the Trust’s care team can apply to the CCG’s “Tertiary Panel” for therapies not available from the Trust’s adult community services. Mr and Mrs X have asked the Trust for therapies they considered may be helpful but were not available through the Trust. We have seen no evidence the Trust explained to them or Miss X how to seek funding for alternative provision. The Trust says it has not had the opportunity to do this because Miss X has not consistently agreed to pursue any alternative therapies.

107. The Trust could and should have given Mr and Mrs X general information about funding for alternative provision in line with the Triangle of Care guidance on engaging with carers. The failure to do this was fault.

108. The failures in section 117 aftercare planning and PHBs, as described above, have led to lost opportunities for discussing and considering alternative provision. A regularly reviewed section 117 aftercare plan and an opportunity to apply for a PHB may have avoided the need to apply to the “Tertiary Panel” or prompted more information about it.

PIP

109. The CPA guidelines state that a care plan may cover a range of support needs, including social inclusion. The Code, in its chapter on the CPA, says that care planning is likely to include considering needs for help with welfare rights and managing finances. We would therefore expect the Trust to have considered Miss X’s need for help with benefits such as PIP as part of her care planning.

110. The Trust says it:

• referred Miss X to its Community Opportunities Service (COS) in 2018. The service could have provided support with benefits, but the Trust says Miss X did not engage with it regularly at the time;

• discussed applying for benefits with Miss X in May 2019, re-referred her to COS and provided support with her PIP application in July and November 2019; and

• helped Miss X with a bus pass application in September 2019 and January 2020, in response to a request Miss X’s family made the previous month.

111. The complainants say the Trust did not help with Miss X’s 2019 PIP application and its input was limited to providing, on request, a copy of its referral letter to Hospital A. They say the Trust also failed to mention Miss X’s history of seizures since 2017, even though these added significantly to her risks.

112. The Trust has not provided evidence of its referrals to COS. There is also no evidence it acted in accordance with guidance by considering Miss X’s need for help with benefits before 2019. These were faults.

Injustice resulting from faults in section 117 aftercare planning

113. Section 117 aftercare is a legal entitlement put in place to help people recover and stay out of hospital. Miss X has lost out on this legal entitlement for about four years. This is despite having dedicated and knowledgeable parents who more than once alerted the organisations responsible for her care about the problem. She has also lost out on a legal entitlement to have a PHB application considered for about two years. The loss of these legal entitlements, and the associated frustration, is an injustice.

114. Miss X and her parents have also experienced avoidable distress because of the uncertainty about whether Miss X could have received more, or different, support had she had a regularly reviewed care plan specifying section 117 aftercare and a PHB in place. We cannot say whether Miss X would have engaged with any extra or different support sooner. However, the complainants are now left with a justifiable sense of uncertainty about whether she could have received:

• therapies not usually available through the Trust; and

• more control over her aftercare through a PHB.

115. Between 2017 and the end of 2019, Miss X experienced incidents causing physical harm or serious risk of harm, as well as difficulties in her relationships. We cannot say, even on balance of probability, that the actual harm to Miss X and her relationships would have been less if the Trust, Council and CCG had not failed to deal with her section 117 aftercare. This is because there are too many unknown variables over a long period of time. However, Miss X’s diagnoses and traumatic life experience from early childhood through to early adulthood mean that she is exceptionally vulnerable to severe distress and physical harm. Her relationships are also very vulnerable. We therefore consider that the Council, CCG and Trust’s failures in managing Miss X’s section 117 aftercare are likely to have increased the risk of harm to her, and her relationships.

116. The complainants have suffered distressing uncertainty about whether the traumatic events and relationship strain could have been avoided or lessened, if Miss X’s section 117 aftercare had been managed properly. Miss X is justifiably outraged over being repeatedly failed by those responsible for providing her with care and support. Miss X’s parents have suffered entirely avoidable time, trouble and distress in trying to ensure the Council, CCG and Trust properly manage the section 117 aftercare Miss X has been legally entitled to since 2017.

117. Flaws in planning and delivering section 117 aftercare meant Miss X did not get information and support with benefits. Miss X received a PIP soon after she first applied for this in 2019. The PIP was for help with both daily living and mobility needs at an enhanced rate, backdated to the date of her application in May 2019. This is because an assessment on behalf of the Department for Work and Pensions (DWP) determined the impact from a combination of her psychiatric conditions and seizures on Miss X’s ability to do 12 tasks justified the enhanced rate award. Based on the records we have seen, we consider that:

• the award was based on points awarded for both psychiatric conditions and seizures, although Miss X received points for some tasks based on the effect of the psychiatric conditions alone;

• the effects of the psychiatric conditions on Miss X’s daily living needs at the time of her PIP assessment in 2019 were of a comparable severity to those she had experienced since leaving hospital in 2017;

• therefore, she is likely to have been awarded the same or similar points for needs relating to her psychiatric conditions, had she applied for a PIP at any point since June 2017;

• the PIP assessment took account of a diagnosis of non-epileptic seizures and Miss X’s account of their effect on her life when awarding points for certain activities. However, she did not get the diagnosis until June 2018;

• we cannot say, even on balance of probability, whether Miss X would have received a PIP had she applied before the diagnosis relating to seizures in June 2018 and, if so, which components and rates she would have received;

• however, the failure to properly consider Miss X’s need for help and information about her welfare rights deprived her of the opportunity to apply for a PIP at the earliest opportunity and has caused her uncertainty;

• it is more likely than not, that Miss X would have received an enhanced rate PIP award for both daily living and mobility from June 2018, if she had been advised to apply for a PIP earlier;

• therefore, the failure to properly consider Miss X’s need for help and information about her welfare rights likely caused her to lose out on the enhanced rate of PIP since June 2018; and

• the law does not allow Miss X to ask DWP to backdate PIPs beyond the date of her application. We have therefore recommended the Council and CCG pay Miss X the equivalent of 11 months of the enhanced rate of PIP to remedy this.

118. The CCG’s delay in complying with the law on PHBs could have affected many other vulnerable people in the area.

119. We have recommended remedies for the complainants and service improvements at the end of this report.

E – local community alternatives to unsuitable personality disorder service

120. The complainants say they did not get information about local community alternatives to a personality disorder service that was unsuitable for Miss X, until they complained to the CCG in 2019. The complainants told the Trust in a letter dated 23 March 2018 that attending the PD Centre would be difficult for Miss X because of memories of a friend’s suicide. In November 2019, the CCG’s complaint response informed them about several services. The complainants say Miss X would have engaged with and benefited from two of the services, Trauma Based Therapy and Individual Psychodynamic Therapy, had they been offered earlier. They say that the fault means Miss X has been unable to access these services.

121. The Trust says:

• it has not explored Trauma Based Therapy or Individual Psychodynamic Therapy with Miss X or her family;

• once Miss X had left school, the Trust tried to focus on and pursue one therapy option at a time rather than mention all possible options because of Miss X’s fluctuating engagement;

• Miss X’s care coordinator regularly attempts to engage her in conversation about psychological approaches to help manage her experiences and behaviours, but she is frequently unwilling to discuss them;

• it considers it important for Miss X to have influence over what happens in her life and that an unhelpful dynamic can happen which could undermine the effectiveness of any treatment if she passively goes along with others’ ideas about treatment. It also considers that any urgency or pressure from others would be counter-productive and make it less likely that Miss X would engage;

• Miss X has always had capacity to make her own decisions about treatment options but has had changing beliefs about and levels of commitment to therapy;

• it has therefore not suggested more than one treatment option at a time;

• the Trust’s pathway for people experiencing behaviours similar to Miss X’s explores and excludes PD Centre as an option before considering other therapies the Trust or external providers could offer; and

• it offered PD Centre as it considered this was the appropriate service for Miss X’s needs and she was willing to engage with it at the time.

122. The PD Centre is in the grounds of a hospital where Miss X was detained as a teenager and where she witnessed a close friend’s suicide. Reaching the PD Centre involves going past locations connected with the friend’s suicide and funeral. Mr and Mrs X told us the event destabilised Miss X to the point the hospital could no longer meet her needs and she had to be moved to an intensive care unit in another part of the country. The Trust was involved in Miss X’s care at the time this happened.

123. Miss X says she regularly discussed the distress she continued to feel about the event with the Trust during the period we are investigating and that the Trust was aware of her distress. The Trust’s records support this. For example, risk assessments completed by the Trust in 2017 and 2018 refer to memories of the incident being an ongoing risk factor for Miss X. The Trust was aware of the complainants’ concerns about the suitability of the PD Centre because of its location from March 2018 at the latest. While Miss X agreed to a referral there, for assessment only, this was because she believed she had to attend the assessment to get treatment at Hospital A.

124. The Trust acted with fault in relation to the PD Centre referral. This is because:

• the referral to the PD Centre was distressing for Miss X, unlikely to gain her engagement, and put collaborative working with her at risk. The Trust should therefore not have referred Miss X there unless it considered the referral was essential;

• there are no contemporaneous records explaining why the Trust considered a referral to the PD Centre essential despite these risks;

• there are no records showing the Trust discussed its reasons, Miss X’s objections and available support with Miss X; and

• this was contrary to paragraphs 1.3.3.1 and 1.3.4.1 of National Institute for Health and Care Excellence (NICE) clinical guideline 78 (CG78).

125. The Trust also acted with fault in relation to providing information about community alternatives to the PD Centre, for the following reasons.

• While it is in line with guidance to focus on one therapy at a time, this does not mean other options cannot be discussed. Contrary to General Medical Council (GMC) guidance on decision making and consent, the Trust’s records indicate it did not discuss all available community alternatives to the PD Centre with Miss X.

• The Trust did not record its reasons for not discussing all available alternatives.

• The Trust discussed dialectical behaviour therapy (DBT), private therapy and family therapy with the complainants in March 2018, but does not have a clear record of discussing the risks and benefits or the outcome of such discussions.

• This undermines the Trust’s reasoning that it wanted to focus on one therapy at a time.

• The Trust’s insistence on the PD Centre despite Miss X’s strong objections also likely undermined Miss X’s influence over what happened, something the Trust has identified as a key aspect of successful treatment.

126. There are too many unknowns for us to be able to say whether the outcomes for Miss X would have been markedly different, or better, if the Trust had not acted with fault. However, what happened adds to the complainants’ uncertainty about this. The Trust’s insistence on the PD Centre as the only community therapy option over several months, despite its location, coincided with a period of unsettled mental health for Miss X, including a hospital admission. Given the Trust’s own risk assessments said memories of her friend’s suicide were a risk factor for Miss X, we consider the faults identified in this section increased the potential risk of harm to Miss X. It is also clear that the lost opportunity to exercise choice and influence over community therapy options over a prolonged period has added to Miss X’s distress. To reflect this, we have recommended remedies for the complainants at the end of this report.

F – family therapy

127. In family therapy, a therapist works with the whole family. The complainants say that the Trust failed to provide family therapy for them as part of Miss X’s section 117 aftercare. Mrs X says she has requested this since 2018. The complainants say this has made it more difficult for the family to understand and manage Miss X’s risks.

128. The Trust says that:

• Mr and Mrs X asked for a session where all three could be present in May 2018;

• the care coordinator was going to discuss this with Miss X at their planned appointment the next day; however

• Miss X did not attend that appointment, was unwell soon after and refused to involve her family at a later attendance at A&E.

129. It is unclear if the session Mr and Mrs X requested was family therapy.

130. The Trust says Mr and Mrs X asked for a family session in January 2019 and the care coordinator told them:

• the Trust “did not have access to formal family intervention”; and

• they could seek this through the referral to Hospital A.

131. The Trust says Miss X’s care coordinator:

• discussed family therapy with her in November 2019 and January 2020; and

• considered Miss X was “neutral” about this but agreed it could be explored further.

132. The Trust says it had no formal family intervention available for people with needs similar to Miss X’s. It said it did not realise until Miss X left Hospital A that family therapy could be accessed from alternative providers with funding from the CCG. The Trust accepts that it missed opportunities to offer support to Mr and Mrs X separately to Miss X and to follow up requests for family support. This was fault which caused further uncertainty to the complainants. The complainants have received family therapy through another service. They found this helpful. However, we cannot say, even on balance, that the complainants would have received family therapy through the Trust if there had been no fault, or that this would have been as effective as the therapy they eventually received through the other service. This is because:

• even a thorough consideration of Mr and Mrs X’s requests for family therapy may have resulted in a valid refusal to provide it; and

• National Clinical Practice Guideline 78 – ‘Borderline Personality Disorder: Treatment and Management’ (Guideline 78) says that while there is some evidence family therapy may be helpful, there is a lack of high-quality empirical evidence for this and a study suggested more information alone could be associated with more distress.

G – referral to Hospital A

133. The complainants say that the Trust did not tell them about Hospital A, delayed referring Miss X there between February and June 2018 and misinformed the family about the process. They say this led to an avoidable delay in Miss X accessing suitable mental health care.

134. The Trust did not tell the complainants about Hospital A. This was in line with Guideline 78 and not fault. Also, the complainants appear to have already been aware of Hospital A.

135. The Trust says:

• Miss X’s family raised Hospital A as a suitable option to meet Miss X’s needs in March 2018;

• Miss X’s care coordinator considered other options should be explored first and that a local service, PD Centre, would be just as effective as Hospital A in meeting Miss X’s needs;

• Miss X’s family formally asked for a referral on 23 March 2018 and the care coordinator told them he would need to see Miss X to discuss this with her;

• on 27 March 2018, Miss X agreed for referrals to both PD Centre and Hospital A;

• on 18 April 2018, the Trust held a CPA meeting with Miss X where she agreed to a referral to PD Centre for assessment as part of exploration of a possibility of a referral to Hospital A;

• PD Centre sent Miss X a written questionnaire to complete in advance of an appointment for an assessment. By May 2018, Miss X had become unwell and went through an unsettled period where she was expressing ambivalence about going to Hospital A. Miss X eventually completed the questionnaire and the Trust sent it to PD Centre at the end of May 2018;

• PD Centre wrote to Miss X on 28 June 2018 offering an assessment for 24 July 2018;

• separately, the care coordinator had contacted Hospital A in June 2018 after Miss X had told him she was still interested in a referral. Hospital A gave him information about how to make a referral on 25 June 2018;

• the Trust sent the referral on 29 June 2018;

• Hospital A told the Trust in early July 2018 that it would be appropriate to wait for the outcome of PD Centre’s assessment;

• the Trust discussed the referral internally and with Hospital A in September 2018;

• Miss X missed her next appointment at PD Centre as she went into A&E in crisis and since then did not attend further groups offered by PD Centre; and

• Miss X agreed to accept the offer of therapy at Hospital A on 20 October 2018.

136. There are good reasons for the time taken between Miss X’s agreement to a referral at the end of March 2018 and the referral at the end of June 2018. It was appropriate for the Trust to discuss the referral at a CPA meeting and to wait until the end of May 2018 for Miss X to recover.

137. The Trust told Mr and Mrs X in March 2018 that the Trust and CCG “will not fund any treatment outside the borough, at least until local services…have been exhausted (and even after that it is currently very unlikely)”. The Trust also told them that any nationally funded service cannot be accessed without agreement and support from the local CCG. This was incorrect and fault. Hospital A is a nationally funded service and referrals do not need prior agreement from the local CCG. Information about this is easily accessible on its website. The Trust acknowledged in September 2018 that it had misunderstood the way funding for Hospital A works.

138. Faults in the way the Trust informed Mr and Mrs X about the process for applying to Hospital A added to Mr and Mrs X’s avoidable time, trouble and frustration in pursuing treatment options for Miss X. However, we consider it unlikely that Miss X would have been able to access treatment at Hospital A sooner, even if the Trust had given them the correct information. This is because Miss X’s own circumstances and decisions by Hospital A affected when she could start treatment there.

H – support for Mr and Mrs X as their daughter’s carers

139. Section 10 of the Care Act 2014 says the Council must carry out a carer’s assessment where a person provides or intends to provide care for another adult and it appears the carer may have any needs for support. The Council must meet the carer’s eligible needs for support. The Council may arrange for other organisations to carry out carers’ assessments and meet support needs on its behalf. However, it remains responsible for ensuring the carer receives the assessment and any support they are eligible for.

140. The Council does not have to carry out an assessment if a carer refuses it.

141. Mr and Mrs X complain that the Council’s support provision for them as Miss X’s carers is inadequate. They say they received £100 and invitations to some support groups which have since closed. Mr and Mrs X have told us they do not have any records of the assessment which led to this support. They consider they are missing out on personalised services which they need as Miss X’s carers, making it more difficult for them to fulfil their caring role.

142. In its first response to our enquiries, the Council could not tell us whether Mr and Mrs X’s needs for support as carers had been assessed. When we queried this, the Council told us that it has a joint agreement, managed by the Trust, to assess and support carers’ needs. When we queried this further, the Council told us that:

• it does not hold information about carers’ assessments for residents in its area;

• in 2017, it commissioned an organisation to carry out carers’ assessments on its behalf but this has since closed;

• since 2018, it has commissioned another organisation to do this (Organisation A); and

• the Council and Trust have a flow chart which states the Trust should refer carers for a carer’s assessment by Organisation A if they appear to have needs for support and agree to an assessment.

143. The Trust’s first response to our enquiries indicated the Trust had a different understanding of its agreement with the Council for carers’ assessments. The Trust told us that it has “a responsibility to complete an annual Carer’s Assessment and, if requested, refer to an external agency funded via Croydon Social Care who will complete a full Carer’s Needs Assessment” (my emphasis). When we queried this, the Trust told us that it follows the process as advised by the Council, by offering assessments to carers and either completing them through its own staff or referring carers to Organisation A.

144. The Trust’s records show:

• it offered Mrs X a carer’s assessment in July 2017, which she declined; and

• Mr and Mrs X asked for carers’ assessments in August 2018. The Trust says it referred them for a “full Carer’s Needs Assessment” around that time but it has not shown us a copy of the referral.

145. The Council has told us that the external agency has not received any referrals for carers’ assessments for Mr and Mrs X.

146. It is therefore unclear on what basis Mr and Mrs X have received the £100 they say was given to them to support them in caring for Miss X and where this came from. However, we consider it more likely than not that:

• the Trust offered Mrs X a carer’s assessment on the Council’s behalf in 2017 and she declined it. There was no fault in this respect;

• the Council did not offer Mr X a carer’s assessment in 2017 and this was fault;

• the Council has not kept adequate records of what happened after Mr and Mrs X requested carers’ assessments in 2018 and this was fault; and

• the Council has not offered further carers’ assessments in 2019 and 2020 and this was fault.

147. As a result, Mr and Mrs X have missed out on the opportunity to have their needs as carers assessed, and any eligible needs met. Mr and Mrs X consider this has made their role as carers more difficult. We cannot say that Mr and Mrs X’s role would have been less demanding and difficult, if there had been no fault here. But again, they are left with a distressing uncertainty about what might have been.

148. We have recommended remedies for Mr and Mrs X and service improvements below.

Conclusions

149. We have identified several areas of fault. These include:

• flawed planning and provision of aftercare under section 117 of the Mental Health Act 1983. As a result nobody knows what services Miss X should be getting as section 117 aftercare. This is despite Miss X being entitled to this for nearly five years and her parents raising concerns regularly;

• failing to ensure PHBs and information about them are available to people eligible for section 117 aftercare, despite this being a legal requirement since 2019;

• poor record keeping;

• failing to hold CPA reviews at least annually;

• failing to refer Miss X for supported living accommodation and to place important documents on her files;

• failure to provide relevant information and share important documents;

• inadequate action in response to a possible risk of harm to Mr and Mrs X; and

• inadequate support for Mr and Mrs X as Miss X’s carers.

150. Having identified fault, we must consider if there has been injustice in this case. We are satisfied that Miss X and her parents have suffered significant and prolonged frustration, distress, inconvenience and uncertainty because of the faults we have identified. It is concerning that, despite repeated efforts by Miss X’s parents and the Ombudsmen’s involvement, Miss X still does not appear to have an up to date care plan setting out in detail what her section 117 aftercare entitlement is.

151. Miss X is an extremely vulnerable young adult who has been exposed to significant trauma in her early and teenage years. We consider this intensifies the impact of these faults on her. We are deeply concerned that others who rely on the Council, Trust and CCG for section 117 aftercare and PHBs may have been affected by similar problems. We therefore consider it in the public interest to issue this report.

Agreed actions

152. We are pleased that all three organisations have accepted all our recommendations in full.

153. All three organisations will write to Miss X and, separately, to her parents to offer meaningful apologies for the the faults identified in this report and their impact on the complainants. They will do this within a month of our decision.

154. The Council will pay the following symbolic sums to the complainants within a month of our decision:

• £2,250 to Miss X in recognition of the avoidable distress, frustration, uncertainty, loss of legal entitlements, increased risk of harm, lost opportunities, and outrage we have identified in sections A and D above; and

• £850 each to Mr and Mrs X in recognition of the injustice we have identified in sections A, D and H above.

155. The Trust will pay the following symbolic sums to the complainants within a month of our decision:

• £1,500 to Miss X in recognition of the injustice we have identified in sections A, B, C and E above; and

• £400 each to Mr and Mrs X in recognition of the injustice we have identified in sections A, B, C and E above.

156. The CCG will pay the following symbolic sums to the complainants within a month of our decision:

• £2,000 to Miss X in recognition of the injustice we have identified in section D above; and

• £250 each to Mr and Mrs X in recognition of the injustice we have identified in section D above.

157. We have identified that Miss X missed out on claiming PIP and that this has had a detrimental effect on her financially. As previously set out, PIP awards cannot be backdated. Therefore, the Council and CCG will pay her £7,000 equally shared between the two organisations (£3,500 each), in recognition of the PIP she missed out on between June 2018 and May 2019.

158. Within one month of our decision, the Council will ensure Mr and Mrs X receive carers’ assessments if they still want these. Any refusal or delay by Mr and Mrs X should be clearly documented. Any delay by the Council should be explained, discussed with the complainants and clearly documented. Should there be any delay by the Council that has not been discussed with the complainants, the Council should pay Mr and Mrs X £50 each for every month of delay. If the Council does not complete this action within six months of our decision, we will investigate this as a new complaint without the need for Mr and Mrs X to go through the Council’s local complaints procedure.

159. Within one month of our decision, the Council, Trust and CCG will ensure Miss X has a CPA care plan that clearly sets out her section 117 aftercare and an explanation of how she can request a personal health budget. Any refusal or delay by Miss X should be clearly documented. Any delay by the Council, Trust or CCG should be explained, discussed with Miss X and clearly documented. Should there be any delay by the Council, Trust or CCG that has not been discussed with Miss X, the organisations should pay Miss X £150 for every month of delay. If the Council, Trust and CCG do not complete this action within six months of our decision, we will investigate this as a new complaint without the need for Miss X to go through the organisations’ local complaints procedure.

160. The Council will, within three months of our decision, review its process for ensuring carers can have their needs assessed in accordance with the Care Act 2014 and associated guidance, especially where carers are more likely to be in contact with the Trust rather than the Council’s adult care services. If the review identifies problems, the Council will produce an action plan to address them within a further three months.

161. Within a month of our decision, the Trust will explain to the complainants what it and they need to do, for the relevant documents to be added to Miss X’s clinical files. The Trust then needs to add those documents and confirm this to the complainants, within a month of the complainants taking any action they need to.

162. The Trust and Council will take action within three months of our decision to ensure relevant staff properly understand the law and any joint processes relating to supported accommodation referrals, and can offer suitable advice.

163. The Trust will, within three months of our decision, review its practice around:

• record keeping;

• working collaboratively with people entitled to section 117 aftercare;

• regular CPA reviews;

• sharing written plans with patients; and

• addressing patients’ disclosures of risks to others. If the review identifies problems, the Trust will produce an action plan to address them within a further three months.

164. The Council, Trust and CCG will work together to ensure that, within six months of our decision:

• their processes and record keeping around section 117 aftercare are in line with the relevant law and guidance, especially the Mental Health Act 1983 and associated Code of Practice, and the CPA Guidelines; and

• everyone to whom the Council and CCG owe a section 117 aftercare duty has a care plan setting out their section 117 aftercare and when this will be reviewed.

165. The CCG will take urgent action to ensure that, within three months of our decision:

• its processes for publicising PHBs and processing people’s requests for PHBs, including any budgetary limits it implements, comply with the relevant law and guidance; and

• relevant staff, patients and external stakeholders are aware of the processes.

166. The Trust will send any action plans resulting from this investigation to the complainants, the Ombudsmen, the Care Quality Commission (CQC) and NHS England & Improvement.

167. The CCG will send any action plans resulting from this investigation to the complainants, the Ombudsmen and its local area team at NHS England.

Final decision

168. We uphold Mr and Mrs X’s complaints against the Council, Trust and CCG. We have issued a public report into our investigation.

Parts of the complaint we did not investigate

169. We did not investigate the complaints summarised in paragraphs 16 and 17.

170. Mr and Mrs X disagree with a sentence in a referral report written by the Trust. The Trust’s local complaint response had provided further comments and explanation from one of the authors of the report. We did not consider that investigating this complaint would achieve any further positive outcomes for the complainants, such as deletion or retraction of the comments. We therefore decided not to investigate this complaint. We are pleased that the Trust has now amended the document to the complainants’ satisfaction.

171. Mr and Mrs X complained about aspects of Miss X’s placement at, and discharge from, a hospital run by another NHS Trust. This provision was fully NHS-funded and distinct from the rest of the complaints put to the Ombudsmen. We therefore decided that it was not suitable for joint investigation and it was appropriate for it to be considered separately by the Parliamentary and Health Service Ombudsman.

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