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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