Summary: Suffolk County Council and Norfolk and Suffolk NHS Foundation Trust did not appropriately assess Miss X’s Section 117 aftercare needs in June 2022. The Council then delayed assessing her aftercare needs for 12 months. Miss X suffered distress and the fault impacted her mental wellbeing. I have recommended the Council and Trust take action to remedy the injustice to Miss X and others.

The complaint

1. Miss X complains about the lack of Section 117 aftercare support after June 2022. Suffolk County Council (the Council) and NHS Suffolk and North East Essex Integrated Care Board (the ICB) are commissioners of Section 117 aftercare.
2. She says the Council and Norfolk and Suffolk NHS Foundation Trust (the Trust) did not assess her aftercare needs before it discharged her from Section 3 of the Mental Health Act (the MHA). She says the Council should have provided a direct payment for certain support, to reduce the chance of her being detained under section again. Also, she says a Social Worker significantly delayed assessing her Section 117 aftercare needs by 12 months.
3. Miss X says the lack of Section 117 aftercare caused her distress and she missed out of support for her mental health. She also says she is in debt, as she used savings for support which should have been paid for by a direct payment.
4. Miss X says the Council and Trust should backdate her current direct payment support to June 2022. She would like a financial remedy to recognise the 12‑month delay assessing her aftercare needs.

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The Ombudsmen’s role and powers

5. The Ombudsmen investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, the Ombudsmen consider whether it has caused injustice or hardship (Health Service Commissioners Act 1993, section 3(1) and Local Government Act 1974, sections 26(1) and 26A(1), as amended).
6. If it has, they may suggest a remedy. Our recommendations might include asking the organisation to take action to stop the same mistakes happening again.
7. 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)

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How I considered this complaint

8. I considered the information Miss X and the organisations sent to me, including their responses to my enquiries. I also considered the relevant national guidance and legislation.
9. Miss X and the organisations had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

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What I found

Relevant legislation and guidance

Community treatment orders

10. Section 29.5 of the MHA Code of Practice (the MHA Code) says: “The purpose of a CTO is to allow suitable patients to be safely treated in the community rather than under detention in hospital and to provide a way to help prevent relapse and any harm – to the patient or to others – that this might cause.”
11. Good care planning, in line with the Care Programme Approach (more on this below) will be essential to the success of a CTO (Section 29.20 of the MHA Code).
12. Patients on a CTO should receive Section 117 aftercare for the entire period they are on a CTO (Sections 29.21 and 33.6 of the MHA Code).

Section 117

13. Section 117 of the MHA requires councils and ICBs to provide free aftercare services to certain people. This includes people who have been discharged from detention in hospital under Section 3 of the MHA. They must provide these services from the point the person leaves hospital until the council and ICB decide the person no longer needs them.
14. Section 117 does not define what aftercare services are. The MHA Code says that: “After-care services mean services which have the purposes of meeting a need arising from or related to the patient’s mental disorder and reducing the risk of a deterioration of the patient’s mental condition (and, accordingly, reducing the risk of the patient requiring admission to hospital again for treatment for mental disorder)” (Section 33.3 of the MHA Code).
15. It notes that Section 117 aftercare can “encompass healthcare, social care and employment services, supported accommodation and services to meet the person’s wider social, cultural and spiritual needs” (Section 33.4 of the MHA Code).
16. The MHA Code also states Council and ICBs should “maintain a record of people for whom they provide or commission aftercare and what aftercare services are provided”. (Section 33.7 of the MHA Code).

The Care Programme Approach

17. The Care Programme Approach (CPA) is an approach used in secondary mental health care. It helps to assess, plan, review and coordinate treatment, care and support for people with complex mental health needs. The MHA Code notes that care planning, including aftercare planning, requires a thorough assessment of the patient’s needs and wishes. It notes this is likely to involve consideration of a range of mental health, physical health and social care factors. (Section 34 of the MHA Code).
18. In 2022, the Parliamentary and Health Service Ombudsman and Local Government and Social Care Ombudsman jointly produced the ‘Section 117 Aftercare: Guidance for Practitioners’. It states: “Central to the CPA process is the care plan. This is a record of any physical, psychological, emotional and social needs associated with the person’s mental health condition. The care plan should be prepared in close partnership with the person from the outset and reflect their needs and wishes. The care coordinator will be responsible for preparing, implementing and evaluating the CPA care plan”.

Background

19. In April 2022, the Trust detained Miss X under Section 3 of the MHA. She remained in hospital under Section 3 until late June when the Trust held a discharge meeting. The Trust agreed to discharge Miss X back to her specialised mental health supported housing under a CTO. Following the discharge meeting, Miss X’s Social Worker emailed the Trust’s Care Coordinator. The Social Worker agreed to complete a Care Act assessment and “do the s117 planning/review”.
20. Following her discharge, Miss X started planning her move to university outside Suffolk. Miss X told the Social Worker she was open to local mental health support when she moved, but meanwhile wanted to occupy her time with activities.
21. During July and August 2022, the Social Worker completed the Care Act assessment which noted Miss X wanted to learn more about healthy relationships, boundaries and how to make friends. She wanted to meet people her own age with similar interests.
22. Between August and September 2022, the Trust planned Miss X’s transfer of care to her new mental health team. That included introducing her new Care Coordinator, liaising with the university’s mental health team and monitoring her mental and physical health.
23. Miss X moved to university in late September 2022.
24. In mid-October, Miss X’s new Care Coordinator emailed the Social Worker. Miss X wanted to join the gym to support her wellbeing. The Care Coordinator asked if that support could be funded under Section 117 aftercare. The Social Worker agreed to fund that support but never completed the correct process.
25. In early April 2023, Miss X called the Adult Social Care Team requesting support. It agreed to carry out a new Care Act assessment and Section 117 review.
26. In early June 2023, the Social Worker shared the Care Act assessment, care and support plan and details about Section 117 and direct payments. The Social Worker had agreed to provide a £106 weekly budget via direct payment. Miss X said she had additional needs; the direct payment should be £511, and it should have been backdated to June 2022.
27. At the same time, the new Care Coordinator told the Social Worker their Trust had discharged Miss X. She had stopped engaging with their service. The Care Coordinator said Miss X was having problems with her university. Miss X may have some unmet Section 117 needs if the university stopped her studies or served notice on her tenancy.
28. In late June 2023, the Council responded to Miss X’s complaint. It said:
• It was sorry the Social Worker delayed assessing her needs after April 2022.
• It agreed Miss X needed gym membership to support her mental wellbeing. But later decided alternative support to be provided in a direct payment. The Social Worker was arranging that support.
• It agreed Miss X was eligible for Section 117 aftercare. But it did not agree to provide a £511 weekly direct payment.
29. Miss X complained to the Ombudsmen in mid-July 2023.
30. In late July 2023, the Council provided a further response to Miss X. It said as she no longer lived in Suffolk, she would have to ask her local area to consider her social care and S117 aftercare needs.

My findings

31. I consider the Council and Trust were jointly responsible for assessing Miss X’s Section 117 aftercare needs before it discharged Miss X in June 2022. The MHA Code is clear that patients on a CTO should receive Section 117 aftercare for the entire period they are on a CTO.
32. Before discharge, the Trust agreed to monitor and support Miss X’s mental health until she moved away to university. That was good practice. But emails between the Council and Trust in June 2022 showed the Council and Trust were aware they needed to consider and support her Section 117 needs. Neither organisation took any action, which was a missed opportunity. That was fault.
33. Once Miss X moved to university, the Trust was not responsible for supporting Miss X. So, I cannot say they acted with fault after that point. I also cannot make any findings against the Trust who supported Miss X at university. They are not subject to this investigation.
34. However, the Council retained responsibility to support Miss X’s Section 117 even when she moved to university. Following June 2022, I have not seen any evidence the Council formally assessed or reviewed her Section 117 aftercare needs under the Care Programme Approach. That was fault, and not in in line with the MHA Code.
35. In October 2022, the Social Worker missed an opportunity to consider Miss X’s Section 117 aftercare needs following contact from her new Care Coordinator. That again was fault. It was only until Miss X approached the Council in April 2023 for support that it recognised it needed to support her Section 117 aftercare needs.
36. Overall, the Council and Trust did not properly assess Miss X’s Section 117 aftercare needs before it discharged her on a CTO. The Council then delayed assessing and supporting Miss X’s Section 117 aftercare needs for 12 months.
37. The ICB told me it did not have a record of Miss X’s Section 117 aftercare. But I do not consider that was fault. That was because the Council and Trust did not follow the correct process for Miss X’s Section 117 aftercare.

The injustice to Miss X

38. I consider the Council and Trust’s poor care planning caused Miss X distress. I agree she missed support for her mental health between June 2022 and June 2023. That lack of support most likely impacted Miss X’s well-being at university.
39. In response to the Ombudsmen’s enquiries, the Council said:
• It discussed discharge planning with Miss X, but the Council and Trust did not formally carry out a Section 117 review before or after the discharge from Section 3. It has apologised to Miss X for that.
• It delayed assessing Miss X’s Section 117 aftercare needs.
• It did not have Section 117 forms on its system after April 2022. It has re‑introduced those forms on its system, including a prompt for staff to arrange Section 117 reviews.
• The Social Worker missed an opportunity to provide a direct payment to Miss X in November 2022.
• The Social Worker completed an assessment of Miss X’s Section 117 needs in June 2023. The Council and ICB have jointly agreed to fund a £357.72 weekly direct payment to meet Miss X’s Section 117 aftercare needs. That would support Miss X to access activities in her community, exercise classes and support from a personal assistant. It said: “The Council and the ICB have also agreed to jointly backdate this direct payment to June 2022, as [Miss X] is quite right, this should have been implemented in June 2022. We have apologised to [Miss X] for any distress this caused her. We have agreed to jointly backdate £24,682.00, [Miss X] is fully aware of this.”
• It has set up a Mental Health Review Team, to consider the needs of all adults living outside of Suffolk.
• It offered a £350 payment to Miss X to remedy the injustice she suffered from its faults.
40. Following my draft decision, the Council clarified the £24,628 backdated payment was to reimburse costs Miss X paid toward support which should have been covered by the direct payment between June 2022 and June 2023. By November 2023, the Council told me it had reimbursed around £6,000 following Miss X submitting evidence. I consider the Council should continue to keep considering Miss X’s evidence and reimbursing those costs where necessary.
41. Also, after my draft decision, the Council agreed to increase the £350 payment to £1,000 in recognition of the severity of Miss X’s injustice.
42. I am happy the Council has taken action to put Miss X back in the position she would not have been in, if not for the fault. Also, its service improvements should avoid similar fault happening to others.
43. The Trust also told me it agreed it did not effectively plan or review Miss X’s Section 117 aftercare needs after June 2022. Compared to the Council, I am not persuaded the Trust has provided a suitable remedy to address the injustice Miss X suffered. Therefore, I have made recommendations below to the Trust.

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Agreed actions

44. Within four weeks of this decision, the Council should pay £1,000 to Miss X for causing her distress and impacting her mental wellbeing.
45. Within eight weeks of this decision, the Council should send the Ombudsmen an evidence-based action plan of its progress towards the service improvements identified during this investigation (paragraph 39).
46. Within four weeks of this decision, the Trust should apologise and pay £100 to Miss X to recognise the distress she suffered in June 2022.
47. Within eight weeks of this decision, the Trust should develop an action plan to improve its Section 117 aftercare planning before it discharges patients detained under any qualifying sections of the MHA.

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Final decision

48. I consider the Council and Trust jointly acted with fault by not assessing Miss X’s Section 117 aftercare needs before it discharged her in June 2022. The Council then delayed assessing Miss X’s aftercare needs for 12 months. That caused Miss X distress and impacted her mental well-being without that support. While the Council has already taken appropriate action, I have made further recommendations to the Council and Trust.

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Investigator's decision on behalf of the Ombudsman