Summary: Wigan Metropolitan Borough Council and Greater Manchester Mental Health NHS Foundation Trust missed the opportunity to support Mr Y’s Section 117 aftercare needs under the Care Programme Approach. That caused him uncertainty, and his mother, Miss X, distress. The organisations should apologise, pay compensation, and carry out service improvements.

The complaint

1. Miss X complains on behalf of her son, Mr Y. She says Greater Manchester Mental Health NHS Foundation Trust (the Trust), Wigan Metropolitan Borough Council (the Council) and Greater Manchester Integrated Care Board (the ICB):
1. Did not provide appropriate support for her son’s mental health between April and September 2021. She says there was no Section 117 aftercare plan in place for her son (while he was on a community treatment order [CTO]) which led to his detention under Section 3 of the MHA.
2. Should have moved her son to different accommodation when he returned home.
3. Did not communicate with her when the Trust moved Mr Y from supported accommodation to live with Miss X.
2. Miss X says events caused her distress, depression, anxiety and is now on sleeping tablets. She also says events also adversely impacted the relationship with her son.
3. Miss X would like the organisations to carry out service improvements and compensation to recognise the impact to them both.

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What I have and have not investigated

4. I have investigated parts a) and b) of Miss X’s complaint. I have not investigated part c) because the Trust has accepted it acted with fault and remedied Miss X’s injustice. An Ombudsmen investigation could achieve little more by investigating that part of her complaint.

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The Ombudsmen’s role and powers

5. The Ombudsmen have the power to jointly consider complaints about health and social care. (Local Government Act 1974, section 33ZA,as amended, and Health Service Commissioners Act 1993, section 18ZA)
6. 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) If it has, they may suggest a remedy. Our recommendations might include asking the organisation to apologise or to pay a financial remedy, for example, for inconvenience or worry caused. We might also recommend the organisation takes action to stop the same mistakes happening again.
7. Section 117 (S117) of the Mental Health Act (MHA) imposes a duty on health and social services to provide free aftercare services to patients who have been detained under different sections of the MHA. This includes patients on community treatment orders (CTOs). Councils and ICBs (which have replaced Clinical Commissioning Groups) cannot delegate these aftercare duties, regardless of the day‑to‑day arrangements for delivering a person’s aftercare. In view of this, the relevant council and ICB will always be included in Ombudsmen investigations about s117 aftercare.
8. When considering complaints, if there is a conflict of evidence, we make findings based on the balance of probabilities. This means we will weigh up the available relevant evidence and base our findings on what we think was more likely to have happened.
9. The Ombudsmen cannot question whether a decision is right or wrong simply because the complainant disagrees with it. We must consider whether there was fault in the way the organisation reached the decision. (Local Government Act 1974, section 34(3), as amended, and Health Service Commissioners Act 1993, sections 3(4)- 3(7))
10. 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

11. I read the correspondence and supporting evidence Miss X sent to the Ombudsmen. I wrote to the Council, Trust and ICB to explain what I would investigate, to ask for their comments and copies of relevant records. I considered their comments and records they provided. I also considered relevant legislation and guidance.
12. Miss X and the organisations had an opportunity to comment on my draft decision.

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What I found

Relevant legislation and guidance

Community treatment orders

13. 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.”
14. 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).
15. Patients on a CTO should receive S117 aftercare for the entire period they are on a CTO (Sections 29.21 and 33.6 of the MHA Code).

Section 117

16. S117 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 S3 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.
17. S117 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).
18. It also notes that S117 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).

The Care Programme Approach

19. 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).
20. 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”.

Housing allocations and the homelessness duty

21. Every local housing authority must publish an allocations scheme that sets out how it prioritises applicants, and its procedures for allocating housing. All allocations must be made in strict accordance with the published scheme. (Housing Act 1996, section 166A(1) & (14))
22. An allocations scheme must give reasonable preference to applicants in the following categories:
• homeless people;
• people in insanitary, overcrowded or unsatisfactory housing;
• people who need to move on medical or welfare grounds;
• people who need to move to avoid hardship to themselves or others;
  (Housing Act 1996, section 166A(3))
23. If a council is satisfied an applicant is homeless, eligible for assistance, and has a priority need the council has a duty to secure that accommodation is available for their occupation (unless it refers the application to another housing authority under section 198). (Housing Act 1996, section 193 and Homelessness Code of Guidance 15.39)

Key facts

24. From 2020, Mr Y lived in supported accommodation under a CTO. A Community Nurse and Care Coordinator (for the Trust) were responsible for supporting his mental health needs in the community.
25. In February 2021, a Psychiatrist for the Trust carried out an annual review of his CTO. They recorded:
• Mr Y’s Care Coordinator and Community Nurse did not have any concerns for his mental health.
• Mr Y did not engage with any support offered by his accommodation.
• He regularly attended appointments to oversee his antipsychotic medication.
• Mr Y was a low risk of self-harm, suicide or harm to others. However, the risk of deterioration in Mr Y’s mental state was unpredictable due to his illicit substance misuse. That could trigger a relapse of his mental disorder.
• He had capacity to understand the conditions of CTO: to take medication, attend appointments and engage with the mental health team.
26. In early 2021, the supported accommodation told Mr Y it would evict him due to substance misuse and dealing to other residents. Miss X told his Care Coordinator she was happy for her son to live with her until he could find new accommodation. However, before then the Trust carried out a review of Mr Y’s CTO. They noted:
• Mr Y would move to live with Miss X (but did not involve her in that decision).
• Mr Y should regularly take antipsychotic drugs.
• His Community Nurse would check his medication and mental health.
• His Care Coordinator would also check his mental health.
• A Social Worker (for the Council) was responsible for supporting Mr Y to find alternative accommodation.
27. Between April and September, Miss X repeatedly raised concerns about her son’s deteriorating mental health and that she struggled to support him at home. The Care Coordinator and Community Nurse did not report any concerns about his mental health.
28. In May, Mr Y’s Social Worker told the Care Coordinator she was developing a care package for Mr Y to access the community. Also, the Social Worker said because Mr Y did not want to return to supported accommodation, it limited his choices. He needed to bid on properties advertised by the Council’s Housing team.
29. In early-June, Miss X told the Community Nurse she did not want her son at home any longer. The Community Nurse advised Miss X check if Mr Y can live with his friends. At this time, the Community Nurse also took on the role of Care Coordinator.
30. A week later, the Council’s Housing Team told the Community Nurse that Mr Y was not known to their homelessness team. The Community Nurse then told Miss X she needed to ask Mr Y to declare himself homeless to start the Council’s duty to house Mr Y.
31. In early July, the Community Nurse spoke to the Social Worker because Mr Y did not have a care package in place. The Social Worker said she could not consider a care package for Mr Y until he moved into a new property. The Community Nurse communicated that to Miss X and Mr Y in a meeting.
32. In mid-July, Mr Y left Miss X’s home to stay with a friend due to their arguments but later returned.
33. During an appointment in August, the Community Nurse recorded she smelt cannabis from Mr Y. But she did not record any concerns about his mental health.
34. On 7 September, Mr Y did not attend his appointment with the Community Nurse. The next day, she visited Miss X’s home, but Mr Y was not present. Miss X repeated her concerns about her son’s mental health. The Community Nurse noted she left a copy of Mr Y’s care plan with Miss X. Mr Y visited the clinic later that day, and the Community Nurse did not record any concerns about Mr Y’s mental health.
35. On 10 September, Miss X told the Community Nurse her son was not taking his medication. The Community Nurse said Mr Y had capacity to make unwise decisions.
36. Three days later, Mr Y attended the Trust as Miss X had asked him to leave and he did not have anywhere to stay. The Trust called the Council’s Housing Team who advised him to visit a local hotel for support.
37. On 15 September, Mr Y’s stepmother called Mr Y’s previous Care Coordinator. She said Mr Y had been at her house, was not taking his medication and hearing voices. The Care Coordinator advised her to contact the Crisis Team if Mr Y returned. Later that day, Mr Y’s aunt called the Trust with similar concerns. The Trust then carried out a psychological assessment of Mr Y. It recorded that Mr Y did not feel he had any support and denied taking any drugs. The Trust agreed for its Crisis Team to support Mr Y.
38. The next day, Mr Y attended the Trust clinic. Mr Y’s previous Care Coordinator noted Mr Y most likely lacked capacity into his mental disorder, but there was no doctor to complete the assessment. Mr Y was showing signs of a mental relapse and told the Crisis Team.
39. On 17 September, Mr Y agreed to an informal admission to hospital to assess his mental health. A week later, the Trust decided to detain him under S3 of the MHA.

The S117 aftercare between April and September 2021

40. Miss X complained to the Trust that it did not support Mr Y’s mental health needs when he returned to live with her in April 2021. She said he did not have a care plan.
41. The Trust told Miss X it checked Mr Y’s mental health regularly between April and September 2021. It would have acted if Mr Y’s mental health deteriorated, including putting a support plan in place. It also agreed to share a copy of Mr Y’s care plan with her.
42. I have considered the relevant evidence, including the Council and Trust’s care records.
43. From the Trust’s records, its main support for Mr Y’s mental health was medication. The Community Nurse regularly reviewed Mr Y and assessed his mental health at each appointment.
44. However, I have not seen any evidence of a CPA or S117 care plan in the Trust or Council’s records. That was fault. The closest to a care plan, was the CTO review in April which included a plan of how to manage Mr Y’s mental health in the community. I consider it would have been good practice to have produced a CPA care plan for Mr Y. A CPA care plan would have included a comprehensive record of Mr Y’s health and social care needs, and how the Trust and Council would meet those needs. I consider that would have been appropriate when Mr Y moved from supported accommodation to Miss X’s home. I will now consider the impact of that fault on Mr Y.
45. Between April and early September 2021, I consider the Trust’s Community Nurse effectively managed Mr Y’s mental health in the community in line with the conditions of his CTO. There is evidence she checked his well-being and did not have any concerns about his mental health.
46. However, on 9 September 2021, Mr Y’s mental health had significantly deteriorated. He was most likely taking illicit substances and homeless. These were triggers of a relapse in Mr Y’s mental health. The Community Nurse had concerns about Mr Y’s behaviour but did not take more action. I am not persuaded the Trust had a plan in the event Mr Y’s mental health deteriorated. Had the Trust supported Mr Y under the CPA, it would most likely have included a plan for that event. I cannot say what difference any support would have made to Mr Y after 9 September. But it leaves him with a sense of uncertainty if events might have been different. That was also a distressing time for Miss X, who raised her own concerns after 9 September.
47. The lack of CPA care planning also meant the Council missed the opportunity to assess and support Mr Y’s potential S117 needs (from a social care view). However, I consider that on the balance of probabilities, Mr Y would not have engaged with any social care support. When Mr Y lived at the supported accommodation, he refused to engage with the support it offered. So, even if the Council identified any support to meet his S117 needs, I am not persuaded Mr Y would have engaged with social care support.
48. The Trust told me it does not hold a Section 75 (S75) agreement with the Council, so they hold any S117 aftercare plans separately. That is not in line with the principle of the Code of Practice. Organisations do not need to hold S75 agreements to jointly manage a person’s S117 needs.
49. I have not found fault with the ICB in Mr Y’s care and support. It jointly commissioned Mr Y’s S117 aftercare, but did not directly provide any support.

The move to alternative accommodation

50. Miss X said when Mr Y returned to live with her in April 2021, it was a temporary solution. The Trust and the Council should have sought alternative accommodation for Mr Y before September 2021.
51. The Trust told Miss X it worked with the Council’s adult social care and housing teams to support Mr Y’s move to new accommodation.
52. I have considered the relevant evidence, including the Council and Trust’s care records.
53. When Mr Y arrived at Miss X’s home, he argued he did not want to move back into supported accommodation. Mr Y had mental capacity to decide that, and the Council could not force Mr Y to move somewhere he did not want to go.
54. While Mr Y lived with Miss X, he could only bid on properties advertised by the Council’s Housing team. The Council’s care records show that it (and Miss X) supported Mr Y to bid on properties it advertised. I am not persuaded the Council needed to prioritise Mr Y while he was bidding on properties. That was because he did not meet the criteria as described in paragraph 22. Therefore, I agree with the Council that between April and September 2021, Mr Y had limited choices finding alternative accommodation.
55. In June 2021, the Community Nurse explained to Miss X that she would need to make Mr Y formally homeless for the Council to have a statutory duty to home him. I understand that would have been difficult for Miss X to do. But it would have lessened the distress caused by her son living with her. From the Trust and Council’s records, Miss X asked her son to leave her home in mid-September. That was just before the Trust detained her son under S3. While Mr Y stayed at hospital, the Council did not have a duty to house him.
56. Overall, I do not consider the Council acted with fault by not moving Mr Y to alternative accommodation before September 2021.

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Agreed actions

57. Within four weeks of this decision, the Council and Trust should each:
• Apologise to Mr Y and Miss X for the uncertainty and distress caused (respectively) by not completing a CPA/S117 aftercare plan when Mr Y went to live with Miss X.
• Pay Mr Y and Miss X £150 and £100 (respectively) to recognise the injustice they suffered.
58. Within eight weeks of this decision, the Council and Trust should review their relevant policies and procedures around completing CPA/S117 care plans for people under a CTO.

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Final decision

59. I consider the Council and Trust missed an opportunity to support Mr Y using the CPA. That meant he suffered uncertainty before he was detained under S3, which also caused Miss X distress.
60. I have not found fault with the Council for not moving Mr Y to alternative accommodation after he moved to live with Miss X.

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Investigator's decision on behalf of the Ombudsman