Summary: We found no fault with the care provided to Miss Y by London Borough of Hammersmith and Fulham, West London NHS Trust and North West London Integrated Care Board.

The complaint

1. Ms X is complaining about the care provided to her daughter, Miss Y, by London Borough of Hammersmith and Fulham (LBHF), London Borough of Ealing (LBE), West London NHS Trust (the Trust) and North West London Integrated Care Board (the ICB) between December 2022 and July 2024.
2. Ms X complains that these organisations failed to provide her daughter with appropriate care and support to meet her mental health and social care needs; and failed to safeguard her daughter, as a vulnerable adult, from abuse.
3. Ms X says these events have been very distressing for both her and her daughter. She says her daughter has been left vulnerable to abuse and without proper support in the community. As a result, Ms X says she has been required to provide support that should have been provided by these organisations.

Back to top

The Ombudsmen’s role and powers

4. The Local Government and Social Care Ombudsman and Health Service Ombudsman 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).
5. We investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, we 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 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. If we are satisfied with the actions or proposed actions of the organisations that are the subject of the complaint, we can complete our investigation and issue a decision statement. (Health Service Commissioners Act 1993, section 18ZA and Local Government Act 1974, section 30(1B) and 34H(1), as amended)

Back to top

What I have not investigated

8. When I made initial enquiries on Ms X’s complaint, the information I received suggested the duty to provide section 117 aftercare services to Miss Y rested with LBE. However, further correspondence with LBE and LBHF has established that LBHF (along with the ICB) held the section 117 duty for the period I am investigating.
9. My enquiries established that LBHF also provided social care services to Ms X and Miss Y and led the various safeguarding processes during this period. Therefore, I am satisfied LBE was not involved in the events Ms X is complaining about.

Back to top

How I considered this complaint

10. In making my final decision, I considered information provided by Ms X and discussed the complaint with her. I also considered evidence provided by Ms X, LBHF and the Trust as well as relevant law, policy and guidance.
11. All parties had an opportunity to comment on my draft decision. I considered all comments I received before making my final decision.

Back to top

What I found

Relevant guidance and legislation

Mental Health Act 1983

12. Under the Mental Health Act 1983 (MHA), 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’.
13. Section 135 gives the police powers to enter private premises with a warrant and temporarily remove a person to a place of safety. This is for the purposes of completing a mental health assessment or to allow for other arrangements to be made for their care and treatment. The warrant required for this process is issued by the courts and known as a Section 135(1) warrant.
14. Section 117 of the MHA imposes a duty on health and social services to meet the health/social care needs arising from or related to the person’s mental disorder for patients who have been detained under specific sections of the MHA (such as Section 3). Aftercare services provided in relation to the person’s mental disorder under S117 cannot be charged for. This is known as section 117 aftercare.
15. The MHA is supported by a Code of Practice (the MHA Code). This provides guidance for health and social care professionals on how to apply the MHA in practice.

Mental Capacity Act 2005

16. The Mental Capacity Act 2005 (the MCA) applies to people who may lack mental capacity to make certain decisions. The MCA is also supported by a Code of Practice (the MCA Code) which sets out steps organisations should take when considering whether someone lacks mental capacity.
17. The MCA Code starts by presuming individuals have capacity unless there is proof to the contrary. The MCA Code says all practicable steps should be taken to support individuals to make their own decisions before concluding someone lacks capacity. The MCA Code says people who make unwise decisions should not automatically be treated as not being able to make decisions. Someone can have capacity and still make unwise decisions.
18. The MCA Code says there may be cause for concern if somebody repeatedly makes unwise decisions exposing them to significant risk of harm or exploitation. The Code says this may not necessarily mean the person lacks capacity, but further investigation may be required.

Care Act - safeguarding

19. Section 42 of the Care Act 2014 says that a council must make necessary enquiries if it has reason to think a person may be at risk of abuse or neglect and has needs for care and support which mean he or she cannot protect himself or herself. It must also decide whether it, or another person or agency, should take any action to protect the person from abuse or risk.
20. Section 6 of the Care Act requires that each local authority must cooperate with each of its relevant partners to protect the adult. In their turn each relevant partner must also cooperate with the local authority.

Multi-Agency Risk Assessment Conference (MARAC)

21. The MARAC model is intended to serve as a multiagency response to high-risk domestic abuse cases. It involves a core team of safeguarding partners, health and social care services, housing, the police and the probation service. This team may also involve other local services depending on the case. The specific role of each organisation will vary according to the circumstances of the case.
22. The MARAC is not an organisation, but rather a process. This means we do not have jurisdiction to investigate it. However, we can consider the actions of the health and social care organisations within this process.

Background

23. Miss Y is a vulnerable woman with complex mental health needs. The working diagnoses for Miss Y have changed over time but have included bipolar affective disorder, severe borderline personality disorder and schizoaffective disorder.
24. Miss Y had been detained several times under the MHA since 2008. As a result, she was entitled to section 117 aftercare services. The duty to provide, or arrange, these services for Miss Y rested with LBHF and the ICB. However, they commissioned the Trust to provide her day-to-day mental health care support.
25. In 2022, Miss Y was living in social housing arranged by LBHF.
26. Between 2010 and 2022, Ms X and Miss Y raised numerous safeguarding concerns on behalf of Miss Y. They said Miss Y had experienced extensive domestic abuse at the hands of her partner. These reports led to involvement by the police, as well as local health and social care agencies.
27. Following a further incident in November 2022, LBHF opened a safeguarding enquiry. The situation was discussed at a MARAC meeting in February 2023. This ultimately led to the Court placing a restraining order on Miss Y’s ex-partner in May.
28. That month, LBHF’s safeguarding team attempted to contact Miss Y, without success. A social worker spoke to Ms X, who reported that Miss Y felt unable to speak to anyone at that time.
29. In early June, a charity worker supporting Miss Y contacted LBHF to report concern that her mental health was declining. This led staff from the Trust to visit Miss Y at home. However, Miss Y did not answer the door and attempts to contact her by telephone were also unsuccessful.
30. In June and July, police attended Miss Y’s property several times in response to calls from her in which she reported being harassed by Ms X and a neighbour. However, on each occasion, Miss Y refused to come to the door when officers attended.
31. In late July, Ms X raised a further safeguarding concern that Miss Y was being abused by a neighbour. In addition, Ms X said other neighbours were attempting to sell Miss Y drugs and that she was at risk of this and further financial exploitation. However, when police attended, Miss Y would only speak to officers through the door and became agitated and aggressive.
32. This led LBHF to open a further safeguarding concern.
33. A multidisciplinary team meeting discussed Miss Y’s case in August. The meeting heard it had not been possible to properly assess Miss Y’s mental health due to her refusal to engage with services. The meeting also heard it would be necessary to ensure Miss Y’s property was safe to visit. This was because Ms X had informed police that one alleged perpetrator had a firearm.
34. That month, a mental health nurse and police made joint visit to Miss Y, with Ms X also present. Miss Y left immediately and was noted to become angry, shouting obscenities at police as she walked down the street.
35. In September, Miss Y contacted police again to report that she had been abused by her brother in the past. Miss Y would not open the door to attending police officers but did confirm the details of her disclosure.
36. During October and November, Miss Y made several further disclosures to police in which she alleged she had been assaulted by various members of the public. In the meantime, Ms X raised further concerns about Miss Y’s wellbeing.
37. In early November, Miss Y contacted police at a local station. She was noted to be “confused” and “erratic” and officers felt “she is not able to look after self.” The officers concluded there was not enough evidence to suggest Miss Y required detention under the MHA. However, they did note that she appeared have a possible mental illness.
38. In early November, a Trust officer contacted Miss Y. Miss Y said she did not want any support from social care or mental health services.
39. Police also attended Miss Y’s property that month to complete a welfare check. This was in response to a call from Ms X, who reported that Miss Y remained subject to abuse from a neighbour. Miss Y spoke to officers. The officers noted Miss Y initially appeared “incoherent” and “very erratic”. She then became calmer, and officers were able to determine that she had recently been grocery shopping and washed clothes.
40. In December, Miss Y attended an appointment with her GP. The GP could not determine Miss Y’s capacity to make decisions about her care. This was because Miss Y was expressing clearly delusional beliefs. The GP noted that Miss Y denied any problems with her neighbour, who she described as a friend. As a result, the GP was unable to say whether Miss Y could keep herself safe as she had no insight into any potential risks.
41. Miss Y continued to call the police throughout the month to report various concerns. She was noted to be erratic and abusive during calls and refused to speak to officers when officers attended.
42. At the end of the month, Ms X contacted LBHF and spoke to an officer with Miss Y on speakerphone. They reported concerns about Miss Y’s property, which they said was unsafe and infested with mice. The LBHF officer suggested carrying out a Care Act Assessment and carer’s assessment to determine the best way to support them. Miss Y became agitated and left the call. The LBHF officer made two further calls to Ms X but was unable to arrange assessments.
43. Miss Y continued to raise concerns throughout January 2024. These included an allegation that Ms X had punched her in the face.
44. The multidisciplinary team held a safeguarding meeting later that month. Ms X was also present. Miss Y declined to attend. The meeting heard services were struggling to get a clear understanding of Miss Y’s mental health and support needs due to her almost total lack of engagement. The meeting agreed a further joint visit would be made to Miss Y and that Ms X would be offered a carer’s assessment. The meeting also agreed LBHF and Miss Y’s housing association would explore ways to make her property more secure.
45. In February, the proposed joint visit took place. Miss Y became immediately agitated, shouting at the visiting professionals and behaving erratically. The visiting professionals ended the visit as Miss Y was becoming increasingly agitated.
46. Shortly after this, Ms X forwarded an email to LBHF from Miss Y suggesting her flat was in a state of disrepair. Ms X asked for repairs to be done. Ms X also contacted the LBHF housing team for support with securing alternative accommodation for Miss Y.
47. Later that month, Miss Y and Ms X attended a property viewing. However, the property was offered to a person with a higher priority rating. Ms X spoke to an LBHF officer the following day to report her dissatisfaction with this process.
48. In March, an LBHF officer contacted Ms X to explain that a medical review had been arranged for Miss Y. Miss Y subsequently failed to attend this.
49. In April, the LBHF safeguarding team received a referral from a housing officer. This described Miss Y’s flat as squalid, with debris throughout and a clear infestation of mice. The housing officer also noted evidence of a previous unreported kitchen fire.
50. The multidisciplinary team met again in early May. A housing association officer confirmed the problems with Miss Y’s property. However, the officer reported that Miss Y’s presentation had been more settled recently. The meeting heard Miss Y’s neighbour had been removed from the neighbouring property as he had been staying there unlawfully. The meeting also heard Miss Y was becoming concerned her ex-partner may contact her.
51. The housing association subsequently reported it was having difficulty making the necessary repairs to Miss Y’s property as she regularly refused access to workers.
52. That month, Miss Y and Ms X attended the Trust’s offices. Miss Y was noted to be highly aggressive towards staff. She threatened to use a kitchen knife if anyone approached her at home and said she did not want any more support.
53. Following further discussion, the Trust decided that a Mental Health Act Assessment (MHAA) would be needed to determine whether Miss Y was suffering from a mental disorder that required assessment and treatment in hospital.
54. Later that month, an Approved Mental Health Practitioner (AMHP) applied for a Section 135(1) warrant. The AMHP attended Miss Y’s property with police and appropriate clinicians to complete the MHAA. This concluded Miss Y should be detained under Section 2 of the MHA. Miss Y was then escorted to a place of safety for further assessment and treatment. Miss Y’s detention was subsequently converted to a Section 3 detention.

My findings and analysis

55. It is important to be clear that the background section above represents only a summary of the contacts between Miss Y, Ms X and local services. The case records contain details of many further interactions involving several agencies and many different professionals.
56. There is strong evidence in the case records to suggest Miss Y needed support. This is apparent from both the submissions made by Miss Y (and Ms X on her behalf) and the observations of the professionals involved in her care. There is also evidence to show that the various agencies involved in Miss Y’s care made extensive efforts to provide this support.
57. This was evidently a very challenging situation due to Miss Y’s complex needs and behaviours. The case records establish a clear pattern in which Miss Y or Ms X would raise a concern about Miss Y’s wellbeing. However, when services attempted to respond, Miss Y refused to engage. Miss Y was unwilling to allow professionals into her property and refused to attend almost all appointments.
58. This meant professionals were often unable to even see Miss Y face to face. In turn, this made it increasingly difficult for them to properly assess her needs. The case records contain evidence of numerous attempts made by the agencies involved in Miss Y’s care to assess her physical and mental health, social care and housing needs. These ended with very little success.
59. There were rare occasions when professionals were able to meet with Miss Y in person. The evidence suggests these interactions were largely unsuccessful. This was often due to Miss Y’s behaviour. Professionals noted she was often agitated and aggressive and would end interactions abruptly.
60. The evidence suggests the situation was exacerbated at times by Miss Y’s occasionally strained relationship with Ms X. It was then further complicated by Ms X’s deteriorating relationship with the professionals involved in Miss Y’s care.
61. Without being able to properly assess her care needs, the services supporting Miss Y found it increasingly challenging to support her effectively.
62. One option open to the professionals was the use of the MHA. This would have empowered them to detain Miss Y against her will for assessment and treatment. Indeed, the case records suggest professionals were considering applying the MHA as early as June 2023.
63. However, the MHA Code sets out five key principles on which the MHA is based. The first of these is the ‘least restrictive’ principle. Effectively, this means professionals should first explore treatment options that would maximise a person’s independence and prevent the need for them to be detained against their will. In my view, the evidence shows the professionals supporting Miss Y were aware of this and were making every effort to support her in the community.
64. I have reviewed the care records extensively. These show how challenging this situation was for all parties. I also recognise that it did ultimately become necessary to detain Miss Y under the MHA.
65. Nevertheless, I am satisfied the evidence shows the services supporting Miss Y made extensive attempts to put appropriate care in place for her in the community. On this basis, I found no fault with the care provided to Miss Y by LBHF, the Trust and the ICB.

Back to top

Decision

66. I found no fault with the care provided to Miss Y by LBHF, the Trust and the ICB.
67. As above, I found LBE was not involved in the care provided to Miss Y during this period and so had no role in the events I investigated.

Back to top

Investigator's decision on behalf of the Ombudsman