Summary: We find fault by West London NHS Trust and London Borough of Hammersmith and Fulham in terms of their delivery of aftercare services to which Mr X was entitled under section 117 of the Mental Health Act 1983. This fault caused Mr X uncertainty and distress. The Trust and Council will apologise to Mr X and the Trust will pay him a financial remedy. The Trust and Council will also ensure Mr X has an appropriate section 117 aftercare plan in place and an allocated care coordinator.

The complaint

1. Mr X is complaining about the care provided to him by West London NHS Trust (the Trust), London Borough of Hammersmith and Fulham (the Council) and NHS North West London Integrated Care Board (the ICB).
2. Mr X complains that these organisations failed to provide him with proper care and support when he was mentally and physically unwell in 2023. Mr X says he made regular efforts to contact the professionals involved in his care for support but was ignored.
3. Mr X says the lack of support left him feeling depressed and neglected and that he made efforts to take his own life.
4. Mr X would like the Council, Trust and ICB to acknowledge the failings in his care and apologise. He would also like a financial remedy in recognition of the distress these events caused.

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The Ombudsmen’s role and powers

5. 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).
6. 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).
7. 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.
8. 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)
9. When considering complaints, we make findings based on the balance of probabilities. This means that we look at the relevant available evidence and decide what was more likely to have happened.

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How I considered this complaint

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

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What I found

Relevant legislation and guidance

Mental Health Act 1983

12. The Mental Health Act 1983 (the MHA) allows that 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. A detention under section 3 of the MHA is for the purpose of providing treatment. A person who has been detained under section 3 of the MHA is entitled to free aftercare services under section 117 of the same legislation. These services are intended to prevent a deterioration in the person’s mental health and reduce the risk of them requiring further admission to hospital. Responsibility for providing or arranging these services in Mr X’s case rests with the Council and ICB.

The Code of Practice that accompanies the MHA sets out that a person’s section 117 aftercare needs should be clearly recorded in their care plan and subject to regular review.

14. The Code of Practice also explains that local authorities and ICBs are required to maintain a record of all local people for whom they provide or commission aftercare. This should include details of what aftercare is being provided.

Care Programme Approach

15. The Care Programme Approach (CPA) is an overarching system designed for coordinating the care of people with mental disorders.
16. The Code of Practice explains that the CPA should be used for patients with complex needs who are at high risk of suffering a deterioration in their mental health. Section 34.8 of the Code of Practice says “[t]his would include most people who are entitled to after-care under section 117 of the [MHA].”
17. The Code of Practice sets out the importance of effective care planning as part of the CPA. It says the care plan “should be prepared in close partnership with the patient from the outset, particularly where it is necessary to manage the process of discharge from hospital and reintegration into the community.”
18. In addition, the Code of Practice requires that a person who is subject to the CPA should have an allocated care coordinator.

Background

19. Mr X has a diagnosis of paranoid schizophrenia. He is entitled to section 117 aftercare services as he had previously been detained under Section 3 of the MHA. The Council and ICB hold the statutory duty to provide or arrange section 117 aftercare services for Mr X.
20. In 2023, Mr X was under the care of one of the Trust’s Mental Health Integrated Network Teams (MINT). Mr X was taking oral Aripiprazole medication to treat his schizophrenia.
21. In early April 2023, Mr X attended hospital as he was suffering from Discoid lupus erythematosus (DLE). This is an autoimmune condition causing red, scaly and inflamed patches on the skin of the face, scalp and ears.
22. Mr X contacted Trust services on 6 April to report concerns about his wellbeing. Mr X explained that he was struggling with his physical health and that his DLE was making it difficult for him to leave his house.
23. Mr X spoke to a doctor in the MINT. He reported feeling very stressed and said he was not receiving support for his physical health. Mr X said he was tolerating his Aripiprazole medication well.
24. On 17 April, Mr X contacted the Trust’s duty team. The duty officer noted that Mr X was agitated and threatened to take an overdose. Mr X said he wanted to be admitted to hospital and reported hearing voices. Mr X agreed to attend A&E or call an ambulance if he was at immediate risk of harming himself or others.
25. Mr X contacted the Trust several times on 18 April. He was noted to be agitated and said he had taken an overdose. However, he was unwilling to speak to the duty team.
26. At 2.20pm, a MINT officer advised Mr X that a senior officer in the team would call Mr X “right away”.
27. That evening, the psychiatric liaison team at a local hospital contacted the Trust. The liaison officer explained that Mr X had attended A&E, reporting that he had taken an overdose. Mr X contacted the Trust’s duty team again shortly afterwards. He said he had left hospital when he had still not been seen after two hours. The duty officer noted Mr X was “fine but just sleepy”.
28. Mr X continued to contact the Trust on 19 and 20 April. He spoke to the MINT duty team and said he had not received a call from a senior MINT officer. Mr X reported feeling suicidal and was unsure whether he could keep himself safe. The duty officer explained that a senior member of the team would call him back.
29. On 20 April, a Trust officer recorded that Mr X was sending inappropriate emails. However, that officer has now left the Trust and it was unable to locate copies of these emails.
30. A doctor called Mr X later that morning. They discussed Mr X’s medication. The doctor noted that Mr X had been more settled when he had taken his medication by depot injection. Mr X consented to depot injections.
31. Later that day, Mr X sent a text to a MINT team member threatening to “hurt myself or members of the public.” The same doctor spoke to Mr X again and discussed the case with a MINT colleague. It was agreed Mr X’s care should be transferred to a different MINT team.
32. A Community Psychiatric Nurse (CPN) from the MINT team visited Mr X at home that afternoon. He noted Mr X appeared very agitated. Mr X reported feeling unsupported with his physical health and mental health. Nevertheless, Mr X subsequently attended a Trust clinic for his depot injection as agreed.
33. On 21 April, Mr X’s GP contacted the Trust to request an urgent follow-up appointment. A member of the MINT updated the GP that day.
34. A member of the MINT duty team spoke to Mr X again on 27 April. The duty officer noted Mr X was keen to know who his care coordinator would be. The officer spoke to the CPN, who confirmed he would be Mr X’s new care coordinator.
35. Mr X attended the Trust for his depot injection in May and June. The care coordinator noted Mr X was calm and cooperative and that the injections appeared to have stabilised his condition. In the meantime, Mr X’s care coordinator supported him with problems related to his property.
36. However, on 23 June, Mr X contacted the MINT duty team to say he would not take the depot injections any longer as he felt unsupported. Mr X said he had taken a further overdose as he felt the MINT had ignored his emotional support needs. Mr X’s care coordinator made several attempts to contact him over the following days, but Mr X did not answer the calls.
37. The care coordinator did speak to Mr X in July. Mr X said he would no longer work with the care coordinator. However, he subsequently changed his mind and apologised for this. Mr X received his depot injection later that month.
38. A doctor reviewed Mr X in August. Mr X acknowledged the depot injections were effective and spoke positively about his move to the new MINT team. A CPA review noted Mr X was feeling much better and was now happy with his care coordinator.

My findings and analysis

Crisis care

39. Mr X complained that he had been left in crisis and that his repeated requests for support were ignored. Mr X said this led him to attempt suicide.
40. The Trust’s complaint investigation found staff had been responsive to Mr X’s needs and developed a plan to support him. It said this included changes to his medication and a clinic appointment.
41. The Code of Practice emphasises the importance of effective care planning for people who are entitled to section 117 aftercare services. These services are intended to prevent the need for readmission to hospital if a person’s mental health deteriorates.
42. The Code of Practice sets out that the CPA should be used for individuals who are at a high risk of suffering a deterioration in their mental condition. The CPA is a comprehensive system for coordinating the care of people with mental disorders. A CPA care plan should detail any areas of need and how these will be met. For patients who are entitled to section 117 aftercare, the care plan should also detail any specific needs to be met under that duty. The Code of Practice is clear that the CPA requires a person to have a named care coordinator for “the preparation, implementation and evaluation of the CPA care plan.”
43. The clinical records show Mr X is entitled to section 117 aftercare services and was being treated under the CPA. However, in response to my enquiries, the Trust confirmed it did not have a care plan in place for Mr X in April 2023. As a result, there was no comprehensive record of his care needs (including his section 117 aftercare needs) and how these would be met. Further, the records show Mr X did not have an allocated care coordinator at the time of his crisis in April 2023. These were significant omissions by the Trust and contrary to the requirements of the Code of Practice. This represents fault.
44. This fault is shared by the Council. This is because the Council’s AMHP service was involved in the sectioning process and so was aware that he had been detained. Despite this, the Council did not become involved in planning Mr X’s section 117 aftercare. Again, this was contrary to the requirements of the Code of Practice and suggests a lack of robust section 117 policies and procedures.
45. I have considered below whether this fault had a significant impact on Mr X’s care in April 2022.
46. The case records show Mr X first contacted the Trust to request additional support on 6 April. At that stage, Mr X was primarily concerned about his physical health. The clinical records suggest a Trust officer attempted to contact the hospital at which Mr X was receiving treatment for his DLE. It is unclear when this call was made as there is no record of it in the clinical notes.
47. By 17 April, Mr X was in evident distress and reported that he felt unable to keep himself safe. A MINT officer advised Mr X that he should contact emergency services if he considered himself to be at immediate risk.
48. In the meantime, the Trust’s duty team requested that a member of the MINT call Mr X to discuss his care. When Mr X did not receive a call back, he made several further calls to the Trust over the following days.
49. A doctor from the MINT subsequently contacted Mr X on 20 April to discuss his care and medication. This led to the decision to recommence his depot injections later that day.
50. The evidence shows there was a short delay of around three days before a member of the MINT contacted Mr X. However, it is important to note that the MINT is not a crisis team and does not provide urgent or emergency care. I am satisfied the Trust’s advice to Mr X (that he should seek support through emergency services if he felt himself to be at risk) was appropriate.
51. I consider it unlikely, on balance of probabilities, that the outcome of Mr X’s care during this period of crisis would have been significantly different even if a care plan and care coordinator had been in place. This is because the evidence shows the Trust did put an appropriate treatment plan in place for Mr X when he made contact.
52. Nevertheless, the lack of a comprehensive care plan and a care coordinator meant wider opportunities were missed to explore whether Mr X needed additional care and support in the community. This caused him distress and uncertainty.

Record keeping

53. An entry in the case records suggests Mr X sent emails of an inappropriate nature to Trust staff. However, the Trust was unable to provide copies of these emails when I requested them. It is of concern that communication of this nature was not saved to the case records.
54. Good record keeping is a fundamental part of effective care. Regulation 17 of the ‘Health and Social Care Act 2008 (Regulated Activities) Regulations 2014’ sets out standards for good governance in the health and care sector. This regulation sets out the need to “maintain securely an accurate, complete and contemporaneous record in respect of each service user”. The Trust’s failure to retain Mr X’s email correspondence was in breach of this regulation. This was fault.
55. The evidence I have seen suggests this omission did not affect Mr X’s care. Nevertheless, I have addressed this in my recommendations in recognition of the importance of comprehensive record keeping to a person’s care.

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Action

56. Within one month of my final decision statement, the Trust and Council should write a joint letter of apology to Mr X for the distress and uncertainty caused to him by their failure to:

• put in place a care plan for him setting out his section 117 aftercare needs and how these will be met; and
• provide him with a named care coordinator in accordance with the requirements of the Code of Practice.

57. The Trust should pay Mr X £300 in recognition of the impact of this fault on him. This recognises the Trust’s central role in Mr X’s care.
58. Within three months of my final decision statement, the Trust and Council should (if they not done so already):

• work with Mr X to produce a detailed section 117 aftercare plan setting out his aftercare needs and how these will be met in the community;
• ensure Mr X has a named care coordinator in keeping with the requirements of the Code of Practice;
• explain to the Ombudsmen what action they will take to ensure they have clear section 117 policies and procedures that reflect the requirements of the Code of Practice. These documents should include a clear process for making section 117 referrals to the Council and ICB, as well as guidance for staff around effective care planning;
• explain to the Ombudsmen what action they will take to ensure staff maintain accurate, complete and contemporaneous records in keeping with the requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014; and
• explain what action they will to take to ensure there is an accurate and up-to-date register of people who are entitled to section 117 aftercare care in the area. This should include details of the aftercare services to be provided, and which organisations will provide these services.

59. The Council and Trust should provide us with evidence they have complied with the above actions.

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Decision

60. I find fault by the Council and Trust with regards to Mr X’s section 117 aftercare. This caused him an injustice. These organisations will now take the above actions to remedy the injustice to Mr X.
61. I find no fault by the ICB, which was not involved in Mr X’s day-to-day care and commissioned the Trust to provide mental health services on its behalf.

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Investigator's decision on behalf of the Ombudsman