London Borough of Croydon (17 002 640)

Category : Children's care services > Other

Decision : Upheld

Decision date : 26 Feb 2020

The Ombudsman's final decision:

Summary: The Ombudsmen find a series of failings in the care of a vulnerable young woman over several years. Social care and health care organisations had clear responsibilities to provide her with suitable joined up care in a timely manner but this did not always happen. This meant there were lost opportunities for more appropriate care, sooner. It has left uncertainty about how the woman’s life would have been different now had the fault not occurred. The relevant organisations have agreed to make apologies, financial payments and actions to learn lessons from the case.

The complaint

  1. Mr and Mrs A complain about the service provided to their adopted daughter, Miss A, by London Borough of Croydon (the Council), South London and Maudsley NHS Foundation Trust (the Trust) and Lambeth Clinical Commissioning Group (the CCG) between October 2013 and December 2015. They complain the organisations failed to work together under s117 of the Mental Health Act 1983 (the MHA) to ensure Miss A had appropriate care and support for her needs.
  2. Mr and Mrs A also complain about the service provided to Miss A by a Cygnet Group Hospital (the Cygnet Hospital) between December 2014 and April 2015.
  3. Mr and Mrs A have further concerns about the service the Trust, a Priory Group Hospital (the Priory Hospital) and NHS England provided to Miss A in 2016 and 2017. In particular, Mr and Mrs A complain about the actions of Miss A’s community consultant, Dr E and two of Miss A’s doctors at the Priory Hospital, Dr H and Dr K. Mr and Mrs A complain the Trust, the Priory Hospital and NHS England failed to fully or properly understand Miss A’s needs. Further, they complain the organisations failed to arrange suitable community support before Miss A turned 18. Mr and Mrs A complain that, as a result, Miss A remained in an inpatient environment for too long, and this was detrimental to her needs.

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The Ombudsmen’s role and powers

  1. The Ombudsmen have the power to jointly consider complaints about health and social care. Since April 2015, these complaints have been considered by a single team acting on behalf of both Ombudsmen (Local Government Act 1974, section 33ZA, and Health Service Commissioners Act 1993, section 18ZA).
  2. 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)).
  3. 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

  1. I read the correspondence Mr and Mrs A sent to the Ombudsmen. I also spoke to them and to Miss A on the telephone. I wrote to the organisations to explain what I intended to investigate and to ask for comments and copies of relevant records. I considered all the comments and records they provided. I also considered relevant legislation and guidance and took advice from two practicing mental health professionals with relevant knowledge and experience and no conflicts of interest.
  2. I shared a confidential copy of my draft decision along with a more detailed appendix with Mr and Mrs A and the organisations under investigation to explain my provisional findings. I invited their comments and considered all those and the additional information I received in response.

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What I found

Relevant legislation and guidance

Section 117 aftercare

  1. Section 117 of the MHA requires councils and clinical commissioning groups (CCGs) 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 CCG decide the person no longer needs them.
  2. Section 117 does not define what aftercare services are. The MHA Code of Practice (the MHA Code) gives some guidance on this. It details 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).
  3. It also notes that 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). It also states that aftercare should aim to support people ‘in regaining or enhancing their skills, or learning new skills, in order to cope with life outside hospital’ (Section 33.5 of the MHA Code).
  4. Patients do not have to accept the aftercare services offered to them (Section 33.24 of the MHA Code).

Looked After Children

  1. The Children Act 1989 is the primary legislation that governs looked after children and fostering services. Section 20 places a duty of councils to provide accommodation to children in its area that need it. If a child does require accommodation under this section they become ‘looked after’ by a council.
  2. Councils have duties to all children looked after by them. The two main duties are: to safeguard and promote the child’s welfare; and, to make such services available for children as are reasonable in the child’s case.

Access to information

  1. The NHS and councils have a duty to protect the confidentiality of all personal information they hold. This is underpinned by the Data Protection Act 1998 (the DPA) which governs the processing of personal data in the UK, including all social services and health records.
  2. There are a number of pieces of guidance available to NHS and council staff who have access to personal information. This includes the Department of Health’s: Data Protection Act 1998 – Guidance to Social Services (2000); Confidentiality NHS Code of Practice (2003); and, Guidance for Access to Health Records Requests (2010). In addition, the Information Commissioner’s Office issued a Guide to Data Protection (2009) and the General Medical Council also published its own guide on confidentiality in 2009.
  3. The Department of Health’s Confidentiality NHS Code of Practice states: ‘Where the patient is incapacitated and unable to consent, information should only be disclosed in the patient’s best interests, and then only as much information as is needed to support their care’ (appendix B, paragraph 13). It also guides that professionals must judge each situation on its merits and need to take great care to avoid breaching confidentiality. Further, the guidance notes that ‘Patients are often asked to indicate the person they would like to be involved in decisions about their care should they become incapacitated. This will normally, but not always, be the ‘next of kin’’ (appendix B, paragraph 15).
  4. The General Medical Council’s guidance on confidentiality states that professionals may need to share personal information with a patient’s relatives to help assess their best interests. However, it notes that this ‘does not mean they have a general right of access to the patient’s records’ (paragraph 62). For patients who lack capacity the guidance notes that ‘it is reasonable to assume that patients would want those closest to them to be kept informed of their general condition and prognosis’ (paragraph 65).

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What I found

  1. Professionals removed Miss A and her brothers from their birth mother’s care when Miss A was four. Miss A’s early years had been traumatic and abusive. Miss A was separated from her brothers, had a number of placements in care and had a failed pre-adoptive placement before Mr and Mrs A adopted her in 2009 when she was ten.
  2. Mr and Mrs A said from the middle of 2013 there was a notable deterioration in Miss A’s mood and behaviour. Mr and Mrs A said this coincided with Miss A contacting her birth mother on social media and wanting to return to her to save her from drink and drugs.
  3. Miss A’s school expelled her at the start of 2014. Shortly after this Miss A attempted to kill herself and went into a mental health acute crisis ward in February 2014 on a voluntary basis. During the admission staff recorded various incidents of significant self-harm. These were acts Miss A had not previously done.
  4. From that point until Miss A’s 18th birthday, three years later in April 2017, she spent the majority of her time in mental health inpatient units. This included over three months at the Cygnet Hospital. It also included over a year and eight months at the Priory Hospital, a low-secure hospital for young people.
  5. On the day before Miss A turned 18 she was moved from the Priory Hospital to an acute adult ward of a different hospital. She stayed there until June 2017 then returned to Mr and Mrs A’s home.
  6. During the period from 2014 and 2017 there were a number of repeated conclusions about Miss A’s not being served well in an inpatient environment, and about the need for a specialist residential therapeutic placement. After delays in completing an assessment of Miss A’s needs the Council concluded it would need to act under the Children Act in order to arrange a placement for Miss A. It applied for a Care Order in June 2015 but later applied to withdraw this. After returning home in 2017 Miss A had placements at two places Mr and Mrs A had previously suggested but which had been ruled out. Mr and Mrs A said they both helped Miss A to manage her emotions and impulsivity.
  7. Mr and Mrs A raised a range of concerns about Miss A’s care. I have looked at these issues and included my full consideration of each in an appendix to this decision statement, which has been shared with the complainants and organisations. However, in order to keep this statement as focused as possible, where I have reached different findings for an organisation I have limited the content here to areas where I have found faults which led to an injustice which remains unremedied. For organisations where this does not apply I have included my finding, regardless of whether an outstanding unremedied injustice remains.

Complaint: The Council and Trust failed to work together and failed to produce a multi‑disciplinary care plan for Miss A during 2014 and 2015

Finding against the Council and Trust

  1. The Council and Trust both hold some responsibility for an avoidable delay (of around a month) in arranging a professionals meeting before October 2014.
  2. By the end of August 2014 there was a shared view that Miss A was benefiting from the inpatient care an adolescent open unit was providing. There was an overall agreement that it would be beneficial for her to stay there, at least for the duration of her s3 detention (i.e. to the end of January 2015). However, there was an understanding that Miss A would need a residential placement after this admission. In effect, this seems to have given services a more concrete timescale to concentrate on – in terms of a time by which they would need to have identified and agreed a placement, and prepared for it.
  3. A professionals meeting took place in early October 2014. In the days running up to it a Council social worker noted that she ‘agreed there has been a time delay is us having this meeting’.
  4. By the end of September 2014 Miss A had been in hospital for three‑and‑a‑half months and been detained under s3 for about two‑and‑a‑half months. It was also about two-and-a-half months since the need for a residential placement had been ‘confirmed’. There had been CPA meetings in the interim, and there had been some contact between Council and Trust professionals, but I agree with the sentiment of the social worker – there was a delay in arranging this professionals meeting. Miss A’s case was a complex one and warranted closer, more formal and structured joint working.
  5. On balance, had a professionals meeting happened sooner, the issues needing clarification and further work would have been highlighted sooner. It follows that they could have been addressed in a more timely manner. Therefore, by this point, things would have been at a more advanced stage were it not for the delay. In short, the delay (of around a month) in arranging this meeting was fault and it had a detrimental impact on Miss A’s care planning. I consider both the Council and Trust bear some responsibility for this fault and injustice.

Finding against the Council

  1. The Council was responsible for a further avoidable delay in progressing Miss A’s case from October to November 2014. In addition, there was fault in the Council’s decision, in November 2014, to place responsibility for care planning with the NHS.
  2. Toward the end of October 2014, around two‑and‑a‑half weeks after the professionals meeting, there is evidence of some contact between the Council and Trust about what type of placement would be suitable for Miss A. However, there should have been greater urgency here. At the CPA meeting in early November 2014 nothing was decided and plans for Miss A’s future remained unresolved. The delay was the responsibility of the Council. The delay had a negative impact on progressing plans for Miss A’s care.
  3. Also, in mid November 2014 the Council said it was for the NHS to find a placement for Miss A. This came out of the blue, was unhelpful and did not reflect the joint responsibilities it and the NHS had towards Miss A’s care. This decision caused unnecessary avoidable disruption to the care planning process, albeit for a relatively short period.
  4. These faults – from September to November 2014 – caused avoidable delays in progressing Miss A’s case. This, in turn, caused avoidable anxiety and frustration for Miss A and Mr and Mrs A. It has also left lasting uncertainty about whether better outcomes could have been achieved earlier, had it not been for the delays. This uncertainty extends the distress Miss A and Mr and Mrs A suffered at the time of the delays.

Finding against the Trust

  1. The Trust was responsible for an avoidable delay (of around a month) in arranging a move from an intensive care unit to a more suitable unit before April 2015.
  2. In early January 2015 there was another professionals meeting. This maintained the collective agreement that Miss A needed a suitable specialist placement. Less than a month into Miss A’s admission to the intensive care unit its clinicians concluded that she did not need to be there. They concluded Miss A would be better served transferring back to a more open unit until her long term care could be arranged.
  3. Miss A remained in the intensive care unit, about 220 miles from Mr and Mrs A’s home, until April 2015 when she was moved at the direction of a Mental Health Tribunal. There are coherent reasons to explain why the Trust was initially reluctant to arrange an interim move before a long term placement was found. However, by early March 2015 it had been established that there may be a wait of up to six months before a place became available. Therefore, I consider the Trust could, and should, have taken steps to help ensure Miss A moved (from the intensive care unit to a more suitable unit closer to home) around a month sooner than occurred. The delay was fault on the part of the Trust.
  4. This fault meant Miss A had to stay in an unnecessarily restrictive environment for a month too long. This unfairly deprived her of personal freedoms and caused her stress. It also caused Mr and Mrs A stress along with avoidable time and trouble in visiting the physically distant facility.

Complaint: There was a long delay before the Council completed an assessment they asked for in October 2013

Finding against the Council

  1. The Council was responsible for a long avoidable delay in completing an assessment of Miss A’s needs. It noted the need for an assessment at the end of October 2013 but did not complete it until March 2014. The Council has already acknowledged this fault but I do not consider it has fully acknowledged the impact.
  2. As a result of this delay unnecessary uncertainty remained about how any placement for Miss A would be funded. This, in turn, meant that formal meetings about Miss A’s care failed to reach firm conclusions. This was a source of frustration in the short‑term and has left uncertainty about whether Miss A missed out on more appropriate care earlier.

Complaint: A Child in Need Plan the Council produced in March 2014 was inadequate

Finding against the Council

  1. The Council was responsible for an inadequate Child in Need plan of March 2014. Again, the Council has already acknowledged this fault but I do not consider it has properly addressed the impact.
  2. Miss A and Mr and Mrs A have been left with avoidable uncertainty about whether subsequent events would have run more smoothly, and whether Miss A might have received more appropriate care earlier, had fault not occurred at this early stage. This uncertainty is a source of lasting frustration.

Complaint: There has been a lack of transparency from the Council and Trust

Finding against the Council and the Trust

  1. Both the Council and the Trust have already accepted they did not act with appropriate transparency, which was fault. This includes, on the Council’s part, failing to tell Mr and Mrs A of the plans for Care proceedings until the day before a court hearing and, from the Trust, continuing to note criticisms of Mr and Mrs A without sharing them with Mr and Mrs A. However, I do not consider either organisation has fully acknowledged the impact of this.
  2. The lack of transparency caused Mr and Mrs A avoidable distress. It has also left further uncertainty about opportunities to progress Miss A’s case were lost because of the failure to work openly.

Complaint: The Council failed to make notes of a visit to Miss A’s birth mother in April 2014, and failed to tell Miss A about the visit promptly

Finding against he Council

  1. The Council was at fault for failing to inform Miss A of a Social Worker’s visit to her birth mother in a timely manner. The Council found fault with record keeping. However, on balance, I consider there is evidence of fault beyond a failure to properly record events.
  2. It is clear from the contemporaneous records that Miss A’s contact with her birth mother was a very important issue for her. As such, it is understandable that she was eager to hear any news of someone else’s contact, essentially on her behalf.
  3. I cannot provide a timeline of what happened here but, on the balance of probabilities, the evidence persuades me that there was a fairly sizeable gap between the social worker’s visit and speaking to Miss A about it. Mr and Mrs A said the social worker and her manager visited Miss A’s birth mother at the end of April 2014. They said they know this because another member of staff told them. I accept the social worker’s view that this was a discussion best had face-to-face. I also accept that there had been unsuccessful attempts to meet before the middle of June 2014. However, given the significance of the news to share, there was scope for a greater level of urgency.
  4. This fault meant Miss A experienced avoidable frustration and upset which, in turn, weakened her trust in professionals.

Complaint: There was a long delay before the Council completed an assessment requested in July 2014

Finding against the Council

  1. The Council was responsible for a long avoidable delay in completing an assessment of Miss A’s needs, between July 2014 and July 2015. The Council has already acknowledged this fault but I do not consider it has fully acknowledged the impact.
  2. The delayed assessment left uncertainty and frustration about whether a more timely assessment would have aided Miss A’s care, which is an injustice to Miss A and Mr and Mrs A.

Complaint: The Council and Trust failed to consider Thornby Hall as a possible placement in early 2015

Finding against the Council

  1. The Council was at fault for failing to work flexibly and give more formal consideration to a possible placement in early 2015.
  2. In early 2015 the Council rejected a possible placement on the basis it was not rated ‘Good’ as a school by Ofsted. However, later correspondence shows the Council had discretion over this decision. There is insufficient evidence to show it properly considered this matter.
  3. This has left Miss A and Mr and Mrs A with uncertainty about possible lost opportunities to get more appropriate care earlier.

Complaint: Cygnet continued to listen in to Miss A’s telephone calls after a police investigation finished

Finding against Cygnet

  1. Cygnet was at fault for continuing to monitor Miss A’s telephone calls without a proper clinical rationale.
  2. The Cygnet Hospital was initially advised to monitor Miss A’s calls because of a police investigation. However, the hospital chose to continue monitoring the calls after the police involvement ended, and after the Council confirmed it was not expecting it to do so. There was no clear clinical rationale for this.
  3. This was an intrusive practice which impacted on Miss A’s (and others) right to privacy.

Complaint: Cygnet withheld important information from Miss A

Finding against Cygnet

  1. Cygnet was at fault for failing to properly consider sharing a letter from an external consultant with Miss A.
  2. It was for the Cygnet Hospital to decide whether to share this letter. There is some superficial evidence to show the clinical team at the Cygnet Hospital made a conscious choice not to share this letter based on their view of its likely impact. However, given Miss A’s acknowledged desire to go back to the adolescent unit, and given that withholding the letter would do nothing to change the underlying decision, there should have been further documentation about this. Therefore, I cannot be assured that staff gave this issue fair and proper consideration. As such, I find fault on the part of Cygnet.
  3. This fault led to avoidable frustration, anxiety and distress for Miss A.

Complaint: Cygnet failed to produce an adequate discharge summary or risk assessment when Miss A left the Cygnet Hospital in April 2015

Finding against Cygnet

  1. Cygnet was at fault of failing to complete an adequate discharge summary in April 2015.
  2. On balance, the absence of a detailed discharge summary is likely to have been detrimental to the following professionals. This also caused avoidable frustration for Mr and Mrs A.

Complaint: The Trust failed to work with the Council prior to Miss A’s move to a Priory Group Placement (the Priory Placement) in June 2015, and failed to raise any objections to the placement

Finding against the Trust

  1. The Trust was at fault for a failure to raise objections about a move to the Priory Placement ahead of time. The Trust has acknowledged it would have been useful for Dr E to have discussed his concerns with the professional network before the move.
  2. The Trust also failed to pass on sufficient information to a CAMHS team in another part of the country, which the Trust has also accepted.
  3. While the Trust has acknowledged failings here, I do not consider it has fully addressed the implications.
  4. These failings meant the unplanned end to the placement was more stressful and disruptive, for Miss A and Mr and Mrs A, then it may otherwise have been.

Complaint: The Trust failed to arrange an informal placement at Snowsfields when Miss A’s placement at the Priory Placement ended in July 2015

Finding against the Trust

  1. The Trust was at fault for failing to consider whether to exercise discretion over its usual procedures for accepting referrals. The Trust had a long, thorough knowledge of Miss A and knew of the complexity of her needs.
  2. On balance, Miss A would have been readmitted to the adolescent unit about a week-and-a-half earlier had the fault not occurred. This, in turn, could have helped to manage Miss A’s distress at this turbulent time. Further, it would have helped reduce the stress and anxiety Mr and Mrs A experienced during this time.

Complaint: The Council and Trust failed to arrange a professionals meeting promptly after Miss A’s placement at the Priory Placement ended in July 2015

Finding against the Council and the Trust

  1. The Council and the Trust are both responsible for an avoidable delay in arranging a professionals meeting after Miss A’s placement at the Priory Placement ended.
  2. The Priory Placement advised the Council Social Worker it could not have Miss A back on 8 July 2015. A professionals meeting took place six weeks later, on 19 August 2015. Despite the complexity and fluid nature of the events, this was an excessive and avoidable delay.
  3. This delay contributed to avoidable frustration for Miss A and Mr and Mrs A. It also, again, left uncertainty about whether Miss A’s could have received more suitable care sooner.

Complaint: The Council failed to follow Public Law Outline Procedures before applying for a Care Order

Finding against the Council

  1. The Council was responsible for failing to do enough to avoid the need for Care proceedings, which it has accepted. However, I do not consider the Council has fully addressed the impact of this.
  2. This Council’s pursuit of a Care Order caused Miss A significant avoidable distress, and caused further distress to Mr and Mrs A. It has also left uncertainty about whether progress in Miss A’s case could have been faster had the fault not occurred. In addition, Mrs A lost out on three weeks’ earnings, totalling over £2,000, because of an understandable and reasonable decision to take time off work for the proceedings. She would not have lost these earnings had the fault not occurred.

Complaint: The Council and Trust failed to investigate their complaints adequately

Finding against the Council and the Trust

  1. The complaints put to the Council and the Trust were detailed and complex and challenging. However, regardless of this complexity, there was fault in the complaint handling of both the Council and Trust. The failings caused Mr and Mrs A avoidable frustration.

Complaint: The Trust continued to discredit them behind their back

Finding against the Trust

  1. The Trust was responsible for a failure to copy Mr and Mrs A in to correspondence about them. The Trust said it would have been good practice to have shared information with Mr and Mrs A or to have recorded why it had not. It said this did not happen and apologised.
  2. This fault caused avoidable Mr and Mrs A avoidable frustration.

Complaint: Dr K failed to adapt his approach to provide a suitable, individualised treatment package for Miss A’s needs

Finding against the Priory Hospital

  1. The Priory Hospital are responsible for a failure to consider alternative therapeutic approaches for Miss A, particularly following a second opinion report. There is no evidence to show the second opinion doctor’s recommendations were properly scrutinised or followed-up.
  2. This meant there was a lost opportunity, with resulting uncertainty, to explore alternatives which may have been of a benefit to Miss A. This has been a source of distress to Miss A and Mr and Mrs A.

Complaint: The Priory Hospital failed to work collaboratively with them

Finding against the Priory Hospital

  1. The Priory Hospital are at fault for failing to work collaboratively with Mr and Mrs A. The Priory Hospital accepted there were failings in the way it worked with Mr and Mrs A, and the care planning process did not work as well as it should have done.
  2. This caused Mr and Mrs A avoidable distress. It has also, again, left uncertainty about whether greater progress could have been made for Miss A at an earlier date had the fault not occurred.

Complaint: The Priory Hospital unreasonably ended family therapy sessions in November 2016

Finding against the Priory Hospital

  1. The Priory Hospital are at fault for failing to properly replace Family Therapy sessions.
  2. Records from late 2015 and into 2016 note that family therapy sessions were going well. The therapist was instructed by the Priory Hospital to end her involvement at the end of November 2016. Following this Mr and Mrs A only had two meetings before April 2017 and they did not include Miss A. Given the Priory Hospital has acknowledged the sessions were not changed because of a change of clinical need this reduction in support, which all parties found beneficial, is fault.
  3. As a result, Miss A and Mr and Mrs A missed out on the opportunity to benefit from a source of therapeutic support for several months. The loss of opportunity, and the associated uncertainty about what more might have been gained, is an injustice.

Complaint: The Trust failed to make appropriate efforts to find and arrange a suitable therapeutic placement before Miss A turned 18 in April 2017; and

The Priory Hospital failed to ensure timely and appropriate efforts were made to find a suitable step-down placement after April 2016

Finding against the Trust and the Priory Hospital

  1. The Trust and the Priory Hospital are both responsible for a failure to work with Miss A and Mr and Mrs A to create a firm transition plan before her 18th birthday. The Priory Hospital agreed a move to an adult mental health ward was an unsatisfactory outcome and represented a failure of the health and care system in this case.
  2. Miss A transferred to the Priory Hospital in August 2015. I accept that the Trust could not control the availability of suitable placements, and could not control which placements would offer residential places, or which would decide they could not meet Miss A’s needs. Further, the Trust’s decision to allow time for Miss A’s to benefit from the Priory Hospital was understandable, and I accept this would have consequences for what needs would be left and what a placement would have to provide.
  3. Nevertheless, the eventual outcome – of Miss A transferring to an adult inpatient ward – was an unsatisfactory one. Miss A had been in the Priory Hospital for around 20 months by this point and there are several records which document the progress she made during that time. Further, it was not until about a month before Miss A’s 18th birthday that the eventual plan was confirmed. There should have been greater consultation with Miss A and Mr and Mrs A to create a firmer transition plan to adult services, including contingency plans.
  4. The lack of a clear plan, and the corresponding uncertainty, caused Miss A avoidable anxiety and distress. It was also a source of stress and frustration for Mr and Mrs A.

Complaint: The Priory Hospital and the Trust arranged to move Miss A to an adult acute ward the day before her 18th birthday

Finding against the Trust and the Priory Hospital

  1. The Trust and the Priory Hospital both hold some responsibility for an inappropriate decision to discharge Miss A to an adult unit the day before her 18th birthday.
  2. I have not seen anything to show there was a specific clinical or legal need to move Miss A before she turned 18. In March 2017 the Trust had noted the need for the move to happen after Miss A’s 18th birthday. The wish to spend time with friends at such a significant birthday is common and understandable. I do not consider the convenience of the receiving unit should have outweighed consideration of Miss A’s feelings or her emotional wellbeing. Overall, the decision to transfer Miss A’s to a new, unfamiliar environment before her 18th birthday was fault, on the part of both the Trust and the Priory Hospital.
  3. The timing of this move caused Miss A avoidable and unnecessary distress. It also meant a missed opportunity to share an important milestone with people she had built relationships with.

Complaint: The CCG failed to work with the Trust and Council and failed to progress Miss A’s case

  1. As detailed above, I have found a variety of fault in the care planning process for Miss A. I have focused on the actions of the professionals directly involved in the day-to-day identification of Miss A’s needs, and the considerations of what type of care was required to meet them. I have not found any fault on the part of the CCG as I did not find evidence it had prevented any plans from being progressed.

Complaint: NHS England failed to ensure Miss A’s case was progressed in a timely and appropriate way

  1. NHS England has acknowledged that it did not have sufficient clinical oversight of Miss A’s case. It said it over-relied on the provider to progress Miss A’s transfer to the community. It apologised for Miss A’s experience and said the circumstances should not be repeated. NHS England said it was reviewing how it commissions and assures its services and changing its structures.
  2. This was an open response from NHS England which has acknowledged fault in its role in this process. It has acknowledged the individual impact on Miss A this contributed to and is taking steps to learn from the case to help improve its service. On this basis I do not consider there is evidence of an outstanding injustice and I have not recommended any further action.

Consideration of overall injustice

  1. Miss A had a traumatic start to life which had a significant lasting impact. This, in turn, made her a very vulnerable member of society and in need of, and entitled to, coordinated support from health and social care services. The lasting impact of Miss A’s start to life, and her need for support, came to the fore in 2014. Since that time the Council and various part of the NHS have been involved in her care.
  2. It is evident from the extensive records that this has been a complex situation for all concerned and there has not been an easily identifiable or obtainable solution. My review of the records has also shown me evidence of concern for Miss A’s welfare, and a desire to help her, from a range of professionals. The records also clearly demonstrate Mr and Mrs A’s commitment to Miss A and their consistent advocacy for her.
  3. However, despite this evidence of good intentions, from 18 January 2014 to 25 April 2017 (when Miss A turned 18) she spent 1,106 days (over three years) in some form of psychiatric inpatient setting – close to 93 percent of the total time. There were considerable portions of this time where it was acknowledged by professionals that Miss A was not in the right place for her needs.
  4. The various complaints processes, along with this investigation, have acknowledged a series of failings in Miss A’s care throughout this time. Because of the intricacies and complexity of the issues involved I cannot say where Miss A would be now, and how her experiences would have been different, had the faults not occurred. Nevertheless, I consider Miss A and Mr and Mrs A have been left with an understandable belief that Miss A would have suffered less distress had it not been for the combined impact of the faults.
  5. In relation to this, Miss A has given clear accounts of the distressing circumstances of various points of her inpatient stays. It is clear she found them, at times, frustrating, demeaning, frightening, unhelpful, upsetting and also abusive. It goes beyond the scope of my investigation to perform a forensic examination of the day-to-day events of Miss A’s admissions during this three year period. However, the account of events Miss A gave me was coherent and I have no reason to dismiss what she told me.
  6. In view of this, I consider the lasting uncertainty – about lost opportunities and about unnecessarily long stays in such environments – is a significant source of injustice in its own right. Miss A (and Mr and Mrs A) has been left with a fair belief that her life need not have been so hard, and that progress did not need to be so slow. Miss A also explained that the lack of clarity or open communication about the plans for her future was very stressful and destabilising.
  7. I do not believe there is an effective way of quantifying the full impact of each failing that occurred, because of the ongoing and inter-related nature of them. The effects of individual failings were compounded by others and all contributed to the injustice Miss A and Mr and Mrs A have suffered.
  8. While the organisations have acknowledged some of the failings that occurred I believe the impact of each failing was not always considered in the wider context. As such, I do not consider the full implications of the faults have been properly acknowledged or addressed. I have made recommendations to help put things right.

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Agreed actions

  1. Within one month of the final decision the Council, the Trust, Cygnet and the Priory Hospital should individually write to Miss A to acknowledge their organisation’s faults, as identified in this decision. The organisations should also acknowledge and apologise for the impact – both immediate and in terms of their contribution to the wider impact – of the faults on Miss A.
  2. Within one month of the final decision the Council, the Trust, Cygnet and the Priory Hospital should also individually write to Mr and Mrs A to acknowledge their organisation’s faults, as identified in this decision. The organisations should also acknowledge and apologise for the impact these faults had on Mr and Mrs A.
  3. Within two months of the final decision the Council should pay Miss A £2,500 as a tangible acknowledgement of its part in contributing to the overall delays in progressing her case, and the lack of clarity Miss A had about her future throughout this time. This includes the delays in arranging meetings, delays in progressing the case, delays and failings in assessments and plans, and failing to work flexibly when considering possible placements.
  4. Within two months of the final decision the Trust should pay Miss A £1,500 as a tangible acknowledgement of its part in contributing to the overall delays in progressing her case, and the lack of clarity Miss A had about her future throughout this time. This includes the delays in arranging meetings, delays in progressing the case and failing to raise objections about possible placements in good time.
  5. Within two months of the final decision the Council should also pay Mr and Mrs A £400 to recognise the impact the failings in progressing Miss A’s case had on them.
  6. Within two months of the final decision the Trust should also pay Mr and Mrs A £200 to recognise the impact the failings in progressing Miss A’s case had on them.
  7. Within two months of the final decision the Council should pay Miss A a further £500 in recognition of the impact of its failure to do enough to avoid care proceedings.
  8. The Council should ask Mr and Mrs A for evidence of Mrs A’s lost earnings related to the unpaid leave she took because of the Care proceedings. On receipt of suitable evidence the Council should reimburse Mrs A for the full amount of these lost earnings. Providing there are no delays which are out of its control, the Council should provide this reimbursement within two months of the final decision.
  9. Within two months of the final decision the Trust and the Priory Hospital should both (individually) pay Miss A £200 in recognition of the impact of the decision to move her to an adult facility before her 18th birthday.
  10. Within two months of the final decision the Council should pay Mr and Mrs A a further £200 to recognise the impact of its lack of transparency throughout the course of these events.
  11. Within two months of the final decision the Trust should pay Mr and Mrs A a further £200 to recognise the impact of its lack of transparency throughout the course of these events.
  12. Within two months of the final decision Cygnet should pay Miss A £500 to reflect the impact of its inappropriate monitoring of calls, the failure to share a consultant’s letter and its poor discharge paperwork.
  13. Within two months of the final decision the Priory Hospital should pay Miss A £750 for the lost opportunities, and consequent uncertainty about lost therapeutic benefits, relating to overall approach and lost family therapy.
  14. Within two months of the final decision the Priory Hospital should pay Mr and Mrs A £500 to recognise the impact its failings had on them, including their lost opportunity to benefit from the family therapy sessions.
  15. Within three months of the final decision the Council and Trust should both review their own handling of this complex complaint. As part of this, the Council and Trust should review their existing policies and procedures and check they are in keeping with the relevant legislation about childrens and health and social care complaints, including the consideration of joint working.
  16. Within three months of the final decision the Council and Trust should work together to review this case to learn lessons their individual and joint case management of complex cases such as Miss A’s. As part of this work it should review relevant legislation and guidelines. The Council and Trust should seek to develop workable and realistic ways of establishing clearer lines of communication and clearer responsibilities for case management in joint cases. The review should also consider matters dispute resolution and escalation. In undertaking this work the Council and Trust may wish to consider approaching the CCG (and other local CCGs) and NHS England to ensure its policies properly account for relevant funding processes and any wider case management and escalation processes.
  17. Within three months of the final decision the Council should review this case and any processes or procedures it has for keeping track of delays in assessments and care planning. The Council should ensure that its processes include suitable and practical ways of highlighting, escalating and addressing any obstacles to the timely and adequate completion of assessments and care plans. The Council should also take steps to ensure its procedures are properly embedded and that relevant staff are aware of them.
  18. Within three months of the final decision the Council should consider its policies and practices for choosing placements for young people eligible for its support. Specifically, the Council should consider whether its procedures are appropriately flexible and realistic to be able to handle complex cases such as this one, where suitable placements are in short supply. The Council should also ensure its policy is clear and that relevant staff are aware of it.
  19. Within three months of the final decision the Council should review this case and consider the issues it highlights around respective duties for Children in Need and/or Looked After Children who are also under s117 and have EHCPs. It should clearly establish its position on its duties and develop clear policies and procedures to guide staff in complex cases with overlapping duties. This might involve clarifying the options the Council has for meeting its various duties and setting out what steps should be taken to meet them. The Council should also take steps to ensure its procedures are properly embedded and that relevant staff are aware of them.
  20. Within three months of the final decision the Trust should review this case and any processes or procedures it has for keeping track of obstacles to young people moving on from unsuitable facilities or placement. The Trust should ensure that its processes include suitable and practical ways of highlighting, escalating and addressing any obstacles. The Trust may wish to contact other Trusts and NHS organisations (such as CCGs and NHS England) to check whether any improvements could be made to its ability to search for and approach specialist placements, or to improve its escalation procedures. The Trust should also take steps to ensure its procedures are properly embedded and that relevant staff are aware of them.
  21. Within three months of the final decision the Trust should review this case and any relevant policies or procedures it has about what should happen when it transfers a young person’s care to other units. The Trust should make sure it has suitable protocols are in place which will help to ensure that sufficiently detailed information and advice is passed on in good time. The Trust should also take steps to ensure its procedures are properly embedded and that relevant staff are aware of them.
  22. Within three months of the final decision the Trust should review this case and any relevant policies or procedures it has about accepting referrals for previous patients. It should consider whether the relevant protocols offer sufficient discretion and flexibility for well-known, complex and urgent cases. The Trust should also take steps to ensure its procedures are properly embedded and that relevant staff are aware of them.
  23. Within three months of the final decision Cygnet should review this case and any policies and procedures it has about the monitoring of communications. It should ensure its policies are fit for purpose and in keeping with relevant legislation and guidance about confidentiality and human rights. Cygnet should also make sure its policies are properly embedded and understood by staff.
  24. Within three months of the final decision Cygnet should review this case and the issues it highlighted about the lack of a detailed rationale for not sharing a letter, and the discharge paperwork. Cygnet should pass on learning to staff about the importance of adequate, sufficiently detailed record keeping and communication.
  25. Within three months of the final decision the Priory Hospital should review this case and the issues it highlights about how it takes account of requests for changes to its therapeutic approach. It should ensure there are suitable mechanisms in place to allow constructive challenges which will be handled in a transparent way with outcomes clearly communicated and explained. The Priory Hospital should also make sure its policies are properly embedded and understood by staff.
  26. Within three months of the final decision the Trust and the Priory Hospital should both, individually, review this case and relevant legislation and guidance about transition from adolescent to adult services. The Trust and the Priory Hospital should make sure it has suitable policies and procedures in place that reflect the guidance and which take account of ‘human factors’ for the service user.

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Decision

I have completed my investigation on the basis there was fault leading to injustice. I have made recommendations to help put things right for Miss A and Mr and Mrs A.

Under our information sharing agreement, we will share this decision with the Office for Standards in Education, Children's Services and Skills (Ofsted) and with the Care Quality Commission (CQC).

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Investigator's decision on behalf of the Ombudsman

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