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Warwickshire County Council (20 009 803)

Category : Children's care services > Other

Decision : Upheld

Decision date : 10 Jan 2022

The Ombudsman's final decision:

Summary: We found fault by the Council, CCG and Private Hospital with regards to how they planned aftercare for a young person following her discharge from hospital after a period of detention under the Mental Health Act 1983. These organisations have agreed to apologise and the Private Hospital will also pay the complainant a financial remedy. We found no fault by the Private Hospital in terms of the consideration it gave to the young person’s diagnosis during her admission.

The complaint

  1. The complainant, who I will call Ms Y, is complaining about the care and treatment provided to her daughter, Miss X, during a hospital admission between November 2017 and April 2018. She complains that
  • Woodbourne Priory Hospital (the Private Hospital) failed to diagnose her daughter’s depression, incorrectly attributing her symptoms to emerging Emotionally Unstable Personality Disorder (EUPD), psychosis and Autism.
  • The Private Hospital, Warwickshire County Council (the Council) and South Warwickshire Clinical Commissioning Group (the CCG) failed to put appropriate Section 117 aftercare in place for her daughter prior to her discharge in April 2018.
  1. Ms Y says these failings caused her daughter serious mental and physical harm and resulted in further hospital admissions for treatment. Furthermore, Ms Y says this situation caused her significant distress.
  2. Ms Y would like the Private Hospital to acknowledge that it misdiagnosed her daughter and apologise for the impact this failing had on her treatment. She would also like the organisations she is complaining about to acknowledge that they failed to put appropriate care in place for her daughter prior to her discharge in April 2018, thereby making further hospital admissions necessary.

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The Ombudsmen’s role and powers

  1. 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).
  2. 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.
  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. In making my final decision, I considered information provided by Ms Y and discussed the complaint with her. I also considered information and documentation provided by the Priory Group and Council, including relevant care records. In addition, I took account of relevant legislation and guidance. Furthermore, I considered comments from all parties on my draft decision statement.

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What I found

Relevant guidance and legislation

Mental Health Act 1983 – Detention

  1. The Mental Health Act 1983 (the Act) says that, when someone has a mental disorder and is putting their safety, or that of someone else at risk, they can be detained in hospital against their wishes. This is sometimes known as ‘being sectioned’.
  2. Section 2 of the Act allows for assessment of a patient’s mental health and to provide any treatment they might need. Patients can be detained under section 2 for a maximum of 28 days.
  3. Section 3 of the Act is for the purpose of providing treatment. Detention under Section 3 empowers doctors to detain a patient for a maximum of six months. At the end of this period, the detention can be renewed for another six months following a review.
  4. Section 136 of the Act is an emergency power. It allows the police to remove a mentally disordered person from a public place to a place of safety if a police officer considers it necessary in the interests of that person or for the protection of others.

Mental Health Act 1983 – Care Programme Approach

  1. The Care Programme Approach (CPA) is a system for coordinating the care of people with mental disorders. It requires the allocation of a care coordinator.
  2. The Mental Health Act Code of Practice 2015 (the Code of Practice) is the statutory guidance that accompanies the Mental Health Act.
  3. Section 34.3 of the Code of Practice explains that a central part of the CPA is the CPA care plan. This should include “a treatment plan which details medical, nursing, psychological and other therapeutic support for the purpose of meeting individual needs promoting recovery and/or preventing deterioration.” The plan should detail how the patient will be supported to meet their personal goals and set out any social care support needs and how these will be met.

Mental Health Act 1983 – Section 117

  1. Miss X was detained in hospital for treatment under Section 3 of the Act. When she was discharged, Miss X became eligible for free aftercare services under Section 117 of the Mental Health Act. These are care and support services intended to meet any needs related to the person’s mental disorder and prevent the need for them to be readmitted to hospital in future.
  2. Responsibility for providing, or arranging, Section 117 aftercare services rests with the local authority and local clinical commissioning group. In Miss X’s case, the private hospital was responsible for arranging Miss X’s discharge from hospital in consultation with a local Mental Health Trust. However, the Council and CCG retained overall responsibility for ensuring Miss X received appropriate Section 117 aftercare.
  3. The Code of Practice emphasises the importance of effective aftercare planning using the CPA.
  4. Section 33.13 of the Code of Practice say that “[b]efore deciding to discharge or grant more than very short-term leave of absence to a patient…the responsible clinician should ensure that the patient’s needs for after-care have been fully addressed, discussed with the patient (and their carers, where appropriate) and addressed in their care plan.”
  5. Section 33.14 of the Code of Practice says that “[a]fter-care for all patients admitted to hospital for treatment for mental disorder should be planned within the framework of the care programme approach…But because of the specific statutory obligation it is important that all patients who are entitled to after-care under Section 117 are identified and that records are kept of what is provided to them under that section.”

Key facts

  1. Miss X is a young person with complex mental health needs and a history of self-harm and suicidal thoughts. At the time of the events Ms Y is complaining about, Miss X was 16 years old.
  2. On 4 November 2017, Miss X absconded from the house of a family friend. She was later found by police attempting to run in front of moving traffic. The police used the powers granted to them by Section 136 of the Act to remove Miss X to a place of safety.
  3. Miss X was subsequently transferred to the Private Hospital for assessment and treatment. Miss X initially refused to take any medication. She told staff she preferred natural remedies.
  4. The on-call consultant visited Miss X the following day. She noted Miss X was showing some potential features of Autism Spectrum Disorder (ASD) and may require further assessment.
  5. On 11 November, Miss X attempted to leave the ward but was persuaded to stay by staff. Shortly after this, staff found Miss X attempting to fashion a ligature around her neck and intervened.
  6. On 14 November, staff observed Miss X banging her head against the wall. She then attempted to fashion a further ligature on 14 November. When staff intervened, Miss X assaulted them.
  7. The Private Hospital completed an Autism Diagnostic Observation Schedule (ADOS-2) on 29 November. This is an ASD assessment tool that forms part of a wider ASD assessment process. This found Miss X had difficulty with social communication, as well as identifying and communicating emotions.
  8. At a multidisciplinary team meeting on 6 December, the clinical team noted that Miss X appeared to be showing some symptoms of psychotic illness. These included delusional beliefs and responding to unseen stimuli. The clinical team arrived at a working diagnosis of ASD and delusional disorder. They noted Miss X may benefit from a prescription of Aripiprazole (an antipsychotic medication) but that she continued to refuse this intervention.
  9. On 14 December, the clinical team became concerned that both Miss X and Ms Y continued to insist that Miss X should be discharged back into the community. The clinical team felt Miss X remained at high risk of harm due to her ongoing suicidal thoughts. The decision was made to detain Miss X under Section 5(2), and then Section 2, of the Act.
  10. Following further assessment, the clinical team felt Miss X may also be displaying symptoms consistent with emerging Emotionally Unstable Personality Disorder (EUPD). This is a mental health condition causing a person to experience intense and fluctuating emotions that can be hard to deal with.
  11. On 2 January 2018, ward staff found Miss X had barricaded herself in her room. She was sitting in her wardrobe and rubbing two knives against her face. Miss X initially would not respond to staff. A search of her room revealed two more knives and staff removed these.
  12. The Council allocated a social worker to Miss X on 5 January to complete a single assessment. This is an assessment document that sets out a young person’s health and social care needs and how these will be met.
  13. The following night Miss X experienced a psychotic episode. Staff observed Miss X fashioning a ligature and banging her head against the walls and floor. When they intervened, she became increasingly aggressive and struck out at staff. Staff administered ‘as needed’ medication (known as pro re nata or PRN medication) to calm her.
  14. Miss X remained agitated and unsettled over the following days, making further attempts to bang her head and create ligatures. Staff also observed Miss X attempting to gouge her eyes repeatedly. The decision was made on 9 January to detain Miss X under Section 3 of the Act for further treatment.
  15. On 24 January, Ms Y consented for Miss X to be treated with Olanzapine (an antipsychotic medication). However, Ms Y continued to voice concerns about the use of medication.
  16. At a meeting with Miss X’s consultant on 30 January, Ms Y said she felt the medication was having a detrimental effect on Miss X and was making her drowsy and unresponsive. The consultant explained that the medication was being used primarily to treat the symptoms of agitation and anxiety arising from Miss X’s ASD diagnosis. The consultant explained that Miss X would be given an alternative antipsychotic medication (Quetiapine).
  17. In the early hours of 5 February, made repeated attempts to gouge her eyes and had to be restrained by staff. She reported being visited in her room by boys she knew who advised her to do it. Miss X’s distressed behaviour continued over the following days. The clinical team changed Miss X’s medication back to Olanzapine to settle her.
  18. The social worker completed the single assessment in early February. This recommended that Miss X be placed on a Child in Need (CIN) plan to ensure her needs could be met.
  19. Miss X’s presentation settled over the following weeks. She began to spend time on leave from the ward with Ms Y.
  20. The Council convened a Child in Need meeting on 5 March at which the single assessment was discussed. The meeting agreed that Miss X should be placed on a Child in Need plan and subject to regular review in the community.
  21. On 26 March, Miss X’s Responsible Clinician discharged her from Section 3. Miss X agreed to remain on the ward as an informal patient.
  22. Miss X was eventually discharged from hospital on 23 April.



  1. Ms Y complained that the Private Hospital failed to diagnose Miss X’s depression. She said the clinical team incorrectly attributed her symptoms to emerging EUPD, psychosis and Autism. Ms Y said the depression diagnosis was not made until Miss X was admitted to a different hospital shortly after discharge.
  2. It is important to be clear that the Ombudsmen cannot diagnose a patient, nor decide what care and treatment that person should receive. As a result, my investigation of this issue has focused on whether the Private Hospital properly considered Miss X’s diagnosis, based on the information available to the clinical team at that time.
  3. The clinical records show Miss X did not have a clear diagnosis on admission to hospital in November 2017. A consultant psychiatrist reviewed Miss X the day after her admission. The consultant felt Miss X was displaying symptoms associated with ASD. This view was shared by the Responsible Clinician, who arranged an ASD assessment. However, the records show the Responsible Clinician also considering a possible EUPD diagnosis. The clinical team agreed to keep Miss X’s diagnoses under review during her admission.
  4. During the early days of her admission, Miss X regularly attended education and therapy groups and was noted to be generally stable and settled in mood. Staff noted on several occasions that Miss X appeared “bright” and “cheerful” and was interacting well with other patients on the ward.
  5. However, Miss X began to display some delusional behaviours. She referred to seeing a serial killer in her room and was noted by staff to be talking and chanting to herself in another language. Miss X also began to show self-harming behaviours. This included banging her head against walls and the floor and attempting to fashion ligatures. The Responsible Clinician began to consider whether Miss X was experiencing psychotic episodes. He noted delusional disorder as a possible additional diagnosis.
  6. The Private Hospital completed the ASD assessment in late November. This confirmed a diagnosis of ASD. The clinical team continued to monitor Miss X’s mental health due to ongoing incidents of self-harm.
  7. In January 2018, responsibility for Miss X’s care passed to another consultant. The new consultant considered ASD to be Miss X’s primary diagnosis. However, she did not challenge the differential diagnosis of delusional disorder recorded by the previous consultant.
  8. I found no evidence in the records to suggest the clinical team specifically considered a diagnosis of depression. However, the treating clinicians were concerned primarily with Miss X’s ongoing incidents of self-harm. The clinical records show these incidents were often accompanied by behaviours that suggested Miss X was responding to unseen stimuli, such as voices or images. In this clinical context, it was appropriate and in keeping with good clinical practice for the clinical team to explore whether Miss X had a psychotic illness.
  9. As I have explained, the Ombudsmen cannot make a diagnosis. This is a matter of clinical judgement for the professionals involved in that person’s care.
  10. The case records show consultants and other members of the clinical team regularly reviewed Miss X throughout her admission. There is evidence to show her diagnosis and care were also discussed during ward rounds and at multidisciplinary team meetings. Furthermore, the nursing staff on the ward made detailed daily observations to inform the diagnostic process. Taking everything into account, I am satisfied the clinical team gave appropriate consideration to Miss X’s presentation and diagnoses throughout her admission. I found no fault by the Private Hospital on this point.


  1. Ms Y complained that the Private Hospital, Council and CCG failed to put appropriate Section 117 aftercare in place for Miss X prior to her discharge in April 2018.
  2. The clinical records show Miss X was detained under Section 3 of the Act for part of her admission to the Private Hospital. This meant she was entitled to free aftercare services under Section 117 of the Act on discharge.
  3. The Code of Practice says the CPA should be used for individuals who are at high risk of suffering a deterioration in their mental condition and require ongoing support. This includes most people who are entitled to Section 117 aftercare. The purpose of this structured support is to prevent deterioration in the person’s mental condition and, accordingly, reduce the risk of readmission to hospital in future.
  4. The Code of Practice emphasises the importance of effective care planning using the CPA process. This is to ensure there is a comprehensive record of a patient’s health and social care needs and how these needs will be met in the community. The CPA care plan should also clearly document what services will be provided to the patient under Section 117. The CPA also requires the identification of a named care coordinator.
  5. The clinical records show the Responsible Clinician met with Miss X and Ms Y on the ward on 23 April to discuss her discharge. The Mental Health Trust that would be providing Miss X’s care in the community was also invited but did not attend. The note of this meeting records that Ms Y was “happy with follow up plans and that [Miss X] is being discharged”.
  6. The notes of that meeting do not detail these follow-up arrangements. I found no evidence of a CPA care plan in the clinical records or any indication that such a plan was shared with Ms Y and Miss X. This was contrary to the requirements of the Code of Practice and represents fault by the Private Hospital.
  7. There also appears to be some dispute as to whether Miss X had an allocated care coordinator at the point of discharge. In its responses to my enquiries, the Private Hospital explained that Miss X had been allocated a care coordinator. However, Ms Y disputes this.
  8. The clinical records show Miss X’s Responsible Clinician discussed her care with a community CAMHS consultant on 19 April. However, I found no evidence in the records of the Private Hospital arranging for a care coordinator to be allocated to Miss X. Similarly, I found no evidence to suggest a care coordinator was present at the discharge meeting on 23 April or otherwise involved in the planning of Miss X’s discharge.
  9. Section 34.5 of the Code of Practice requires the clear identification of “a named individual who has responsibility for co-ordinating the preparation, implementation and evaluation of the CPA care plan.” This is a significant part of the CPA care planning process. I found no evidence in the clinical records to suggest the Private Hospital arranged a care coordinator for Miss X. This was fault.
  10. The Council and CCG held the statutory duty for providing or arranging Section 117 services for Miss X. In my view, they share the Private Hospital’s fault as they failed to ensure that Miss X’s Section 117 aftercare was planned in accordance with the Code of Practice.
  11. I am unable to say whether Miss X’s subsequent deterioration and readmission to hospital would have been prevented, even if the Private Hospital had planned her discharge in accordance with the Code of Practice. The clinical records show Miss X’s mental health was stable at the point of discharge and that a physical health review had identified no problems. Furthermore, the Private Hospital did ensure Miss X had some care in the community. This included an appointment with a CAMHS consultant on 27 April, a referral for family therapy and ongoing medication.
  12. Nevertheless, I recognise the lack of clear care planning caused Miss X and Ms Y significant distress and uncertainty.

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Agreed actions

  1. Within one month of my final decision statement, the Council, CCG and Private Hospital will take the following actions.
  • The Council, CCG and Private Hospital will write to Ms Y and Miss X to apologise for the distress caused by their shared failure to plan Miss X’s Section 117 aftercare in accordance with the Code of Practice.
  • The Private Hospital will also pay Ms Y and Miss X £100 each in recognition of the impact of this fault on them.
  1. Within three months of my final decision statement:
  • The Private Hospital will review its Section 117 and discharge policies and procedures to ensure these reflect the requirements of the Code of Practice. This review should consider whether there are robust procedures in place for completing CPA/Section 117 care plans. It should also ensure there is a clear process for arranging the allocation of a care coordinator prior to an eligible service user’s discharge.
  • The Private Hospital will write to the Ombudsmen to explain the outcome of this review and detail any further actions arising from it.

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Final decision

  1. I found fault by the Council, CCG and Private Hospital with regards to the planning of Miss X’s Section 117 aftercare.
  2. I found no fault by the Private Hospital with regards to the consideration it gave to Miss X’s diagnosis.
  3. In my view, the actions these organisations have agreed to undertake represent a reasonable and proportionate remedy for the injustice caused to Miss X and Ms Y by the fault I identified.
  4. I have now completed my investigation on this basis.

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Investigator's decision on behalf of the Ombudsman

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