The Ombudsman's final decision:
Summary: The Ombudsmen find fault in the way a Council, NHS Trust and private provider worked together when a specialist placement ended in an unplanned way. The provider did not keep others properly informed of the resident’s deterioration, and the Council and Trust did not work together effectively to arrange alternative care in a timely way. This caused the young woman distress, and her parents stress. The organisations will apologise and provide symbolic financial payments to recognise this injustice. They will also take steps to learn from the case and prevent recurrences.
- Mr and Mrs G complain about the care and support of their daughter, Miss H, between November 2015 and late 2017. Their complaint is about:
- Warwickshire County Council (Warwickshire Council)
- Warwickshire Partnership NHS Trust (the Trust)
- Cambian Group Plc (Cambian), as the owner and operator of Purbeck View School (the School), and
- Dorset County Council (Dorset Council).
- Mr and Mrs G complain:
- The Trust’s Child and Adolescent Mental Health Services (CAMHS) team discharged Miss H when she moved into the School and failed to notify Mr and Mrs G
- The Trust’s CAMHS team failed to act on a letter Mr and Mrs G sent in February 2017
- Cambian failed to take appropriate or adequate action to address a deterioration in Miss H’s behaviour from late 2016. Mr and Mrs G said the School did not take appropriate and agreed steps to address the causes of Miss H’s deterioration. Further, Mr and Mrs G said the School failed to obtain any support from CAMHS, and said the in-house psychiatric support was inadequate.
- Cambian and Dorset Council failed to properly follow the ‘blue light protocol’ or assess Miss H adequately before she was detained under section two of the Mental Health Act in February 2017. Mr and Mrs G said no one has accepted responsibility for chairing the required ‘blue light’ meeting. Further, they said there are no notes of the meeting. Mr and Mrs G said professionals did not adequately involve them or Warwickshire care teams in the process. In addition, Mr and Mrs G said the professionals did not properly consider Miss H’s mental health at the time, and inaccurately reported that she was distressed and disturbed during this period. Mr and Mrs G said this ultimately led to an unnecessary decision to detain Miss H. They said this caused them and Miss H significant distress.
- The Trust failed to act on a referral to its service in a timely manner when Miss H returned home in February 2017. Mr and Mrs G said there were significant delays in completing an assessment of Miss H’s needs. They said this meant there was a long delay before Miss H and the family were offered any support. Mr and Mrs G said this caused them all distress and Miss H’s mental health deteriorated.
- Warwickshire Council failed to provide or arrange appropriate care and support, and, with Cambian, failed to decide if Miss H could return to the School in a timely manner after Miss H returned home in February 2017. Mr and Mrs G said the prolonged uncertainty caused them and Miss H distress.
- Warwickshire Council and the Trust failed to work in a joined up way to meet Miss H’ needs via an Education, Health and Care Plan (EHCP).
The Ombudsmen’s role and powers
- 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, as amended, and Health Service Commissioners Act 1993, section 18ZA).
- The Ombudsmen investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, the Ombudsmen consider whether it has caused injustice or hardship (Health Service Commissioners Act 1993, section 3(1) and Local Government Act 1974, sections 26(1) and 26A(1), as amended).
- If 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).
How I considered this complaint
- I read the correspondence Mr and Mrs G sent to the Ombudsmen and spoke to Mr G 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 took advice from a Consultant Child and Adolescent Psychiatrist with relevant knowledge and experience. I also considered relevant legislation and guidance.
- I shared a confidential copy of my draft decision with Mr and Mrs G and the organisations under investigation to explain my provisional findings. I invited their comments and considered all those that I received in response.
What I found
- In 2015 professionals understood Miss H had an autistic spectrum disorder and a borderline learning disability. Miss H also suffered from anxiety and depression and displayed challenging and disruptive behaviour as well as some incidents of self‑harm.
- Miss H had a Statement of Special Education Needs (a Statement) and was under the care of the Trust’s CAMHS team. She went to two special secondary schools but could not stay at either due to her behaviour which continued to get worse. Miss H stopped attending school in May 2015 and got support from a teaching assistant at home.
- Miss H moved to the School in November 2015. Miss H had a residential placement, staying in the School for 38 weeks a year. Education, Social Care and Health funded the placement equally. It was hoped the School would help Miss H reintegrate into the family home or into supported living.
- The School states its ‘ethos is to provide a package or education, care and therapy for young people with complex needs…support them in developing skills, empowering them in making decisions and taking responsibility for their actions as part of the process of preparing them for a more independent pathway and we aim to achieve this in a least restrictive environment…’
- In February 2017 the School took Miss H to a local hospital after an incident. The following day professionals conducted a Mental Health Act (MHA) assessment and recommended Miss H be detained for assessment under section two of the MHA. The decision to detain Miss H was reversed two days later. Miss H returned to Mr and Mrs G’s house. The School said it could not take Miss H back until she had a mental health assessment.
Complaint (a): The Trust’s CAMHS team discharged Miss H when she moved into the School and failed to notify Mr and Mrs G
- In response to Mr and Mrs G’s complaint the Trust said CAMHS discharged Miss H in 2015 when she moved out of its area. There are no nationally recognised criteria for discharge decisions from CAMHS. It is common practice to discharge someone who is moving to another area, especially when moving to receive care and therapeutic services. Miss H received psychiatric and psychological support from the School (although I acknowledge Mr and Mrs G have concerns about the adequacy of this). Therefore, I find no fault in the Trust’s decision to discharge Miss H.
- However, there was fault in the way the discharge was managed. The Trust has already acknowledged this. The Trust said there was no evidence that staff completed discharge paperwork fully or that anyone told Mr and Mrs G of this decision. The Trust apologised for a shortfall in communication and acknowledged its record keeping was not in line with acceptable standards.
- As I have not found fault in the underlying decision I consider the Trust’s apology is a proportionate remedy. As such, I have not recommended any further action.
Complaint (b): The Trust’s CAMHS team failed to act on a letter Mr and Mrs G sent in February 2017
- Mr and Mrs G wrote to CAMHS in February 2017, two days before the School took Miss H to hospital. They noted Miss H still suffered with severe anxiety and engaged in high risk behaviour. Mr and Mrs G said this had become worse in recent months and there had been incidents of suicidal behaviour.
- The Trust has acknowledged it received Mr and Mrs G’s letter. It said a Psychiatrist filed it but did not arrange any follow up. Further, the Trust said no one forwarded the letter to the local Clinical Commissioning Group (CCG), which was partly funding Miss H’s placement. The Trust apologised for the uncertainty and distress that caused.
- On the balance of probabilities, even if the Trust had acted upon Mr and Mrs G’s letter it would not have resulted in action which would have prevented events two days later. Any input CAMHS might have had is highly likely to have taken longer than two days to arrange. Further, I do not know how helpful any potential CAMHS input would have been at that stage. Therefore, the Trust’s apology is a proportionate response to the fault that occurred.
Complaint (c): Cambian failed to take appropriate or adequate action to address a deterioration in Miss H’s behaviour in late 2016
- The School assessed Miss H before she moved in, and a Psychiatrist and Psychologist assessed her shortly after she arrived. There is evidence in the Cambian’s and Warwickshire Council’s records that the School kept Miss H under regular review and noticed the deterioration in her behaviour. The School kept risk assessments and behaviour plans and contributed to Council-led reviews of Miss H’s placement.
- In September 2016 a male student moved into the house Miss H lived in. Their personalities clashed. They continued to live in the same house which caused Miss H distress. Mr and Mrs G told the School they felt Miss H was struggling and asked it to review her medication.
- Mr and Mrs G had a telephone meeting with the School Psychologist and the School Psychiatrist in early October 2016. They discussed an increase in incidents along with plans, strategies and medication. The Psychiatrist recorded a rationale for the use of a specific medication and suggested moving the time of the evening dose, again with a rationale.
- An annual review took place in November 2016. This noted an increase in the range of behaviours including self‑harming behaviours. It said the latter part of the year had been particularly difficult for Miss H. The therapy team took part in the review. It noted it had been working with Miss H in a number of ways and said its work was ongoing.
- Miss H continued to act in very risky ways in December 2016. Members of the School’s therapy services spoke to each other about the increase in incidents and noted the need for staff to be clear about relevant management plans. In the middle of December 2016 the School advised Warwickshire Council there had been a few concerning incidents that week and had updated its risk plans accordingly. The School also noted it had reinstated keypads on two doors to help control Miss H’s access to staircases.
- In the middle of December 2016 Mr and Mrs G met with staff from the School and discussed the situation. Staff noted a possible plan for Miss H to move to different accommodation within the School. In early January 2017 the School confirmed there was a plan to move Miss H to another specific house. At the end of the month Warwickshire Council completed a Looked After Child review. It recorded there were no concerns about the placement but an imminent house move was needed.
- At the start of February 2017 the School told Mr and Mrs G the planned move to another house would not go ahead. The School told Warwickshire that another resident had been moved into the house and needed to stay there and, as such, Miss H’s move could not go ahead. Mr and Mrs G emailed the School Psychiatrist and said the situation was urgent. They asked for an assessment to make sure Miss H’s needs were being met.
- The following day, in internal communication, the School Psychologist queried whether ‘we should be considering a mental health act assessment, as high risk behaviours have been present for a week’. They gave their view that Miss H’s behaviour needed to be managed ‘in a secure/specialist/ligature free environment. Further assessment of her mental state is required at the current time and a MHA assessment would provide this’.
- The School Psychiatrist replied to Mr and Mrs G the next day and said she would review Miss H the following day. In the event the School decided to take Miss H to hospital the next day.
Concerns raised by Warwickshire Council after the events
- In mid‑February 2017 the Council wrote a report about Miss H’s situation. This contained the Social Worker’s views which included:
- The School had identified environmental triggers and risk factors for Miss H but had not moved her, despite discussing this as a need in December 2016
- The School had not sought the support or advice of the Dorset CAMHS team to prevent the need for detention under the MHA
- ‘No concerns were raised by [the School] with myself as the allocated Social Worker about [Miss H’] mental health deteriorating to the extent that they could not keep [Miss H] safe there, there was some communication with parents but this does not appear to have been to the extent needed considering [Miss H] was later detained in hospital under the MHA’.
- In September 2017 staff from the Council met staff from the School to reflect on the breakdown of Miss H’s placement and see what lessons could be learned. The notes of the meeting recorded that Miss H’s request to move accommodation was never acted upon. They also said ‘This delay was felt to be a significant factor and would have potentially reduced the risks’.
- In response to my enquiries Cambian said it accepted there had been breakdowns in communication. It said it agreed the School should ensure it communicates changes in need and circumstances to councils in a timely fashion and in line with guidance.
- Cambian did not identify any failings in the psychiatric or psychological support it provided. It said it used appropriate interventions and Miss H’s behaviour worsened despite its best efforts.
- Cambian did not contact a CAMHS service (either in Miss H’s home area or in the local area) until the day it took Miss H to hospital. Cambian said it only uses local CAMHS services in crisis because it provides its own therapeutic services. In response to the complaint Cambian said it recognised that CAMHS involvement could have happened sooner. However, it said it was unlikely that CAMHS would have been able to undertake an assessment and provide interventions within the period of Miss H high risk behaviours in December 2016 to January 2017.
- In response to my enquiries, Cambian said it had reflected on these issues with Warwickshire Council and recognises that benefits can be had from having local support. It said, as such, it had spent time building links with the local CAMHS team to ensure its pupils can access local services if necessary. Cambian said a named liaison had been established.
- In terms of the proposed change of living arrangements Cambian said it had been planning and risk assessing for this move in January 2017 alongside other strategies. Cambian said it then chose to place a different student in the other accommodation due to other needs in the School. Cambian said, as a result, it could not move Miss H. Cambian also said it did not believe a move to different accommodation would have eliminated all risks.
- It is not the Ombudsmen’s role to undertake a forensic examination of Miss H’s day-to-day care at the School over a prolonged period. We do not have the resources necessary and it would not be in keeping with our remit. As such, I have looked at the School’s approach in the round.
- The School’s overall approach to Miss H’s care was in line with relevant guidelines. There is evidence to show the School completed suitable care plans and risk assessments and kept them under review. There is also evidence of regular monitoring of Miss H’s wellbeing, and detailed reviews. In addition, there is evidence of multi-disciplinary discussions about her care. Therefore, I find no fault in the overall approach the School took to Miss H’s care.
- It is very unfortunate that Miss H could not move to different accommodation. Cambian has provided an explanation for why this did not happen. It was not unreasonable for the School to consider the needs of all residents and make judgements about whose needs were of a greater priority. It is not for the Ombudsmen to remake such decisions which rely on professional judgement. I do not consider the lack of a move is evidence of fault.
- Overall, while it is evident that Miss H’s behaviour worsened during her time at the School, I have not found compelling evidence to show this was because of inadequate care. Nevertheless, Miss H’s mental health did deteriorate. In this situation Cambian should have kept Warwickshire Council informed about the situation. This did not happen, as Warwickshire Council has highlighted itself. In addition, and as Cambian has acknowledged, it could have contacted the local CAMHS service. This failure to properly communicate with other agencies is fault.
- This fault meant Warwickshire Council did not know about the deterioration in Miss H’s behaviour, and nor did NHS mental health services. This, in turn, meant they were not in a position to offer any further support or advice. For example, by arranging a multi‑disciplinary review of the situation. We do not know if either Warwickshire Council or CAMHS would have been able to intervene in a meaningful way that would have prevented the unplanned end to the placement. However, on the balance of probabilities, better communication would have helped to make the later events less chaotic. Better communication could have led to discussions about the possibility of the placement breaking down, and what the contingency plans should be. This, in turn, would have helped to reduce later delays. It is not possible to do anything other than speculate on what the eventual outcome would have been without the fault as there are many variables. Nevertheless, the uncertainty about this is an injustice in its own right, and flowed from the fault I have identified. Cambian has noted steps it has taken to improve its service for the future. I have made recommendations to address the injustice Miss H (and Mr and Mrs G) suffered.
Complaint (d): Cambian and Dorset Council failed to properly follow the ‘blue light protocol’ or assess Miss H adequately before she was detained under a section of the Mental Health Act in February 2017
Suicide risk protocol
- The School first wrote a Management of Suicidal Expression (Verbal and Behavioural) protocol in December 2015. This included a plan that, if Miss H became very difficult and unsafe to manage, the School would take her to A&E to be assessed by the liaison psychiatry service. The School shared this plan with Mr and Mrs G. In response to Mr and Mrs G’s concerns about the part of the plan noted above, the School said Miss H ‘would only be taken to hospital if there were highly risky behaviours that could not be managed within the school, that the staff felt unable to deescalate’. The School also made Warwickshire Council aware of the protocol and referenced it in Miss H’s main risk assessment. Cambian renewed this protocol several times during Miss H’s placement.
- As noted above, in early February the School Psychologist queried with colleagues whether ‘we should be considering a mental health act assessment, as high risk behaviours have been present for a week’.
Events leading to Miss H’s admission to hospital
- In an afternoon in early February 2017 Miss H attempted to climb over a stair bannister approximately 30 feet above the ground and said she wanted to kill herself. Staff intervened. The School called the emergency services as well as the local CAMHS Crisis Team. An ambulance took Miss H to an acute hospital in the early evening. Later in the evening the School contacted Warwickshire Council’s Emergency Duty Team and advised it of the events.
- A couple of hours before this the School Psychiatrist had emailed Mr and Mrs G and said ‘we need to consider an assessment under the MHA and liaising with the social worker’. She provided an explanation of why she felt a MHA assessment was warranted.
- In comments to the Ombudsmen the Psychiatrist said she saw Miss H in the morning and arranged to review her later. She said a High Priority Group discussed Miss H that afternoon and agreed her mental state was unstable and they needed to proceed and ask for a MHA assessment. The Psychiatrist said she had another meeting so needed to email Mr and Mrs G about the outcome of the group’s review.
- Mrs G tried to call the Psychiatrist but was unable to speak to her. She then emailed and asked the Psychiatrist to call back to discuss the situation.
- The hospital admitted Miss H and noted there was to be a psychiatric assessment. Several staff members from the School stayed with Miss H. Later in the evening hospital staff noted Miss H ‘appears very happy at the moment’ and that she was ‘Alert, chatty’.
Events on the day of the MHA assessment
- The following morning hospital staff noted Miss H had been settled overnight. Staff from the School recorded that, in the morning, Miss H ‘Spent time chatting to [School] staff and decided to play some board games. Had a wash and waited for lunch’. At a similar time staff from the hospital’s CAMHS Psychiatric Liaison team noted Miss H ‘appears calm and awake on observation, just about to eat her lunch’.
- A CAMHS Social Worker got in touch with the Dorset Approved Mental Health Practitioner (AMHP) Hub and asked for a MHA assessment. An AMHP tried to contact Miss H’s Social Worker at Warwickshire Council but was not able to. The Warwickshire Council Emergency Duty Team told the Warwickshire Council Social Worker of Miss H’s admission. The Social Worker recorded in her notes that this was the first she had heard of it and that she had not received any contact from the School about it.
- In its response to the complaint Dorset Council said a member of the AMHP Hub advised the allocated AMHP of the need for a ‘blue light’ meeting. Dorset Council said the AMHP contacted the School Psychiatrist and advised them of the need for a ‘blue light’ meeting urgently, before a MHA assessment. It said the School Psychiatrist was unaware of the ‘blue light’ protocol and it was left to the AMHP to lead the meeting.
- Mr and Mrs G travelled to Dorset. They went to the School first and then to the hospital. They said the ‘blue light’ meeting had already started by the time they arrived at the hospital. The meeting was with the AMHP, School Psychiatrist, an independent Psychiatrist, a hospital Nurse and member of staff from the School.
- The meeting concluded there was no alternative to a MHA assessment because:
- The School would not have Miss H back until her mental health had been formally assessed
- Miss H refused to stay in hospital as a voluntary patient
- Miss H did not have the capacity to understand the potential for accidental death caused by her deliberate self-harming behaviour
- The level of restraint and supervision needed to keep Miss H safe went beyond that which could be authorised by parental control, so the Children Act could not be used.
- A MHA assessment then took place. The assessment concluded Miss H was at high risk of accidental death and her diagnosis impacted on her understanding of this. It said an admission under section two of the MHA was required. Professionals could not find a suitable hospital place so Miss H remained in the acute hospital in a general paediatric ward.
- In the evening hospital staff noted Miss H was very upset after being told she would be detained and asked to go back to the School. Around an hour later hospital staff noted Miss H was much calmer and having a joke with them.
Events over the following days
- The following morning hospital staff noted Miss H was calm overnight and came out to choose a DVD before bed and seemed bright and calm. In the early afternoon School staff noted Miss H ‘ate some lunch. Played game and watched TV. Happier mood’.
- Miss H remained in the acute hospital. The following day Mr and Mrs G appealed the decision to detain Miss H. The appeal was approved and Miss H was discharged. Hospital staff noted Miss H had had a really settled day. Miss H left hospital and returned home with Mr and Mrs G.
Cambian’s response to the complaint
- Cambian said it sought a MHA assessment as it no longer felt it could keep Miss H safe. Cambian said this has been appropriate in the context of Miss H’s behaviour. It also said the ‘blue light’ meeting was carried out in line with NHS England requirements. Cambian said the AMHP chaired the meeting and no minutes were circulated. During this investigation Cambian maintained that it kept Warwickshire Council appropriately informed of incidents via relevant reports, and notified appropriate professionals when it arranged for Miss H to go to hospital.
Dorset Council’s response to the complaint
- Dorset Council said that in February 2017 not all its staff from its AMHP Hub were aware of the ‘blue light’ protocol.
- Dorset Council said it was not its responsibility to arrange the ‘blue light’ meeting. It said the commissioner should have called the meeting but this did not happen. Therefore, Dorset Council said, as the meeting had not happened and as the School Psychiatrist was unfamiliar with the requirements, the meeting was impromptu and driven by the AMHP. Dorset Council said the AMHP tried to ensure the situation was discussed as fully as possible. However, Dorset Council said its AHMP was clear she did not chair the ‘blue light’ meeting and said the School’s Psychiatrist had. Dorset Council also said it did not have any minutes or notes from the meeting. It said staff from the School declined to take minutes.
- Dorset Council said the ‘blue light’ meeting determined there was no alternative to a MHA assessment. Further, it said the AMHP managed this process appropriately. In relation to this, Dorset Council said it appropriately took account of information from Cambian that Miss H had been increasingly disturbed and difficult to manage on the ward. It said, alongside this, the AMHP took account of a wealth of information including medical recommendations from specialist Learning Disability Psychiatrists, one of which came from a Psychiatrist unconnected to the group. Dorset Council said that, because of the urgency of the situation, it was not possible to invite any staff from Warwickshire Council or the local CAMHS team who had requested the MHA assessment.
- Therefore, Dorset Council said the principles of the ‘blue light’ protocol were upheld, if not the format and structure.
- Dorset Council said it had since shared the ‘blue light’ protocol with the team and they had learnt from these events. It said it would now ask for confirmation a ‘blue light’ meeting had been conducted when it responded to requests for MHA assessments from schools or similar establishments.
- In terms of Miss H’s presentation, Dorset Council said Miss H was calm when the AMHP met her. However, it said the AMHP had to take account of the verbal reports about the level of distress from the staff who had been present with her all night.
Concerns raised by other professionals after the events
- As noted above, in mid‑February 2017 the Council wrote a report about Miss H’s situation. This contained the Social Worker’s concerns about whether enough had been done to address Miss H’s deterioration before seeking a MHA assessment.
- In September 2017 staff from the Council met staff from the School to reflect on the breakdown of Miss H’s placement and see what lessons could be learned. The notes of the meeting recorded the Council thought it had been inappropriate to pass on information via email about Miss H being assessed under the MHA.
- The evidence shows staff at the School felt this was an emergency situation. In such an emergency situation it was appropriate to prioritise Miss H’s safety. The School’s actions were in line with the relevant protocol it had in place, which had been regularly reviewed. Therefore, I find no fault in the School’s decision to take Miss H to hospital, and to consider a MHA assessment.
- It is clear from all the evidence I have seen that the ‘blue light’ meeting was hastily arranged. There is a lack of clarity about who led this and there are no notes of the meeting. This should not have been the case, and this is fault.
- ‘Blue light’ meetings should be arranged by the relevant commissioner. In this case the commissioner was Warwickshire Council. However, as detailed above, no one told Warwickshire Council what was happening so it could not have arranged the meeting. As such, I do not consider Warwickshire Council to be responsible for this fault. Cambian and Dorset Council do not agree about who led the meeting. The evidence shows that that neither party was well versed in the guidance about these meetings at the time, and neither party was able to ensure minutes were kept. As such, I consider the responsibility for this fault to lie equally with the Cambian and Dorset Council.
- Despite the lack of minutes, the accounts of Mr and Mrs G and the organisations provide some reassurance that professionals did hold a relevant discussion about the situation. Specifically, there is evidence to show the meeting allowed relevant people to consider the issue at hand, about whether to proceed to a MHA assessment. Therefore, I do not consider the poor administration of the ‘blue light’ meeting led to an injustice in its own right.
- The subsequent MHA assessment was conducted in line with the MHA Code of Practice. This resulted in a decision to detain Miss H. As the process was followed correctly it is not the Ombudsmen’s role to replace the replace judgement of the AMHP involved. In practical terms, following the MHA assessment Miss H remained in the acute hospital and then went home. While I do not discount that this process was distressing for Miss H and Mr and Mrs G, I do not consider this distress came as a result of fault.
Complaint (e): The Trust failed to act on a referral to its service in a timely manner when Miss H returned home
- On the day Miss H left hospital and went home staff from the hospital referred her to the Warwickshire Adult Mental Health Service. The Trust assigned the case to its Adult Services’ Needs and Wellbeing Team. Staff from the team visited Miss H in early March 2017 three weeks after receiving the referral and began assessing her needs.
- In June 2017 the Trust decided there was no role for one of its Integrated Practice Units (IPU) to play. (The IPU in question provides specialist age-appropriate services to people suffering from severe or complex anxiety, as well as mood and personality disorders.) The team discharged Miss H and referred her to the Trust’s Learning Disability Team.
- The Learning Disability began assessing Miss H in September 2017. At the end of November 2017 the team wrote to Mr and Mrs G and said it felt Miss H’s difficulties were best attributed to autism and not a learning disability. It concluded there was no support it could offer and said it felt Miss H would be more appropriately supported by social care.
Trust’s response to the complaint
- The Trust said its file was still closed when the referral came in. It said the referral did not include any information about an EHCP. The Trust said because of these two factors it assigned the case to its Adult Services’ Needs and Wellbeing Team and the team did not request any information from CAMHS.
- The Trust said it should have allocated the referral to its Crisis Resolution and Home Treatment Team, for follow-up within 48 hours. The Trust apologised this did not happen and for the delay it caused.
- As the Trust have noted, the referral it received contained limited information and meant the full circumstances were not immediately known. However, the Trust should have acted on the referral more quickly. It has already accepted this.
- I think it is worth noting here that the fault I have found on the part of Cambian may have had an impact on these events. When Miss H returned home it seems possible the initial confusion at the Trust might have been avoided if concerns about Miss H’s placements potentially breaking down had been voiced earlier. This may have led to mental health services being better prepared for Miss H’s return home.
- There is evidence in the Trust’s notes to show that it did expedite the referral once it received more information from Mr and Mrs G and other professionals. In this context I consider the Trust’s response to this issue was proportionate, as it did take steps to speed things at the time once it had more information. The Trust then completed appropriate assessments. Therefore, I have not recommended any further action.
Complaint (f): Warwickshire Council failed to provide or arrange appropriate care and support, and, with Cambian, failed to decide if Miss H could return to the School in a timely manner after Miss H returned home in February 2017; and
Complaint (g): Warwickshire Council and the Trust failed to work in a joined up way to meet Miss H’s needs via an EHCP
Background about Miss H’ Statement
- Miss H first received a Statement in June 2008. There was a meeting as part of the transition from a Statement to an EHCP in March 2015. Attendees included Mr and Mrs G, someone from Social Care, someone from CAMHS and someone from Miss H’ school at the time.
- Warwickshire Council issued a draft EHCP at the end of February 2017. It issued the final EHCP in July 2017.
Events after Miss H returned home in February 2017
- After Miss H returned home in February 2017 the School told Warwickshire Council it would not have her back until she had a mental health assessment. In the following days the Social Worker spoke to colleagues to arrange 12 hours a week of support for Miss H while she was at home. She also noted the need for a multi-disciplinary meeting to involve Children’s Services, Adults Services, Health and Education.
- After Miss H returned home she was clear that she wanted to go back to the School. She enjoyed the School and missed her friends. Mr and Mrs G asked for this to happen. The Social Worker advised them it was uncertain what would happen. The School said it would work with Warwickshire Council to resolve the situation.
- Later in February the Social Worker emailed a range of professionals and noted Miss H had been left without education and desperately wanted to go back to the School. She said she was trying to arrange a multi-agency meeting to move things forward.
- At the same time Mr and Mrs G asked whether Miss H could go back to the School on an education-only basis. The School said this could not happen due to the level of risk.
- A professionals meeting took place at the start of March 2017. It noted Mrs G had proposed that she could support a day placement at the School by staying with her in privately rented accommodation close to the School. The Trust noted its staff would be assessing Miss H (beginning the same afternoon) but said it could not predict how long the assessment would take. The meeting planned to offer more short-term support while a long-term plan was agreed.
- Later in March 2017 Warwickshire Council noted the situation remained unclear. It detailed the Social Worker wanted to use a ‘twin track’ plan – to check what other residential placements were available while keeping the option of a return to the School open.
- At the end of March 2017 a Trust Psychiatrist completed their review of Miss H. The Psychiatrist produced a report of their findings and said it was for the School to decide if it had the resources to meet Miss H’s needs and challenging behaviour. The Psychiatrist also said that, if Miss H remained in the local area, they would discuss the case with the Learning Disability Team. They said they would do this with a view to assessing her suitability for ongoing support and monitoring.
- In the days after this the School gave six weeks’ notice to terminate Miss H’s residential placement. Miss H was no longer a Looked After Child and became a Child in Need. In early April 2017 the final Looked After Child review noted the option of returning to the School as a day pupil was still being considered. The chair of the meeting noted the situation needed urgent resolution.
- Later in April 2017 Warwickshire Council noted the option of a day placement was still being explored. It also noted that no other residential placements were offering to support Miss H. A Warwickshire Council assessment at the start of May 2017 noted Miss H ‘presents largely now as depressed, withdrawn’ and her educational needs were not being met. It also noted ‘the family all seem close to breakdown and are desperate for clarity of steps’.
- Around a week later, in early May 2017, a High Needs Panel considered Miss H’s case. It decided an education-only place at the School would not be sustainable. It recommended looking into three other colleges.
- In June 2017 Warwickshire Council arranged for a different college to provide some education for Miss H at home, with an aim to get her back into education. However, Miss H was reluctant to engage with this.
- Mr and Mrs G contacted Warwickshire Council’s Emergency Duty Team in August 2017. They said they were at the end of their tether. Mr G said no one was helping them and services had just left them. Mr G said there was a lack of joint intervention and health were not supporting them. A professionals meeting later in the month noted there did not appear to be clarity in understanding responsibilities and guidance for joint protocols and multi-agency working.
- In early September 2017 there was a Pathway Plan meeting. It was noted CAMHS had attended the last review and had provided information for this meeting and clarified the types of care Miss H would require.
- Later in September 2017 an Educational Psychologist completed a report about Miss H. They noted she remained without access to an educational placement and she did not feel able to engage with learning. In addition, they noted Miss H’s range of day-to-day experiences (both academic and social) had vastly reduced of late.
- Toward the end of October 2017 the Trust’s Community Learning Disability Team produced a summary of its assessments. It concluded she needed an autism specific service that could support her to manage her anxieties but allow her to become independent.
- In February 2018 a Pathway Plan review meeting noted Miss H should be provided with three days of education but this was yet to be fully organised.
Warwickshire Council’s response to the complaint
- Warwickshire Council commissioned a Stage 2 report which investigated Warwickshire Council’s role in these events. The report found:
- There was no explanation of why Miss H’s case was not considered at an earlier High Needs Panel
- Regardless of the outcome of the panel, Education should have given greater consideration, earlier, to whether Miss H’s placement at the School should be ended. The report said the School had already refused to take Miss H back as it could not meet her needs and felt she needed a mental health assessment
- Adult Social Care did not start a search for support did until July 2017, six months after Miss H returned home.
- However, the report also concluded that Miss H had complex needs which needed support from health services. It said, despite this, health services had played little part in progressing a plan for Miss H’s future.
- Overall, the report said there was little evidence of a coordinated approach between Health, Social Care and Education. Nevertheless, it concluded the final EHCP was fit for purpose. It said there had been input from health, although this was minimal.
- In correspondence to the Ombudsmen, Warwickshire Council said it would be good practice to reconvene a joint protocols meeting when a placement breaks down. It said this would help ensure that all services are involved and reduce delays in decision making.
Warwickshire Council’s comments to the Ombudsmen
- Warwickshire Council said it accepts the EHCP was not issued within the expected 20 weeks. It said Miss H’s unplanned departure from the School and the period of uncertainty about this contributed to the delays. However, Warwickshire Council said Miss H’s Statement remained in place so the lack of a finalised EHCP did not prevent education being agreed.
- Warwickshire Council said ‘the difficulty experienced in fully engaging the health services at every stage have had more impact than the completion or otherwise of the EHCP itself’. It said ‘It is [Miss H’] mental health that is seen as having most impact on her being able to access appropriate school-based education and it has not always been easy to engage with health services and they have not been present at key meetings to which they have been invited’.
Trust’s response to the complaint
- The Trust said it had contributed to Miss H’s transfer from a Statement to an EHCP while she lived in its area in 2015. However, the Trust said there was no evidence Warwickshire Council shared a draft or final EHCP with it.
- The Trust also said that no one made it aware of the EHCP when it was conducting its own assessment of Miss H’s needs. The Trust acknowledged that its staff had been unaware of the need to ask Miss H if she had one. It apologised for a shortfall in communication and the resulting delay in putting in place appropriate support for Miss H.
Cambian’s response to the complaint
- Cambian said after Miss H went to live with her parents it kept in touch with her and provided remote learning. Cambian said, prior to the residential placement formally ending on 12 May 2017, it worked with Warwickshire Council to find a way forward for Miss H. It said on 20 April 2017 it discussed the logistics of a day placement during a conference call. However, it said a High Needs Panel then decided a day placement would not be suitable.
- It is easy to understand why Mr and Mrs G expected this situation to be handled with some urgency:
- their daughter had been removed from the School by the emergency services, without prior arrangement
- their daughter had been detained in hospital on the basis that professionals felt there were no less restrictive ways of ensuring her safety
- the School had said Miss H could not go back – to where she lived, and was cared for, not just where she was educated – until mental health professionals more specialised than the School’s own mental health professionals had assessed her mental health.
- From my perspective, it is plain to see why Mr and Mrs G understood this to be an urgent situation.
- The Council has already accepted that, after Miss H returned home, it should have moved things along more quickly. It has also noted its own frustrations with the Trust’s involvement. The Trust, in turn, has suggested important information was not always shared with it, but has acknowledged its staff should have done more to ask for pertinent information. The Trust acknowledged this had an impact on the time it took to put appropriate support in place.
- Overall, there was a lack of urgency and lack of timely progress in Miss H’s care after she returned home in February 2017. This was fault. In this situation it seems clear that the joined up working required did not happen as it should have. There may be a number of practical, administrative and cultural reasons for this. As such, I do not consider it would be correct or helpful to conclude the responsibility for the fault lay solely with one organisation, or to try to work out an arbitrary ‘split’ in the responsibility. Further, any improvement for the future will lie in the respective organisations working out these issues and taking steps to improve things. Therefore, I consider both Warwickshire Council and the Trust bear some responsibility for the fault that occurred; namely, unnecessary delays in establishing a clear plan for how all of Miss H’s social, mental health and educational needs would be met.
- As a result of this fault Miss H was left in an uncertain position, without comparable specialist support as she had at the School. There is evidence this caused Miss H distress and upset. This, in turn, caused Mr and Mrs G stress. This is an injustice I do not consider has been fully remedied. As such, I have made a recommendation to address it.
- Miss H is a vulnerable young woman with complex needs. Miss H, and Mr and Mrs G, were entitled to expect Warwickshire Council, the Trust and the Cambian to work together to ensure her needs were met effectively. It was also reasonable to expect that any problems would be addressed in a consistent and appropriate way. Crucially, it was right for the family to expect professionals to work together effectively, in a joined up way, to plan Miss H’s care. This did not happen.
- The Cambian did not keep other professionals – from Warwickshire Council and from mental health services– updated about Miss H’s deterioration. This, in turn, meant an opportunity was lost to make the end of Miss H’s placement less chaotic. However, regardless of the unplanned nature of the end of Miss H’s placement, Warwickshire Council and the Trust should have worked together more effectively to address the situation and put new support in place.
- Warwickshire Council and the Trust have already acknowledged failings during the period after Miss H returned home. However, I do not consider the Cambian, Warwickshire Council or the Trust have done enough to fully address the injustice these faults caused.
- Within one month of the date of the final decision:
- The Cambian will write to Mr and Mrs G to acknowledge the failure to keep other professionals (at the Council and CAMHS) informed of Miss H’s deterioration. It will also apologise for the impact this had when Miss H’s placement ended in an unplanned way – in creating uncertainty and distress for Miss H and stress for Mr and Mrs G.
- Warwickshire Council will write to Mr and Mrs G to acknowledge its part in the multi-agency failure to effectively progress Miss H’s case after she returned home. This may mean reiterating acknowledgements of failings it has already given. Warwickshire Council will also apologise for the impact this had in creating uncertainty and distress for Miss H and stress for Mr and Mrs G.
- The Trust will write to Mr and Mrs G to acknowledge its part in the multi‑agency failure to effectively progress Miss H’s case after she returned home. This may mean reiterating acknowledgements of failings it has already given. The Trust will also apologise for the impact this had in creating uncertainty and distress for Miss H and stress for Mr and Mrs G.
- Pay Miss H £500 as a tangible acknowledgement of its part in creating the avoidable distress Miss H experienced after she returned home.
- Pay Mr and Mrs G (as a couple) £250 as a tangible acknowledgement of its part in creating the avoidable stress they have been caused by these events.
- I have completed my investigation on the basis that there was fault on the part of the Cambian, Warwickshire Council and the Trust which lead to an unremedied injustice. These organisations have agreed to my recommended actions to address this injustice.
Investigator’s decision on behalf of the Ombudsmen
Investigator's decision on behalf of the Ombudsman