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Lancelot Medical Centre (15 005 495b)

Category : Health > General Practice

Decision : Upheld

Decision date : 03 Jan 2018

The Ombudsman's final decision:

Summary: Mr X complains that the Council and Trust have failed to provide services for his health and social care needs. There is evidence both the Council and Trust have failed to offer appropriate services. There is also evidence of fault in the way the Practice removed Mr X from its register. The Council has agreed to remedy the injustice to Mr X. However, the Trust has now offered Mr X appropriate services and he is registered with a new practice.

The complaint

  1. Mr X complains about the way the Council, the Trust and Practice have been involved in his care. In summary, Mr X:
    • says there are faults in the assessments of his care and mental health needs since 2015, leading to him losing out on social care provision and the mental health care, treatment and support he requires;
    • believes there are flaws in the related risk assessments;
    • considers the organisations have falsified his records;
    • disputes the change in his diagnosis of bi-polar disorder;
    • is concerned he was de-registered from the Practice; and
    • does not consider the Council, the Trust and the Practice have responded to his complaints properly;
    • believes he is being victimised for complaining.

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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,as amended, 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), as amended).
  3. 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.
  4. 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 have considered a written complaint from Mr X. I have invited comments from the Practice, the Trust and Council and considered the comments with supporting documents. I have sought advice from a consultant in general adult psychiatry and taken relevant law and guidance into account before coming to a view.

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What I found

  1. Mr X is in his 50s and was diagnosed in 2007 with bipolar disorder (formerly known as manic depression, a condition that causes extreme mood swings). In 2012 Mr X was diagnosed with social phobias and agoraphobia (a fear of being in situations where escape might be difficult or where help would not be available if something went wrong).
  2. Mr X has previously made a complaint to the Ombudsmen about the Trust, The Council and the Practice. The investigation found fault in relation to the Council’s assessment of Mr X’s social care needs in an assessment completed in 2012. The Ombudsmen took the view the Council had not properly considered Mr X’s social care needs. However, that investigation also concluded the Trust had appropriately assessed Mr X’s mental health needs and he did not meet the criteria for support from secondary mental health services at that time.
  3. The organisations completed a new assessment for Mr X on 9 March 2015 and wrote to him in June 2015 to explain the outcome. Mr X and his mother and carer, Mrs H, raised a formal complaint on 31 May 2016.
  4. On 24 June 2016, the Practice deregistered Mr X.
  5. Mr X complained to the Ombudsmen on 27 March 2017.

Relevant law and guidance

Social Care

  1. The eligibility threshold for adults with care and support needs and carers is set out in the Care and Support (Eligibility Criteria) Regulations 2014. The threshold is based on identifying how a person’s needs affect their ability to achieve relevant outcomes, and how this impacts on their wellbeing. For a person to have needs which are eligible for support, the following must apply:
    • The needs must arise from or be related to a physical or mental impairment or illness.
    • As a result of the needs, the adult must be unable to achieve two or more of the following outcomes:
      1. managing and maintaining nutrition;
      2. maintaining personal hygiene;
      3. managing toilet needs;
      4. being appropriately clothed;
      5. being able to make use of their home safely;
      6. maintaining a habitable home environment;
      7. developing and maintaining family or other personal relationships;
      8. accessing and engaging in work, training, education or volunteering;
      9. making use of necessary facilities or services in the local community including public transport and recreational facilities or services; and
      10. carrying out any caring responsibilities the adult has for a child.
  2. As a consequence of inability to achieve these outcomes, there is likely to be a significant impact on the adult’s well-being.
  3. Where councils have determined that a person has any eligible needs, they must meet those needs. When the eligibility determination has been made, councils must provide the person to whom the determination relates (the adult or carer) with a copy of their decision.

Mental health services

  1. The Improving Access to Psychological Therapies (IAPT) programme began in 2008. IAPT services provide primary-care, evidence-based treatments for people with anxiety and depression. IAPT services offer cognitive behavioural therapy (CBT, a talking therapy commonly used to treat anxiety and depression). IAPT services typically consist of six to ten CBT sessions. Patients with more complex needs, significant risk or who need longer-term CBT (up to 20 sessions) are usually referred to secondary health services.
  2. Those referred to IAPT are usually triaged to ensure short-term therapy is appropriate. This is a clinical decision made by the service.

Registration

  1. The National Health Service (General Medical Services Contracts) Regulations 2004 (the Regulations) set out the criteria for deregistering a patient from a general practice. Schedule 6 of the Regulations includes provisions on contractual terms.
  2. The Regulations say that a patient may only be removed from a register if he or she has been warned about the risk of removal in the previous 12 months.

Analysis

Health and social care assessments

  1. I have reviewed the April 2015 assessment which considered Mr X’s health and social care needs.
  2. The assessment covered the following areas:
    • Mental health: Mr X felt that he should have had access to CBT.
    • Physical health: Mr X was diagnosed with Crohn’s disease and had to be careful what he ate.
    • Daily living skills: Going out in public aggravated Mr X’s anxiety as he struggled to be around people. Ms H did his cleaning, laundry, collected his medications and helped him to pay bills.
    • Social situation: Mr X had a very limited social life.
    • Occupation and leisure: The options were limited due to Mr X’s difficulties being around people.
    • Carers issues: Ms H was Mr X’s main carer. She was due to go into hospital and Mr X did not have any ideas about how he would manage for this period.
    • Support, care and treatment: One of the social workers agreed to send another referral for CBT. Mr X identified five areas of social care needs with which he struggled. The assessors agreed to meet with him again to discuss how to manage these needs.
  3. The assessment recorded Mr X struggled in many areas, for example, maintaining his home environment and personal hygiene. The assessment recorded that Ms H provided support in many of these areas but this was becoming difficult due to her own health needs.
  4. The assessment identified eligible care needs in ten areas. However, it is unclear from the assessment whether the Council would provide support or whether it considered Ms H was meeting his needs. I have seen evidence the social worker completing the assessment referred Mr X to the IAPT service shortly after the assessment.
  5. On 15 May 2015, the IAPT wrote saying Mr X was not suitable for the service. However, it suggested a joint assessment with the mental health team and a CBT practitioner.
  6. Two social workers visited Mr X on 22 June 2015. The notes of the meeting record the following:
    • Mr X said there were several inaccuracies in the April assessment. These included that he had a child when the assessment did not record this and his bipolar disorder had been overlooked.
    • Mr X had been charged with actual bodily harm rather than grievous bodily harm. He provided evidence to support this and outlined his recollection of events.
    • The assessment did not reflect Mr X’s diagnosis of bipolar.
    • Mr X disputed the April assessment included his social care needs.
  7. Mr X agreed to provide further detail about what he disagreed with in the assessment and the social worker agreed to consider how his comments could be incorporated. The notes also record Mr X wanted to ensure the assessment was correct before any consideration was given to how his needs would be met. Finally, the social worker confirmed the April 2015 assessment included Mr X’s social care needs.
  8. Also in June 2015, a link worker from the mental health team visited Mr X to assess him following the request for CBT and whether he needed access to psychological services. Mr X expressed dissatisfaction about the fact his bipolar diagnosis had been changed and reiterated he had not received a copy of his social care assessment.
  9. The Trust completed another visit on 22 July 2015. It discussed CBT and what that might involve. The note of the meeting records Mr X’s mood was stable. However, at the end of the meeting Mr X said he did not wish to have another appointment as he felt the social worker at the meeting had lied to him. The Trust therefore ended its involvement with Mr X on the basis he would not engage.
  10. On 27 August 2015, the CBT practitioner who assessed Mr X wrote expressing the view IAPT could not offer enough CBT sessions to establish the necessary trust and support Mr X required. The letter also suggested Mr X’s diagnosis was ‘firmly established’ before any treatment options were offered.
  11. I consider there is evidence of fault in the Council failing to properly consider Mr X’s social care needs at this stage. The April 2015 assessment appears to have identified social care needs that may have been eligible for support. The inaccuracies Mr X alleged in the assessment did not affect this and should not have halted the provision altogether. The Trust, on behalf of the Council, should have offered Mr X support based on any eligible care needs.
  12. In July 2016, a doctor visited Mr X as he had been deregistered from the Practice and was therefore unable to access his medication. The plan was to discharge Mr X back to his GP and support him to register with another GP practice. There was some difficulty as Mr X did not have photographic identification, which most practices required.
  13. The Trust arranged another assessment on 16 September 2016 with Mr X’s care coordinator and mental health nurse. The care coordinator decided to allocate a support worker to help Mr X register with a GP and book a psychiatric review. The review was booked for 23 September 2016. However, the Trust was unable to contact Mr X to confirm. When it sent an urgent letter, Mr X cancelled the appointment as the letter did not include enough detail.
  14. The Trust completed a care plan for Mr X on 19 September 2016 as follows:
    • Mr X was to have a review with a consultant psychiatrist.
    • The Trust would allocate a support worker to help Mr X register with a new GP.
    • Whether Mr X should receive CBT would be decided after the review.
  15. In October 2016, a consultant visited Mr X. The consultant formed the view, based on her observations, that Mr X had paranoid personality disorder. She did not consider Mr X met the criteria for bipolar disorder.
  16. The consultant visited Mr X again on 11 November 2016. She explained her view that Mr X did not meet the criteria for bipolar. Mr X disagreed with her opinion. It appears the visit in October 2016 was the first since the IAPT decided Mr X needed a more definite diagnosis. This is evidence of fault. The Trust made the decision to await a firm diagnosis before offering treatment options, including secondary care services. More than a year seems to have elapsed between the IAPT decision and the consultant review. This is evidence of fault. Further, the consultant who reviewed Mr X decided to refer Mr X back to IAPT. Given that the IAPT service had made it clear it did not consider its services were appropriate, this too is evidence of fault.
  17. However, following my draft decision, the Trust provided a ‘transfer of care’ letter it sent to Mr X’s GP in May 2017. The letter indicates the Trust offered Mr X referrals for secondary services but he has not engaged with its efforts. I therefore cannot conclude that Mr X would have accepted a secondary service sooner had it been offered.
  18. I have not listed all the interactions between the Trust and Mr X. However, I have seen evidence it supported Mr X to register with a new GP. There are several instances where Mr X’s support worker tried to obtain the relevant photographic identification for Mr X. Initially, by trying to renew Mr X’s driver’s license, then by applying for a passport.
  19. However, I have seen no evidence the Trust or Council clarified Mr X’s eligible social care needs or put in place support to meet these needs. The April 2015 assessment recorded Ms H supported him in many areas. I have not seen any consideration of a contingency plan if this support was unavailable, or whether Mr X was entitled to support in spite of Ms H’s input. This is evidence of fault. Mr X cannot be certain he has had access to services to which he may have been entitled.

Risk assessments

  1. The Trust completed a risk assessment for Mr X on 13 April 2015. The assessment included the following events as evidence of risks posed:
    • Mr X assaulted an individual in 2003 and was charged with grievous bodily harm. The assessment recorded Mr X had no memory of this and disagreed with the event being recorded on the risk assessment.
    • Three previous episodes of self-harm. However, Mr X confirmed he had no current or recent such thoughts.
    • Mr X had struggled with his mental health in the past and there had been no input from mental health services.
    • Mr X explained he had difficulty with caring for himself in completing tasks such as preparing food and maintaining his personal hygiene. However, the assessment recorded his mother helped him with these tasks. It also recorded Mr X was in the process of having his social care needs assessed.
  2. The risk assessment is incomplete. The section of the assessment covering the risk and crisis management plan is blank.
  3. The fact that the risk assessment is incomplete is evidence of fault. There was no crisis or contingency plan. This is important as when someone is at risk and in distress, he or she will often need a plan where any actions are in writing, even if this is simply to call a crisis team. The form has fields for this information but is incomplete.
  4. However, the form records Mr X was not at ongoing risk. I therefore do not consider he has suffered an injustice as a result of the fault identified.

Falsifying records

  1. The Trust has responded to Mr X and the Ombudsman on this point. It explained Mr X often audio records his interactions with professionals involved in his care. He therefore has a detailed record of what has been said, whereas the Trust merely keeps a written record with the appropriate level of detail required.
  2. Mr X wrote to the Council on 14 July 2015 questioning the content of the April assessment. The Trust and Council replied on 23 July 2015. The response explained Mr X had been provided a copy of the assessment, it addressed Mr X’s health and social care needs and the next step was for Mr X to comment on the accuracy or otherwise of the assessment.
  3. Mr X has explained he disagrees with the comments in the assessment. This does not amount to falsifying records. It is usual practice to give service users a copy of the assessment so they can comment on any inaccuracies. I have seen no evidence to suggest the professionals involved in Mr X’s care deliberately recorded false information. I share the Trust’s view that visiting professionals will often write a summary of what has been discussed. This may not include the level of detail Mr X would like. However, this is not fault.

Diagnosis

  1. I have not investigated the original decision that Mr X no longer met the criteria for a bi-polar diagnosis. I have outlined my reasons at the end of this statement.
  2. However, I have sought advice on the most recent consultant review which took place in October 2016.
  3. Mr X was well known to mental health services. His records are electronic so I consider the consultant had access to this information. In these circumstances, a consultant would not necessarily complete a full psychiatric assessment but would take into account the person’s history and observations in meeting with him or her.
  4. The consultant explained to Mr X that paranoid personality disorder is:

‘…characteri(s)ed by an enduring pattern of behaviour based on the pervasive belief that the motives of others are malevolent and that they should not be trusted. The latter is expressed as suspiciousness, hypersensitivity, and mistrust.’

  1. There is a standard diagnostic framework, the ‘International Classification of Disease’ 10th Edition (ICD-10). ICD-10 defines paranoid personality disorder as follows:

Personality disorder characterized by excessive sensitivity to setbacks, unforgiveness of insults; suspiciousness and a tendency to distort experience by misconstruing the neutral or friendly actions of others as hostile or contemptuous; recurrent suspicions, without justification, regarding the sexual fidelity of the spouse or sexual partner; and a combative and tenacious sense of personal rights. There may be excessive self-importance, and there is often excessive self-reference.

  1. Therefore, I consider there is no evidence of fault in the consultant concluding Mr X’s symptoms were consistent with her diagnosis. She refers to the enduring nature of Mr X’s behaviour which is consistent with the established definition. This was based on Mr X’s history and observed behaviour in meeting with him. I am also satisfied this was clearly explained to Mr X.
  2. Further, the consultant explained to Mr X that diagnoses are fluid and can change over time. The key consideration is what support Mr X was entitled to in order to meet his mental health needs.

The Practice

  1. The Practice wrote to Mr X on 24 June 2016. It explained it had deregistered him as he was no longer able to visit the surgery. The Practice therefore considered it was unable to treat him safely as it could not effectively complete reviews of his medication or symptoms.
  2. I have seen no evidence the Practice wrote to Mr X in the 12 months prior warning him about the removal. The Regulations require this prior warning. The failure to do so is evidence of fault.
  3. However, I have seen evidence the Trust supported Mr X to obtain his medication and his support worker was making efforts to have him registered with another GP. Further, I understand Mr X is now registered with another GP and the Practice has revised its policy for removing patients from its register. I therefore consider this resolves this aspect of the complaint.

Complaint procedures

  1. Mr X wrote to the Council, the Trust and the Practice on 31 May 2016. He wrote again on 31 October 2016 as he had not received an acknowledgement or response.
  2. The Trust and Council sent a joint response on 28 November 2016. In summary, the Trust and Council:
    • Apologised for the delay in responding to the complaint.
    • Acknowledged the April 2016 assessment did not make it clear whether Mr X had eligible care needs.
    • Agreed parts of the assessment were inaccurate and it therefore should be completed again.
    • Accepted Mr X should have been given a care plan. However, Mr X now had a care plan for his health and social care needs.
    • Explained an officer from the mental health team had visited Mr X on 28 July 2016 and concluded his mental health was stable. A community mental health nurse completed an assessment with Mr X on 16 September 2016.
    • Noted Mr X had undertaken two medical reviews since September. As a result, his diagnosis and medication had been changed.
  3. The organisations wrote again on 24 March 2017. The response included the following points:
    • Mr X alleged staff had lied to him. While the Trust and Council accepted there may have been instances of miscommunication due to the number of professionals involved in assessments, it explained it needed evidence staff had lied in order to investigate further.
    • Diagnoses are made based on the information and the person’s behaviour evident at the time of the relevant assessment.
    • Mr X’s support worker was helping him to register with a new GP and had recently accompanied him to a walk-in centre as part of this. In the interim, arrangements had been made for Mr X’s prescription.
    • The Trust and Council offered an appointment with a senior manager to discuss the contents of his assessments and Mr X’s concerns about false records.
  4. Mr X was not satisfied and complained to the Ombudsmen shortly after.
  5. There is some evidence of fault in the initial delay in responding to Mr X’s complaint. However, the Trust and Council have apologised for the delay and this is a suitable remedy to any injustice Mr X has suffered. I do not consider there is evidence of fault in the complaint responses themselves. The responses have addressed Mr X’s complaints. While I accept he does not agree with the content of the responses, this is not fault in the responses themselves, but rather a difference of opinion.
  6. However, I consider there is evidence of fault in the Practice failing to respond to Mr X. The only correspondence I have seen from the Practice is the letter notifying Mr X that he was no longer on the register.
  7. I do not consider there is evidence of Mr X being victimised because of his complaints. It is clear that professionals have found engaging with Mr X challenging. It is perhaps also the case there have been misunderstandings because of this. However, I do not consider this is a result of Mr X’s complaints but rather due to more general communication difficulties.

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Recommendations

  1. Since Mr X complained to the Ombudsmen, his mother and main carer has, sadly, passed away. Given the lack of clarity around the 2015 assessment, the Council has agreed to offer Mr X a reassessment to determine whether he has eligible social care needs which are not being met. It should do this within one month of my final decision.

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Final decision

  1. There is evidence of fault in the Council and Trust’s failures to ensure Mr X was offered appropriate services. The Trust has now offered Mr X a referral to secondary services and the Council will offer Mr X a reassessment of his social care needs.
  2. Mr X’s risk assessment is incomplete and this is evidence of fault. However, as he was not at ongoing risk I cannot conclude he has suffered an injustice. I do not consider there is evidence the Trust or Council have falsified his records. I also do not consider there is evidence of fault in the Trust’s diagnosis.
  3. The Practice failed to follow correct procedures when it removed Mr X from its register. However, the Trust ensured he had access to his medication throughout and he is now registered with a new practice.
  4. There is some evidence of fault in the complaint responses. However, Mr X has now received an apology. This is appropriate.
  5. I have therefore completed my investigation.

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Parts of the complaint that I did not investigate

  1. The Ombudsmen cannot investigate late complaints unless they decide there are good reasons. Late complaints are when someone takes more than 12 months to complain to the Ombudsmen about something an organisation has done. (Local Government Act 1974, sections 26B and 34D, as amended, and Health Service Commissioners Act 1993, section 9(4).)
  2. I have not considered the part of the complaint which relates to the original removal of Mr X’s bipolar diagnosis. The relevant assessment took place in 2012. That assessment has been considered during a previous investigation by the Ombudsmen. That investigation concluded the assessment and conclusions were appropriate. While the previous investigation did not specifically consider the diagnosis, I consider Mr X had an opportunity to raise the issue with the Ombudsmen at the time. I therefore do not propose to investigate now.

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Investigator's decision on behalf of the Ombudsman

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