The Ombudsman's final decision:
Summary: The Ombudsmen have found fault in the way section 117 aftercare services and interrelated adult social care services were arranged for a young adult, which caused her and her mother injustice. The Council has agreed to take steps to put things right.
- The complainant, whom I shall refer to as Mrs C complains on behalf of her daughter, whom I shall refer to as Miss G, about the services provided by Hampshire County Council (the Council), Southern Health NHS Foundation Trust, and Portsdown Group Practice (the GP Surgery).
- The complaint also involves the Child and Adolescent Mental Health Service (CAMHS). At the time of the events Mrs C is complaining about, this service was provided by Hampshire Partnership NHS Foundation Trust. This Trust no longer exists and CAMHS services in the area are now provided by Sussex Partnership NHS Foundation Trust (the Sussex Trust).
- In particular, Mrs C says:
- That the CAMHS team made representations to the Council in January 2010 which detailed Miss G’s ongoing needs, and outlined the support services which it considered necessary to prevent her deteriorating following her discharge.
- That the Council subsequently failed to assess Miss G or arrange services in line with the Trust’s recommendations. Mrs C says that social workers at the Council appeared to be unaware of their duties around section 117 aftercare.
- That when Miss G transferred to adult social care there was no mention of her entitlement to section 117 aftercare services. Mrs C says that Miss G has regressed significantly since her discharge from hospital in 2010, which she feels is linked to the Council’s and CAMHS’ failure to arrange aftercare services.
- Mrs C also complains there has been a failure to arrange clinical mental health services and social care services for Miss G following her transition to adult services, despite this being an identified need. Mrs C says:
- She was led to believe that clinical mental health services would be arranged by a community mental health team operated by Southern Health, but was told in January 2015 that this team only provides social care support to Miss G.
- That neither the Council nor Southern Health have supported her in accessing clinical support for Miss G, and she has been put to considerable time and trouble in trying to secure support through other agencies.
- There has been a failure to conduct regular reviews of Miss G’s needs and care plan following her transition to adult services. Mrs C says that only one assessment has been carried out (in 2014), and that it was not shared with her and Miss G for comment.
- The Council failed to conduct a carer assessment when Miss G transferred to adult social care, which has meant she has missed out on support services.
The Ombudsmen’s role and powers
- The Ombudsmen have the power to conduct joint investigations and to report jointly on complaints that cross the boundaries of their jurisdictions. From April 2015 the Ombudsmen introduced a new process for investigating complaints about both health and social care services. These complaints are now investigated by single team acting on behalf of both Ombudsmen. (The Regulatory Reform (Collaboration etc. between Ombudsmen) Order 2007)
- 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)).
- 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.
How I considered this complaint
- In considering this complaint I had a telephone discussion with Mrs C and considered the written materials she sent me. I made enquiries of the Council and Trusts, and GP Surgery and considered their comments and supporting evidence.
- I took account of relevant law, statutory guidance, and local policy and I took account of advice provided by a practising psychiatrist who has no association with the people or events complained about.
- I also considered the notes of a telephone interview with the Service Manager for Mental Health and Social Care at Southern Health.
- Furthermore, I considered comments from Mrs C, the Council and the Trusts on my draft decision statement.
What I found
- In 2007 Miss G, then 13 years of age, began receiving support from CAMHS due to a history of school refusal, severe social isolation, self neglect, poor motivation, aggression and extreme beliefs around food contamination.
- In May 2009 Miss G was detained under section 3 of the Mental Health Act after absconding from a voluntary admission to a psychiatric hospital. During her subsequent detention, Miss G was diagnosed with severe depressive episodes, social anxiety, and autistic spectrum disorder.
- Miss G was discharged from hospital in early 2010 with a recommendation from the psychiatrist that the Council arrange a residential school placement as part of her section 117 aftercare package. The Council decided against this on the grounds that Miss G had expressed a wish to attend a local college. The college placement broke down after several months, and Miss G did not subsequently re‑enter education.
- In February 2012 a family psychotherapist from CAMHS completed a transition report for Miss G’s move to adult services. The report recommended that Miss G receive long term ongoing support to enhance her self-help skills and overcome her anxieties and phobias. The report said that mental health services would act as the lead agency for Miss G following her transition. CAMHS sent the report to Southern Health in late February 2012 and again the following month.
- Miss G turned 18 in March 2012 and her care transferred to a Community Mental Health Team (CMHT) run by Southern Health, and which provided adult social care services on behalf of the Council.
- A social worker within the team acted as Miss G’s care coordinator and was responsible for discharging the Council’s statutory duties for adult social care. Following an initial meeting with Miss G, the social worker allocated a support worker for one hour per week.
- The social worker wrote to Miss G’s GP on 20 March 2012 and asked that a referral be made to a private assessment clinic which specialised in autism. The GP made the referral, and an assessment was carried out on 15 August 2012. The assessment concluded that Miss G’s ‘anxiety and depression need to be assessed in their own right by the adult mental health team.’ The report went on to note of Miss G that ‘[a]s [she] has a diagnosis of Asperger’s [she] is entitled to an assessment of [her] needs from the Adult Social Care Team. I am aware that there is likely to be ongoing discussion about whether this should be from the [Learning Disability] team, or the mental health team.’
- The GP subsequently referred Miss G to the learning disability team at Solent NHS Trust (the Trust from which the GP Surgery commissioned secondary mental health services). A learning disability nurse completed an assessment of Miss G in January 2013 and found that he would not be suitable for learning disability services. The assessor’s letter reflected his understanding that Miss G’s mental health care needs were being met by the CMHT (part of Southern Health).
- The GP re-referred Miss G to Solent NHS Trust’s initial assessment team in July 2013. This resulted in a brief period of intervention from an occupational therapist. Miss G was discharged from the service in March 2014. This was because the occupational therapist felt that he did not suffer from a severe and enduring mental health problem. She also explained that the Trust was not commissioned to provide specialist autism services.
- The social worker from the CMHT carried out a social care needs assessment in November 2014 after Mrs C complained about a proposal to reduce Miss G’s support worker to 1 hour per fortnight. The assessment resulted in a care package of 5 hours per week (later increased to 8 hours per week) which would be arranged through direct payments. The direct payments started in April 2015.
- In August 2015 an autism diagnostic centre (ADRC Southampton) conducted a further assessment following a referral from Miss G’s GP. The assessment found Miss G’s presentation was consistent with a diagnosis of autism. The report made detailed recommendations about how support should be arranged for Miss G.
- In January 2016 a psychiatrist from Solent NHS Trust wrote to Southern Health to request a psychiatric assessment of Miss G, explaining that it could not provide specialist autism services.
- On 1 March 2016 a psychiatrist from Southern Health assessed Miss G and concluded that her current care package was ‘inadequate either to address [her needs] or, indeed, to offer the level of respite necessary to enable [her] mother to continue as [her] main carer’.
- Miss G’s new care coordinator (another social worker within the CMHT) undertook a further social care assessment. The Council subsequently increased Miss G’s care package to 17.5 hours per week of support worker time, arranged through direct payments.
Clinical and administrative context
- At the time of the events Mrs C is complaining about, the Mental Health Code of Practice (the Code of Practice (2008)) provided statutory guidance for councils and health commissioners. This has since been superseded by a revised code of practice published in 2015, although the duties surrounding section 117 aftercare are broadly similar in both editions of the guidance.
- The Code of Practice says that section 117 of the Act requires Primary Care Trusts (PCTs – the predecessors to Clinical Commissioning Groups) and councils, in co-operation with voluntary agencies, to provide or arrange for the provision of aftercare to patients who have been detained in hospital for treatment under section 3 of the Mental Health Act 1983. The duty to provide after-care services continues as long as the patient is in need of such services to prevent their readmission to hospital and to support them in regaining or enhancing their skills, or learning new skills, in order to cope with life outside of hospital.
- The aftercare plan should be recorded in writing. Once the plan is agreed, it is essential that the statutory agencies discuss the plan with the patient, as well as other relevant persons, before the services are implemented. The aftercare plan should be regularly reviewed and it is the responsibility of a designated care co-ordinator (or other officer responsible for its review) to arrange reviews of the plan until it is agreed that it is no longer necessary.
Transition from Child & Adolescent Mental Health Services to Adult Mental Health Services
- At the time of Miss G’s transition between CAMHS and adult services, there were no national NHS guidelines or standards for transition services between CAMHS and adult mental health in 2012, although it was recognised as a problem area. However, in March 2012 the Joint Commissioning Panel for Mental Health (JCPMH) released a document entitled Guidance for commissioners of mental health services for young people making the transition from child and adolescent to adult services.
- Page 8 of that guidance explains that there is no set model to meet the needs of young people in transition from adolescent to adult mental health services. However, the guidance highlights a process that reflected established good practice at that time, which notes:
- The young person’s key worker/case co-ordinator with CAMHS should liaise with the Adult Service Team Leader to co-ordinate transition. This may involve a period of joint working up to the point of transition
- A written referral is made to the Adult Team and care co-ordination documentation is completed – this will include a history of professional involvement with the young person and the relevant family history
- The Adult Service confirms acceptance of the referral in writing, copied to the relevant professionals, the young person and their carers
- The Adult Service confirms acceptance of the referral in writing, copied to the relevant professionals, the young person and their carers
Adult social care assessments
- Prior to April 2015, section 47 of the NHS and Community Care Act 1990 placed a duty on councils to conduct an assessment when an adult appeared to need community care services. The assessment would generally be carried out by social workers and/or occupational therapists, although this is not mandatory requirement.
- Councils then had a duty to decide whether to provide or arrange community care services based on their eligibility criteria. If a person’s assessed needs met a council’s eligibility criteria, it had a legal duty to provide enough support to meet those assessed eligible needs, subject to means testing.
Analysis of complaints
Section 117 aftercare services
- The Code of Practice placed a statutory requirement on the Council to work collaboratively with the local PCT (now CCG) to produce a written aftercare plan following Miss G’s discharge from hospital. The Code of Practice says the aftercare plan should take account of psychiatric advice, and set out the services Miss G would receive to prevent her readmission to hospital, and to help with her reintegration into the community. The Council and PCT had a duty to allocate a key person to oversee Miss G’s aftercare services. The plan should have been discussed with Mrs C and Miss G, and their views taken into account before the plan was finalised. The provision of services should have continued until such a time as all the agencies had decided the services were no longer necessary.
- There is no evidence the Council produced an aftercare plan in line with these requirements. This was fault. The fault is compounded by the fact the psychiatrist made written representations to the Council explaining that aftercare must be provided under section 117 of the Mental Health Act, and expressed concern that social workers at the Council seemed unfamiliar with these duties.
- The psychiatrist commented that Mrs C would be unable to provide sufficient support for Miss G following her return home, and that the most appropriate course of action would be for the Council to arrange a specialist residential school placement for Miss G, along with a package of social care support. The psychiatrist’s letter expressed concern at the Council’s planned course of action, which was for Miss G to return home to Mrs C’s care, and for her to start a local college placement in the September 2010.
- As I understand it, the Council did not pursue a residential placement as Miss G had expressed a preference to attend a local college. I do not find fault with this decision, as it was made in line with Miss G’s preferences, and because the Council was not bound by the psychiatrist’s recommendation. However, it was fault that no formal review of the aftercare plan took place following the breakdown in the college placement. This would have provided an opportunity for health and social care professionals to decide on the best course of action to support Miss G.
- There is also no evidence of collaboration between the Council and PCT around aftercare services. This was fault, as both iterations of the Code of Practice place a legal requirement on the Council to work collaboratively with PCTs (now CCGs) around section 117 aftercare.
- Finally, there is no evidence that the aftercare services were taken into account during Miss G’s transition to adult services. This is fault.
Transition to adult services
- Mrs C has complained that no clinical mental health services were arranged for Miss G following her transition to adult services. Mrs C says the CAMHS transition report indicated that Miss G would receive both clinical and social care services through the CMHT based at Southern Health. However, she says she was told in early 2015 that the integrated team was unable to arrange clinical services for Miss G, as her GP Surgery commissioned clinical mental health services from Solent NHS Trust. Mrs C also complains that Miss G did not receive an assessment of her social care needs following her transition, and did not receive a package of care to meet her needs until 2016.
- The transition report produced by the Council in October 2011 noted that ‘[l]ast August the Complex Needs Panel decided that Adult Mental Health Service will take lead responsibility for [her] when [she] is 18 in March 2012.’ The report also said that CAMHS would make a referral to a CMHT for ongoing support.
- A transition report prepared by CAMHS in February 2012 recorded that Miss G would require ‘ongoing support over a long period of time’. The report did not specify which agency should provide this support, though it noted ‘unaided, [she] would fare very poorly.’
- In March 2012 a psychotherapist from CAMHS wrote to Southern Health with a copy of Miss G’s transition plan, and requested that a needs assessment be carried out. He noted that ‘[Miss G’s] problems are likely to require further ongoing support through mental health services and there is both vulnerability for [her], and indeed [her] mother.’
- Also that month, Miss G’s care coordinator wrote to her GP to explain that Southern Health had received the referral. The care coordinator asked the GP to refer Miss G for a specialist autism assessment. This assessment found that he would require ongoing support but that it was less clear whether this would need to be provided by the learning disability team or adult mental health team.
- The evidence shows Southern Health did act when it received the CAMHS referral, therefore, and attempted to arrange clinical input for Miss G. The care coordinator’s care notes also show she advised Mrs C and the GP that Southern Health would be unable to provide Miss G with mental health care.
- It is clear the complex commissioning arrangements in the area caused considerable confusion. There was also a lack of clarity as to where responsibility lay for providing care at times.
- The care coordinator contributed to this confusion when she wrote to the GP in May 2012. She advised that a psychiatrist from Southern Health would be prepared to assist the GP in reviewing Miss G’s medication. While this was clearly intended to be helpful, it contributed to the impression that Southern Health remained involved in Miss G’s mental health care.
- In my view, all parties could have done more to clarify care arrangements in this case. Nevertheless, I found no evidence of actions or omissions by the Council or Southern Health that could be considered so significant as to amount to fault in this respect.
- In response to my enquiries, Southern Health provided information that demonstrates it now has robust procedures in place for managing referrals. This includes daily multidisciplinary screening of referrals. I am satisfied there are no enduring systemic problems in this area, therefore.
- I also considered the GP’s handling of the referrals. In October 2012, when the GP received the autism assessment, he referred her to the learning disability team at Solent NHS Trust (in October 2012). When the learning disability team decided Miss G would not be eligible for its services, the GP made a further referral, this time to Solent NHS Trust’s adult mental health services.
- In May 2015, following discussion with Mrs C and the care coordinator, the GP obtained funding for Miss G to be assessed by a specialised autism diagnostic centre. This assessment identified that Miss G would need clinical input to treat her depression and anxiety and social care support to give more structure to her days.
- A psychiatrist from Solent NHS Trust’s adult mental health team subsequently contacted Southern Health in January 2016 to advise that the team could not meet Miss G’s needs as it could not provide a service for patients with autism spectrum disorders. A psychiatrist from Southern Health agreed to assess Miss G. This took place in March 2016.
- Taking everything into account, I am satisfied the GP responded appropriately to the referrals made to him. This led to several clinical assessments for Miss G, as detailed above. I find no fault on the part of the GP Surgery in this regard.
Social care assessment
- In its response to the Ombudsman’s enquiries, the Council accepted it did not carry out an assessment of Miss G’s needs following her transition in 2012. It noted the first assessment of Miss G’s needs was carried in 2014, which was over two years after Miss G’s transition. This is fault. The fault is compounded by the fact that many of the clinical assessments undertaken during this period identified that Miss G was entitled to, and required, a full assessment of her needs and a package of social care support.
- The Council said the absence of an assessment did not prevent it from arranging support services for Miss G. The Council highlighted social care records which show ongoing input from the CMHT social worker from 2012 onwards, and the provision of support services to promote Miss G’s independent living skills. The Council also noted that Miss G’s poor level of engagement hindered attempts to conduct assessments and arrange support.
- The social care records do support the Council’s comments on this matter to an extent. Miss G’s care coordinator and a colleague from the CMHT were actively engaged with Miss G in the period following her transition to adult care services on 2012. The notes show they visited Miss G regularly during this period and attempted to encourage her to develop her independent living skills, with limited success. This does seem to have been largely attributable to Miss G’s reluctance to engage consistently with any input from the CMHT.
- The records show Miss G’s social worker had extensive input into Adam’s care and that she did conduct care reviews. However, I am not persuaded that this was an adequate substitute for a full social care assessment. The need for an assessment was identified in August 2012, but the Council did not carry this out for a further two years. This is fault.
- In my view, this omission represented a missed opportunity to put appropriate care in place at an earlier juncture. This in turn meant Mrs C was required to provide support that might otherwise have been provided as part of a care package. It is notable that following the full social care assessment in 2014, the Council increased Miss G’s support.
- On the balance of probabilities then, it seems likely Miss G would have received a greater level of support following her transition had the Council carried out a needs assessment in line with statutory guidance at an earlier juncture.
- In her comments on my draft decision, Mrs C clarified this aspect of her complaint. She said she is complaining that, while she did receive a carer’s assessment, this was not carried out in accordance with the Care Act. Mrs C said she did not receive the support she is entitled to.
- I found that Southern Health carried out an assessment on behalf of the Council in 2012. This preceded the Care Act, which did not come into force until 2014. The guidance in place at that time was the Prioritising need in the context of Putting People First (2010) guidance.
- The assessment found that Mrs C was struggling to support Miss G and felt overwhelmed. Following the assessment, Southern Health wrote to Mrs C on 12 April 2012 to offer her information about local carer support services, one‑to-one support sessions, and access to a carer’s support telephone line and mailing list. Mrs C agreed to this plan, which was finalised in June 2012.
- Southern Health completed a further carer assessment in December 2014. This identified similar needs. Mrs C subsequently made some amendments and the revised plan was agreed on February 2015.
- In January 2016, Mrs C wrote to the Council to ask why she had not received a financial assessment as part of the carer’s assessment. She also queried whether she would be eligible for Direct Payments in her capacity as a carer.
- The Council wrote to Mrs C in February 2016. It explained that Direct Payments for carers are not based on a person’s income and so a financial assessment was not necessary. The Council explained that the payments can be used to support carer’s in their caring role (such as by paying for certain respite activities). The Council offered to undertake an assessment to determine Mrs C’s suitability for Direct Payments.
- I appreciate that Mrs C’s role as a carer has placed a significant burden on her. However, there is evidence that the Council appropriately assessed Mrs C’s needs as a carer and provided support. I find no fault on the part of the council in this respect.
- The evidence shows there was a failure to arrange section 117 aftercare services for Miss G following her discharge from Hospital in 2010, and a subsequent failure to arrange adult social care services following Ms G’s transition to the CMHT. I have considered whether this caused injustice.
- Miss G’s reluctance to engage with support is a recognised symptom of her conditions, and is the reason why CAMHS urged for support services to continue following her transition to adult service, and for a multi agency needs assessment to take place at the point of transition.
- There is some evidence of positive progress following the hospital discharge, with Miss G attending college and a package of support being provided by CAMHS and children’s social care. However, matters began to deteriorate following the breakdown in the college placement, and the absence of an aftercare plan meant there was no proper review of services.
- With that said, it is important to recognise Miss G’s general unwillingness to engage with the support services she has been offered. The Council’s case records show that Miss G frequently refused to engage with her social worker or support workers following her transition to adult services.
- There is no evidence to suggest the situation improved significantly, even with the introduction of additional care hours. At a review meeting in May 2017, it was noted that Miss G was not using all her allocated hours of support. This was also reflected in the logs of one of Miss G’s support workers, which show that she frequently refused to engage when she visited.
- With this in mind, it is not possible to say with any certainty that the outcome of Miss G’s care would have been different even if she had received this increased support earlier than she did.
- Nevertheless, the Council fail to carry out a review of Miss G’s aftercare needs under section 117 and did not assess her social care needs for a significant period. This represented a lost opportunity to consider what extra care she required to support her as she made the transition to adult care services.
- It was also well documented that Mrs C would struggle to cope with providing effective support for Miss G. Due to the failure to properly arrange support services, it does appear that Mrs C has suffered considerable stress, time and trouble in trying to support Miss G and try to secure services for her, including incidents of Miss G becoming physically aggressive and confrontational with her when she has tried to implement boundaries. This injustice is compounded by the fact Mrs C tried to pursue a complaint about this at time of the event, which the Council did not respond to.
- I found evidence of fault causing injustice. To put things right, within one month of my final decision statement, the following actions will take place:
- The Council will apologise to Miss G and Mrs C for failing to meet its duties around section 117 aftercare planning. The Council will also apologise for its failure to conduct a needs assessment and produce a proper care plan following Miss G’s transition to adult services.
- The Council will pay Miss G £800 for the impact caused by its failure to review her section 117 aftercare needs following the breakdown of her college placement and the delay in undertaking a full social care assessment.
- The Council will pay Mrs C £800 for the avoidable distress and time and trouble caused by the failure to arrange services for Miss G. This payment is higher than the usual rate recommended for distress payments, to reflect the extended period over which the injustice occurred.
- The Council will review its policy and procedures in respect of section 117 aftercare. This review should consider whether local guidance appropriately reflects the Council’s statutory duties and the Code of Practice.
- If it has not already done so, the Council will produce a section117 aftercare plan for Miss G which meets the requirements of the Code of Practice. This should be a multidisciplinary consideration of Miss G’s needs and should include input from her and from Mrs C as her carer.
- I found evidence of fault on the part of the Council that resulted in an injustice to Miss G and Mrs C. In my view, the actions the Council has agreed to undertake represent a reasonable and proportionate remedy for the injustice caused to Mrs C and Miss G by this fault.
- I found no evidence of fault on the part of Sussex Partnership Trust, Southern Health or the GP Surgery.
Investigator's decision on behalf of the Ombudsman