Summary: Mr A has complained about a lack of aftercare planning by a Council, Integrated Care Board and a Mental Health Trust for his daughter, Miss B. Mr A said this led to deterioration in her mental health. We found fault with these organisations who have agreed to carry out our recommendations to remedy the injustice to Mr A and his daughter.

The complaint

1. Mr A has complained about NHS Surrey Heartlands ICB (the ICB), Surrey County Council (the Council), South West London & St George's Mental Health NHS Trust (the Trust) about a lack of s117 of the Mental Health Act aftercare for his daughter, Miss B, after she was discharged from hospital in 2023.
2. The Council and ICB have joint responsibility for s117 aftercare. Mr A said that the lack of aftercare left his daughter traumatised, with a distrust of social care and health workers.
3. Mr A said the rushed discharge from hospital meant his daughter was left without suitable aftercare.
4. Mr A is looking for acknowledgement of the issues raised, service improvements to prevent this happening to others, and financial remedy.

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The Ombudsmen’s role and powers

5. The Local Government and Social Care Ombudsman and Health Service Ombudsman have the power to jointly consider complaints about health and social care. (Local Government Act 1974, section 33ZA, as amended, and Health Service Commissioners Act 1993, section 18ZA).
6. We investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, we 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).
7. 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.
8. When investigating complaints, if there is a conflict of evidence, we make findings based on the balance of probabilities. This means that during an investigation, we will weigh up the available evidence and base our findings on what we think was more likely to have happened
9. If we are satisfied with the actions or proposed actions of the organisations that are the subject of the complaint, we can complete our 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

10. I considered evidence provided by Mr A, the Council, ICB and the Trust as well as relevant law, policy and guidance.
11. I gave Mr A and the organisations an opportunity to comment on my draft decision before I made this final decision.

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What I found

Relevant legal and guidance framework

12. Section 3 of the Mental Health Act is for the purpose of providing treatment. Detention under section 3 empowers doctors to detain a patient for a maximum of six months. The detention under section 3 can be renewed for another six months.
13. Section 117 of the Mental Health Act imposes a duty on health and social services to meet the health/social care needs arising from or related to the person’s mental disorder for patients who have been detained under specific sections of the Mental Health Act (e.g. Section 3).
14. Before the person is discharged, a social care assessment should take place to assess if they have any social care needs that should be met. People who are discharged from section 3 will not have to pay for any aftercare they will need. This is known as s117 aftercare.

Background

15. Miss B was a child and detained under the Mental Health Act in 2023. She was an inpatient in the Trust’s hospital for two months before being discharged to Mr A’s home in a different county.
16. Mr A complained about a lack of discharge planning between the Trust and the Council before his daughter was released from hospital.
17. The Council said there was no s117 plan in place when Miss B left hospital. It said this was the responsibility of the hospital and was also due to a lack of joined up thinking between the Council and the organisations in the new county that Miss B was discharged to.
18. Regarding discharge, the Trust said that it was not a specialist environment for Miss B’s mental health condition and the detention was to lessen the current crisis Miss B was having. It accepted that at the time Mr A felt the discharge was being rushed. However, it said there had been small improvements in her mental state. She was engaging in activities of daily living and managing around others.
19. The Trust was concerned if Miss B stayed in hospital she could pick up bad behaviours from peers on the ward. It said the specialist treatment she needed would normally be provided in the community. It said that it would not have been appropriate to keep Miss B in hospital for social issues and she was discharged to her local Children Adolescent Mental Health Services (CAMHS) team which would handle her treatment.
20. The Trust admitted that it should have communicated better with Miss B’s parents about discharge discussions and the ward team would take learning around communicating with families.
21. The Trust said that discharge planning was comprehensive and involved multiple meetings with professionals to support transition from the ward back to a community setting. It discussed s117 aftercare at the discharge meeting and this should have been actioned by the Council.

Analysis

22. The Mental Health Act Code of Practice (the Code) is clear that aftercare planning should begin as soon as the person is admitted to hospital. This is to ensure appropriate aftercare services are identified and put in place in good time for their discharge.
23. Before deciding to discharge a person from hospital, the clinician in charge of their treatment (known as the responsible clinician) should ensure their aftercare needs have been addressed.
24. This involves a comprehensive assessment of the person’s needs using the Care Programme Approach (CPA). The CPA is an overarching system for coordinating the care of people with mental health conditions.
25. When making decisions in relation to the care and treatment of children and young people, practitioners should keep them as fully informed as possible and give them clear and detailed information concerning their care and treatment. The child or young person’s views, wishes and feelings should always be sought, their views taken seriously and professionals should work with them collaboratively in deciding on how to support that child or young person’s needs.
26. Prior to their discharge from hospital all children and young people should have an assessment of their needs, on which a care plan for their aftercare is based.
27. Section 117 aftercare does not replace existing arrangements under the CPA. Where appropriate, these arrangements should run in tandem with each other.
28. The hospital had a discharge meeting and the notes of this meeting state ‘Discussions relating to Section 117 aftercare provisions and the legal requirement for continued social care (educational and health) support following discharge.’ and ‘Entitlement to Section 117 aftercare discussed.’.
29. These are the only references to s117 aftercare in the meeting and do not provide evidence that the Trust was working with the Council and ICB in formulating a s117 aftercare plan from the time Miss B was admitted, until her discharge. The lack of a s117 aftercare plan also illustrates this.
30. Miss B was discharged from hospital without a s117 aftercare plan. This was fault on the part of the Council, ICB and the Trust. Miss B was readmitted to hospital four months later. This was one month after the Council belatedly drew up a s117 aftercare plan.
31. On the balance of probabilities, we cannot say Miss B’s readmission was solely due to this lack of a s117 aftercare plan. However, she had only slightly improved, and this was a missed opportunity to provide her with support on leaving hospital. It also put her at risk of readmission, and this happened relatively shortly after leaving hospital. In addition, as a child, Miss B was more vulnerable to risk of harm from these issues than most adults.
32. The lack of planning also caused Mr A distress in seeing that his daughter may not receive adequate support and was at risk of deteriorating again and having to be readmitted.
33. Since this complaint, the Council has a multiagency s117 working group which has produced guidance for social workers. This guidance is likely to have been launched in August 2025.
34. Social workers have been able to access support from a local service which has extensive experience in working with children eligible for s117 aftercare, to aid the creation of comprehensive plans.
35. There is a Joint Commissioning Panel (JCP) which has oversight of s117 plans. The Council has been providing s117 consultations to social workers since November 2024 who have attended Assessment and Adolescent service meetings to provide an overview of s117. There is also full day s117 training available through Learning and Development for all social workers.
36. This new guidance for the Council puts in timescales for when plans should be implemented and assessments carried out post discharge.
37. The changes the Council has made are appropriate to help prevent this situation arising for other families. It also apologised about the lack of communication with the family about s117 aftercare.
38. However, the actions taken individually in this case did not address the injustice to Miss B and her father.

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Action

39. Due to the distress caused to Miss B and her father by the faults of both the Council, ICB and Trust, I make the following recommendations.
40. By 24 December 2025:

The Council:

• write to Miss B and her father, apologising for the missed opportunity caused by the lack of a s117 aftercare plan; and
• pay Miss B £400 and Mr A £200 for the distress caused by this missed opportunity.

The ICB:

• write to Miss B and her father, apologising for the missed opportunity caused by the lack of a s117 aftercare plan; and
• pay Miss B £400 and Mr A £200 for the distress caused by this missed opportunity.

The Trust:

• write to Miss B and her father, apologising for the missed opportunity caused by the lack of a s117 aftercare plan; and
• pay Miss B £400 and Mr A £200 for distress caused by this missed opportunity.

41. I also recommend that by 25 February 2026:

• The Trust should write to Miss B and her father outlining how it has improved the drawing up of s117 aftercare plans for patients admitted to its hospital.
• The ICB review its process for ensuring people whose s117 aftercare it is responsible for have aftercare plans on discharge and timely reviews, in line with the Code.

42. The organisations should provide us with evidence they have complied with the above actions.
43. Under our information sharing agreement, we will share this decision with the Office for Standards in Education, Children’s Services and Skills (Ofsted).

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Decision

44. I found fault causing injustice on the part of the Council, ICB and the Trust. I have made recommendations for the organisations to prevent a recurrence of this situation.

Investigator’s decision on behalf of the Ombudsmen

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Investigator's decision on behalf of the Ombudsman