Tees, Esk & Wear Valley NHS Foundation Trust (17 002 243a)

Category : Health > Mental health services

Decision : Upheld

Decision date : 05 Oct 2018

The Ombudsman's final decision:

Summary: The Ombudsmen uphold a complaint against the Trust for a delay in diagnosis of a mental health patient but not against the Council for inappropriate residential placements.

The complaint

  1. The complainant, whom I shall refer to as Mrs A, has complained on behalf of her son, Mr B about his care and treatment by Durham County Council (the Council) and Tees, Esk & Wear Valley NHS Foundation Trust (the Trust). I am investigating:
    • Misdiagnosis, leading to a delay in correct treatment of Mr B and inappropriate residential placements
    • Lack of support from social workers for Mr B and his family
    • Inconsistencies and delays in medical assessments of Mr B
    • Delay in the complaint investigation and response
    • A lack of independence in the Council’s investigation of Mrs A’s complaint
  2. The impact of these failings was avoidable distress to Mr B and his family. Mrs A said the failings have had a negative effect on Mr B’s personality, wellbeing and family. They may potentially never recover from this emotionally, mentally, physically and financially.
  3. The outcomes that Mrs A would like are a better explanation of what happened, acknowledgement of fault, compensation and service improvements to prevent this happening again.

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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. During the course of my investigation I have considered the following evidence:
    • Papers, emails and a telephone conversation with Mrs A
    • Papers and emails from the Council including the complaint file and Mr B’s social care records
    • Papers and emails from the Trust including the complaint file and Mr B’s medical records
    • Independent clinical advice from a Consultant Psychiatrist (our Adviser)

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What I found

  1. Mr B has cerebral palsy and had been living with his partner and children before facing mental health difficulties in October 2015.


  1. Mrs A felt from October 2015 her son was extremely unwell and suffering from psychosis. However doctors diagnosed delirium. A diagnosis of a psychotic illness was not made until Mr B had a second opinion in June 2016.
  2. Mrs A said this delay led to a worsening in her son’s mental and physical wellbeing as well as incidents at his residential placements. She felt doctors related his issues to having a learning disability rather than taking into account how much he had deteriorated in the past months.
  3. The Trust has accepted it got the diagnosis wrong and said that treatment could have been different if Mr B was diagnosed earlier.
  4. When the diagnosis of delirium was first made in November 2015 the evidence shows the assessment was properly carried out with suitable treatment and Mr B’s symptoms improved for a period. Our Adviser agreed with this conclusion.
  5. However, Mr B had further issues in early 2016 which ended with him being assessed under the Mental Health Act in January 2016 and admitted to hospital. At this stage mental health professionals held a meeting and decided Mr B had Dissociative Personality Disorder.
  6. The Council and the Trust then gave community placements and treatment according to this diagnosis. After Mr B was admitted in January 2016 he was discharged on 26 February to a community placement. This placement did not include the level of support that Mr B would have had if he had been diagnosed with a psychotic illness.
  7. Mr B had issues at this placement which staff did not relate to mental illness. Mr B’s behaviour worsened and there were several incidents including assaulting another patient and damaging the home. This resulted in a move to another community placement in April 2016 which also did not give Mr B the level of support he needed. This was again due to the delay in diagnosis.
  8. Mr B continued to hallucinate and became more agitated until he was sectioned again in May 2016. At this point anti psychotic medication was prescribed which was appropriate in the circumstances. Mrs A felt this medication calmed her son and improved his behaviour.
  9. In the documents given to us there was little evidence to support the diagnosis of Dissociative Personality Disorder and our Adviser agreed with this conclusion. Given that, when Mr B had a second opinion in June 2016, he was diagnosed with a psychotic illness and there had been no change in his behaviour and symptoms since February 2016, had the mental health professionals meeting properly considered Mr B’s symptoms, they would have concluded he was suffering from a psychotic illness at that time. I have looked at what impact this delay in treatment had on Mr B, including the residential placements he had.
  10. The Council has said in response to my enquiries:

“Had the Learning Disability Service been aware that Mr (B) was suffering with a psychotic illness as opposed to a dissociated personality disorder, the type of placement accommodation offered would have been specialist residential care with experience of mental health or residential care with nursing support. Additionally it is highly likely that 1:1 support would have being commissioned.

Supported accommodation and Bed and Breakfast accommodation would not have been considered as suitable, given the later diagnosis.”

  1. Bearing in mind that Mr B was sectioned before the fault identified, and he has been sectioned again after, I cannot say on the balance of probabilities that the difficulties he subsequently had would not have happened if he had been treated earlier, but an opportunity was lost which means Mrs A will never know if this situation could have been avoided. In addition Mr B was undergoing increased distress due to the lack of correct anti-psychotic medication.

Lack of support from social workers for Mr B and his family

  1. Mrs A said social workers were insensitive with the family and Mr B. She says comments were made alluding to the fact that Mr B had to ‘stop his behaviour and act his age’ when in reality he was mentally ill and not in control of his decisions or behaviour.
  2. The Council’s care records for 21 January 2016 show a social worker spoke to Mrs A over the phone. The notes say the social worker had explained it was the view of other professionals that her son’s issues were behavioural rather than a mental health issue. The notes go on to say a specialist health team had seen Mr B that week and judged this to be the case. The social worker also stated, regarding Mr B’s placement, Mr B had exhausted all other alternatives.
  3. I can understand how this was upsetting for Mrs A to hear from the social worker. However the social worker was taking a lead from mental health services’ view at the time. Despite a more serious diagnosis given to Mr B later I do not find it was insensitive to relay this information to Mrs A at the time.

Inconsistencies and delays in medical assessments of Mr B

  1. I have set out the inconsistencies in the medical assessments above. There were several full psychiatric assessments in the earlier admissions and shorter assessments thereafter when much of the clinical picture was already known. Taking into account clinical advice, the evidence shows there were no significant delays in assessments both in hospital and the community.

Delay in the complaint investigation and response

  1. The investigation and complaint response took from August 2016 to January 2017. The Trust took the lead with the complaint and kept Mrs A updated with the progress of the investigation. It thanked her for her patience in awaiting the response and explained why it took some time.
  2. I do not find the time taken to investigate this complaint was excessive due to the complexity of the complaint and the number of individuals consulted. In addition the Trust kept Mrs A updated during this time.

A lack of independence in the Council’s investigation of Mrs A’s complaint

  1. Mrs A complained the manager of the social workers carried out the Council side of the investigation. Mrs A felt this was a conflict of interest and the investigation should have had a degree of independence or been at arm’s length to the social workers.
  2. I have found no fault in employing the social workers’ principal to investigate the complaint. This is part of the role of a Principal Support Officer.

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  1. With regard to the failings I have identified in paragraphs 12 and 18 and the injustice to Mrs A and Mr B I recommend the Trust, by 5 November:
  • Pay Mrs A £500 and Mr B £1000 in recognition of the distress and uncertainty caused by the failings I have outlined above
  • Apologise to Mrs A and Mr B for the distress caused by the above faults

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  1. I partly uphold the complaint against the Trust in relation to a delay in diagnosis of Mr B. I do not uphold the complaint against the Council.

Investigator’s decision on behalf of the Ombudsmen

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Investigator's decision on behalf of the Ombudsman

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