Summary: The Ombudsmen did not take further action with Mr H’s complaint about the mental health treatment provided to his daughter, Miss G, by a Council, CCG and a Trust. Although there was some fault by the Trust, we have not found this led to a shortfall in Miss G’s treatment.

The complaint

1. Mr H complains on behalf of his daughter, Miss G, regarding the care and treatment she received from Nottinghamshire Healthcare NHS Foundation Trust (the Trust), Nottingham City Council on behalf of Nottinghamshire County Council (the County Council) and Nottingham City Clinical Commissioning Group (the CCG) between July 2016 and September 2017.
2. Mr H complains that after his daughter’s discharges from section 3 of the Mental Health Act (MHA) in 2016 and 2017 the arrangements made for her aftercare under section 117 (s.117) of the MHA were inadequate. He also complains the transition from child to adult mental health services when his daughter turned 18 in 2017 was not properly planned or managed.
3. Mr H said failings by the Trust have delayed his daughter’s recovery and that this has had significant implications for both her and the rest of the family. He also felt although some faults have been identified and apologies given, no changes or service improvements have been made to prevent this situation arising again.
4. Mr H would like an acknowledgment of failings and service improvements to prevent similar circumstances happening to other patients.

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The Ombudsmen’s role and powers

5. 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)
6. 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)).
7. If it has, they may suggest a remedy. 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. 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

9. Whilst investigating this complaint I have considered information from the Council, Trust, the CCG and Mr H. I also obtained independent clinical advice from a Consultant Psychiatrist. In addition, I have considered the relevant national guidance and legislation. I sent a draft decision to Mr H and the organisations and considered all their comments before making this final decision.

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What I found

Legal, local and national background

10. Section 3 (s.3) of the MHA allows for a person to be admitted to hospital for treatment if their mental disorder is of a nature and/or degree that requires treatment in hospital. In addition, it must be necessary for their health, their safety or for the protection of other people that they receive treatment in hospital
11. Under s.117 of the MHA 1983, councils and CCGs have a joint duty to provide or arrange free aftercare for people who have been detained under s.3. CCGs only commission care, they do not provide it directly.
12. Aftercare services must meet a need arising from or related to the person’s mental disorder and reduce the risk of their mental condition worsening and the need for another hospital admission again for mental disorder.
13. To address someone’s s.117 aftercare needs, professionals should determine:

• What was the mental disorder for which they were detained under a qualifying part of the MHA?
• What needs do they have which directly arise from or are related to that mental disorder?
• What services are required to meet those needs?
• Which of those services are required to reduce the risk of a deterioration in the person’s mental disorder?
• Which of those services are required to reduce the risk of them needing admission to hospital for that mental disorder?

14. Care planning for s.117 aftercare should be done via the Care Programme Approach (CPA) framework. It should start when the person is admitted to hospital. CCGs and councils “should take reasonable steps” to ensure aftercare services are in place in good time for discharge
15. When a person is entitled to services under s.117, they are not entitled to Continuing Healthcare funding (CHC) for those services. Continuing Healthcare funding is to pay for a person’s health and social care if they have what is called a primary health need. However, they may be entitled to CHC for additional care needs as well as s.117 aftercare for the needs arising from their mental disorder.
16. The Section 117 after-care local policy and guidance (Nottingham
17. City and Nottinghamshire county councils, Nottinghamshire Healthcare NHS Foundation Trust, Clinical Commissioning Groups 2015) states:

“ the aftercare of the detained patients should be included in the general arrangements for implementing the care programme approach”

18. NICE Guidance (NG69) ‘Anorexia nervosa: treatment for children and young people’ states:

“Many children and young people with anorexia find it helpful to have a talking therapy that family members or carers can take part in too. This is called family therapy.”

19. Transition planning should be in line with the relevant NICE guideline (NG43) 'Transition from children's to adults' services for young people using health or social care services '. Paragraph 1.2.1 recommends:

“…practitioners should start planning for adulthood from year 9 (age 13 or 14) at the latest. For young people entering the service close to the point of transfer, planning should start immediately.”

Background

20. In 2016 Miss G was 16 and suffering from an eating disorder. She had been under the care of the Children and Adolescent Mental Health Service (CAMHS) for an eating disorder, anxiety and depression since 2012. CAMHS in Nottingham is provided by the Trust.
21. In March 2016, Miss G was detained for treatment under s.3 of the MHA because of her refusal to eat. She was admitted to an adolescent inpatient unit (the Unit). The Unit takes care of young people with mental health issues for assessment and treatment. Miss G was discharged from the section in May 2016 but remained at the Unit for treatment.
22. In July 2016 Miss G left the Unit. The Trust subsequently stated in its complaint response that this was against medical advice. The Trust said staff had told Miss G her choice was to stay there and carry on her care plan or leave against their advice.
23. Mr H complained about a lack of aftercare for his daughter following this discharge. He said the care plan was inadequate and there was only one single joint meeting involving a psychiatrist and a dietician. Mr H said the family sought a second opinion at Great Ormond Street Hospital which recognised the seriousness of Miss G’s issues, but this was too late to prevent a readmission to inpatient care. He said it had a detrimental effect on her and the family.
24. The CCG in its investigation report of April 2018 admitted fault in that it and the Trust did not follow the s.117 procedure in carrying out a joint assessment. It apologised for this. The CCG said that Miss G did not benefit from the full range of options a s.117 assessment would have offered. However, it stated the actual impact on Miss G was hard to quantify. As the Trust had pointed out, she did have a care plan and support from CAMHS in place and family therapy was also offered. The Trust apologised for not providing actual s.117 aftercare but said it had put care in place and welcomed the second opinion from Great Ormond Street.
25. Unfortunately, in December 2016, Miss G was again detained under s.3 of the MHA, this time being admitted to a hospital in Scotland (the Hospital). The Hospital provides services for children and young people with complex needs or a combination of mental health or eating disorders. The CCG said the section was removed in June 2017 as Miss G no longer met the criteria under the MHA. Miss G was discharged two days later when she decided not to come back following a period of home leave.
26. Mr H said the Trust took no action, as far back as April 2017, to start planning for his daughter’s discharge. He said the self-discharge was because to return to Scotland would have caused his daughter great distress. Mr H went on to say the failure of CAMHS to offer adequate support post discharge meant his daughter did not have access to a personal health budget under s.117. He felt this would have been the best method of offering continuity of care for his daughter who was extremely distressed following her discharge.
27. Mr H said he did not feel a proper package of care was in place. There was no support for daily activities and no family therapy. There was also a lack of psychiatric support.
28. The Trust, in its contribution to the CCG’s investigation report, said on her return to Nottingham, it liaised with the Hospital over Miss G’s ongoing treatment and care plans. The Trust said it also liaised with Nottingham Citycare Partnership about CHC funding and was advised to follow the s.117 aftercare process. Nottingham Citycare Partnership is a community health service that offers nursing, nutrition and dietetics services in the Nottingham area.
29. A CPA meeting was held on 19 July 2017 with Miss G and her parents. One of the actions from that meeting was for Miss G’s care co-ordinator to complete a s.117 application.
30. Citycare said it received a referral from a CAMHS psychiatrist on 24 July 2017 but it was incomplete and it did not receive a full referral until 8 August 2017. A meeting was held on 16 August 2017 without the family because they were on holiday but a s.117 assessment was carried out by Citycare with the family and the input of a social worker on 6 September 2017.
31. The s.117 assessment was considered on 26 September 2017 and funding agreed. The Nurse Assessor agreed a care and support plan with Miss G and a personal health budget was set up.
32. The Trust in its complaint response said it made an application for a s.117 assessment four weeks after Miss G discharged herself. It said during this time many other tasks were being carried out by community team in order to support Miss G’s care. There were referrals to other inpatient providers, requests for day service assessment, requests for paediatric review and planning for her transition into adult services. It said some services were offered but declined by Miss G’s family.
33. The CCG said in its investigation report the s.117 assessment eventually took place with Miss G and her family in early September 2017. The CCG accepted the usual discharge arrangements were compromised as Miss G discharged herself. However, it said there was a delay from discharge in June until early August 2017 in the s.117 referral being made by the Trust.
34. It went on to say the multi-disciplinary team offered a package of care designed to meet Miss G’s support needs, some of which she declined to take up.
35. During this period Miss G turned 18 in August 2017. Mr H criticised the lack of transitional arrangements from CAMHS to adult psychiatric services which impacted on his daughter’s mental health. He said preparations should have been made many months before she turned 18.
36. In response the Trust said it had for some time been considering how to manage the transition. However, at the time Miss G was in the Hospital and it took into account the fact she could be remaining there past her 18th birthday. In June 2017 it made a referral to an Adult Eating Disorder Team. However, the team did not accept her as a patient due to her ‘unsettled presentation’.
37. The Trust went on to say in early June 2017 there was a CPA meeting attended by the CAMHS Eating Disorder team and the Adult Eating Disorder Team Lead. During the meeting the Lead explained how the team functioned and how the transition would be handled. There followed a multi-disciplinary meeting in the team about the transition.
38. The Trust rang Miss G a week later and explained how the transition would work. A meeting was then offered with the CAMHS and the Adult Eating Disorder team to introduce the Adult Team and discuss the transition. However, Miss G did not attend the meeting.
39. The Trust explained the following week it held a meeting with Miss G, her mother, her GP and members of the CAMHS to discuss the transition. Further meetings took place and CPA meetings were offered to the family in July 2017 but were declined. The CPA meeting eventually took place later in July and agreed a care plan. Further appointments were then offered to discuss the CPA and transition, but Miss G did not attend.
40. The CCG concluded in its investigation that planning had been taking place while Miss G was an inpatient and following her discharge. This included both the CAMHS and Adult Teams and a CPA was put in place. It also found that services were offered but not always taken up.
41. In its response to the Ombudsmen’s enquiries, the Trust outlined the improvements it has made to the service since 2017. It has appointed a Transition Specialist Practitioner to provide assessment and ongoing treatment for patients from the age of 17.5 years. This Practitioner continues treatment into the adult eating disorder services ensuring there are no gaps in provision. An Occupational Therapist has been appointed to support young people with reintegration back to community. In addition, an Occupational Therapist Assistant has been appointed to work across CAMHS to build a young patient’s independence.
42. Furthermore, local specific Commissioning for Quality and Innovation (CQUIN) framework forums and transition champions have been appointed. CQUIN supports improvements in the quality of services and the creation of new, improved patterns of care.

Analysis

Lack of s.117 aftercare in 2016

43. From the records Miss G had over 100 appointments with CAMHS during 2016 including during inpatient stays.
44. The Trust offered individual support, family therapy, psychiatric follow up, dietetics and liaison with Miss G’s school and GP. This was a comprehensive care package from CAMHS. This package of treatment would also be in line with NG63 for eating disorders. Not all of these appointments were attended. In addition, the CCG and Trust apologised for the lack of further options offered under s.117.
45. Taking this into account, although the s.117 process was not strictly followed, there was no fault by any organisation as she had a comprehensive care package in place in line with NICE guidelines.

Lack of aftercare in 2017

46. From looking at the records and the information provided by the Trust and CCG, in 2017 a care package in line with the NICE guidelines was offered by the Trust. However, it proved difficult to deliver this complete package and a number of appointments were not attended. With regard to the delay in the s.117 referral, there was an excessive delay in making a s.117 referral and this was partly because the application was not properly made by the Trust.
47. However, I have not found fault with the care package that was offered while the s.117 referral was being put together. Although a personal health budget could have been offered sooner, the package already offered was suitable for Miss G’s needs. At that time there was no legal requirement to offer a personal health budget as part of a s.117 aftercare plan. In addition, when a social care assessment was carried out it did not identify any social care needs for Miss G. Therefore, although there was a fault on the part of the Trust in the delay in making the s.117 referral, it did not lead to a quantifiable shortfall in the care that was offered to Miss G.
48. Regarding the personal health budget, there was a delay in this being obtained due to the faults outlined above. I recognise Mr H’s frustration with this delay. However, at the time there was no legal requirement for the personal health budget and there is insufficient evidence that this had a negative effect on the provision of Miss G’s care because I am satisfied there was a suitable package of care in place to meet Miss G’s needs. .

The transition from CAMHS to adult care services

49. The first reference in the notes to a consideration of this transition was in May 2017, four months before Miss G’s 18th birthday. At this point Miss G was still an inpatient at the Hospital and the discussion was around whether in the future she could be moved to an adult inpatient facility in Leicester or Nottingham. The discussion concluded staff should speak to Miss G to see what she wanted to do in the future with her care. Transition planning was formally started as part of a CPA meeting (5 June 2017). There were then further meetings taking place and offers to Miss G to attend an introductory meeting before her birthday.
50. Appointments were offered as part of the transition plan, but these were not attended. Transition planning was not linked sooner to a specific local service as there was a possibility that Miss G would have needed to continue in an inpatient service for treatment following her 18th birthday. There were a number of different services involved at this point, including a Great Ormond Street eating disorder consultant, a therapist from Scotland and the Leicester Eating Disorder service as well as local CAMHS.
51. However, Miss G had already received considerable CAMHS input from the age of 13 and had already had a number of hospital admissions, including under section 3 of the MHA and had not recovered. Therefore it would be expected that ongoing adult mental health input would be needed and formal transition planning, including the family, should have started sooner.
52. Taking into account the above and NICE guidelines (NG43), based on the information I have seen so far, there was fault by the Trust in not starting transition planning earlier. However, my view is this did not lead to a shortfall in her care as she had involvement from a suitable range of professionals by the time she turned 18 in August 2017.
53. Although it did not assure Miss G in this instance, it may provide some reassurance to Mr H that the Trust, as outlined in Paragraphs 41 and 42, has improved its transition arrangements for other patients as this was one of the outcomes he wanted to see as a result of this complaint.

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Final decision

54. After considering further comments from Mr H and the organisations complained about, I do not recommend further action by the Council, CCG or Trust. Based on the information I have seen, there was no fault with the Council or CCG and although there was a delay in s.117 aftercare and transition planning by the Trust, it did not lead to an obvious detriment in Miss G’s care. The Trust has also apologised and made improvements to its services.

Investigator’s decision on behalf of the Ombudsmen

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Investigator's decision on behalf of the Ombudsman