Summary: The Ombudsmen find that Oxford Health NHS Foundation Trust missed the opportunity to ensure Mrs X had appropriate support in place when it discharged her from section 3 of the Mental Health Act. However, there was no injustice to Mrs X. She would most likely have refused the Trust’s support in favour of private care and treatment.

The complaint

1. Mrs X says when Oxford Health NHS Foundation Trust (the Trust) discharged her from section 3 of the Mental Health Act in May 2019, there was no meeting to understand her mental health needs. She says the Trust, Buckinghamshire County Council (the Council) and Buckinghamshire Clinical Commissioning Group (the CCG) did not provide any section 117 aftercare until she was sectioned again in October 2019.
2. Mrs X also says the CCG should be paying for her private care under section 3 in York since October 2019.
3. Mrs X says she suffered significant distress and her mental health worsened after May 2019.
4. Mrs X would like all the organisations to improve to avoid similar fault happening to others.

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What I have investigated

5. I have investigated Mrs X’s complaint in paragraph one. The final section of the statement contains my reasons for not investigating paragraph two.

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The Ombudsmen’s role and powers

6. 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)
7. 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).
8. The Ombudsmen will not generally investigate a complaint unless they are satisfied the matter has been brought to the relevant organisation’s attention and that organisation has had a reasonable opportunity to investigate and reply to the complaint. (Local Government Act 1974 section 26(5), as amended and Health Service Commissioners Act 1993, section 9(5))
9. When investigating complaints, if there is a conflict of evidence, the Ombudsmen may 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. 
10. 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

11. I have considered information provided by Mrs X, the Council, the CCG and the Trust. I have also spoken with Mrs X on the telephone. Ms X and those organisations had an opportunity to comment on a draft decision.

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What I found

Background

12. Mrs X suffers with dissociative identity disorder (DID). This used to be called multiple personality disorder. The person may feel the presence of other identities, each with their own names, voices and mannerisms.
13. In early 2019, issues in Mrs X’s personal life led to a decline in her mental health. She later admitted herself to the Schoen Clinic in York, who specialise in people suffering with DID.
14. After struggling to manage Mrs X under section 3, on 21 May 2019, the Schoen Clinic transferred Mrs X to the Trust to assess her mental health needs. The Trust was her local mental health service. Mrs X’s wife, as nearest relative, sought the immediate discharge of Mrs X from the section 3 at the Trust.
15. The next day Mrs X’s responsible clinician met with Mrs X and her wife. The responsible clinician agreed to discharge Mrs X. The responsible clinician recommended the Trust’s psychotherapy service, which worked with patients diagnosed with DID. However, Mrs X wanted private treatment at a clinic in London. The responsible clinician recognised Mrs X’s risk of self-harm and suicide when she is under one of her personalities, and recommended Mrs X’s wife lock away dangerous items as a short-term safety plan. He provided her with details who to contact in a crisis. The responsible clinician recommended Mrs X follow the treatment plan with the clinic in London, as she would not engage with the Trust. The responsible clinician also assigned Mrs X a care coordinator, and the Trust would follow her up within 48 hours.
16. A social worker followed Mrs X up on 24 May 2019. Mrs X told the social worker she could not get help from the clinic in London because she needed an NHS referral. She felt the NHS did not fully understand her diagnosis, and only private treatment could support her. The Schoen Clinic later sought funding from the CCG for a long-term psychotherapy placement back in York. Mrs X supported that request.
17. The care coordinator first met Mrs X on 11 June 2019, despite contacting her earlier. Mrs X reiterated the NHS should fund private treatment. If it did not, Mrs X said she would return to the Schoen Clinic anyway. A week later, the care coordinator referred Mrs X to the Trust’s psychotherapy service.
18. In September 2019, the Trust’s psychotherapy service decided Mrs X would benefit from care coordination. Once her mental health stabilised, it could consider different therapies. A month later, the care coordinator confirmed the result of the referral to Mrs X. Mrs X was unhappy the psychotherapy service did not review her in person.
19. In October 2019 Mrs X admitted herself as an informal, self-funding patient back to the Schoen Clinic. Mrs X remained there until July 2020. During her admission, the care coordinator attended Mrs X’s CPA reviews.
20. In response to Mrs X’s complaint, in October 2019 the Trust said:
• The May 2019 discharge plan was Mrs X’s section 117 aftercare plan.
• It was sorry for the delay communicating the result of the psychological services assessment of Mrs X’s mental health needs.
• The treatment at the Schoen Clinic was not evidence based, so the Trust and CCG could not agree to fund that support to meet Mrs X’s mental health needs. The Schoen Clinic had also previously struggled to manage her behaviour and mental health.

Analysis

21. Anyone who may have a need for community care services is entitled to a social care assessment when they are discharged from hospital to establish what services they might need. 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 persons mental disorder for patients who have been detained under specific sections of the Mental Health Act (e.g. section 3). Aftercare services provided in relation to the persons mental disorder under section 117 cannot be charged for. This is known as section 117 aftercare.
22. The Care Programme Approach (CPA) is the process by which mental health services assess a patient’s needs, plan how to meet them and ensure they are met. Under Refocusing the Care Programme Approach (Department of Health, 2008), people under CPA should have a comprehensive assessment of their health and social care needs. They should have a care coordinator; have a care plan to show how their needs will be met and have the care plan reviewed by a multi-disciplinary team (MDT). When a patient is in hospital, their care coordinator is the key person responsible for arranging the care and support they will need on discharge.
23. Before the Trust discharged Mrs X from section 3 on 22 May 2019, it should have carried out an assessment of her mental health needs to decide how to support her under the CPA. The Trust told me the nearest relative’s discharge order meant that the responsible officer’s discharge plan for Mrs X was essentially her section 117 aftercare plan.
24. I have reviewed the responsible clinician’s discharge plan. The discharge plan is not as comprehensive as one completed under the CPA. However, the responsible clinician assessed Mrs X’s mental health and completed a risk assessment, which recognised the risk of self-harm and suicide (when under one of her personalities). The responsible clinician developed a short-term safety plan, and appropriately provided Mrs X with contact details in the event of a crisis.
25. However, there is little evidence the responsible clinician ensured Mrs X had appropriate support in place before discharging her from section 3. On 22 May 2019, he noted that Mrs X should “continue with the treatment plan from [private clinic in London]”. Yet two days later, Mrs X told the social worker she could not engage with the private clinic in London. I consider the responsible clinician missed the opportunity to explore what support Mrs X had in place with the private clinic in London before he discharged her. I understand the discharge from section 3 was sudden, but that was still fault and not in line with the CPA.
26. I do not consider there was any injustice to Mrs X. Throughout the Trust’s medical records, Mrs X repeatedly refused NHS support for private care and treatment. At one point, the social worker noted Mrs X “has been reluctant to use the NHS system”. Therefore, even if the responsible clinician had not acted with fault, on the balance of probabilities, Mrs X would have not engaged with any further support the Trust may have offered.
27. I do not find the Council, or the CCG, were at fault for the issues I have investigated. They were joint commissioners of section 117 aftercare, and not actively involved in Mrs X’s aftercare.

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Final decision

28. While the Trust did not ensure Mrs X had appropriate support in place before discharging her from section 3, there was no injustice to her. Mrs X would most likely not have engaged with any further support the Trust may have offered.

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Parts of the complaint that I did not investigate

29. I have not investigated the CCG’s decision not to pay for Mrs X’s private support in York since October 2019.
30. In January 2020, Mrs X applied to the courts to be released from section 3. A mental health tribunal upheld the decision to keep Mrs X under the section 3. The tribunal noted the support in York was meeting Mrs X’s needs. However, the CCG should decide if it can appropriately support Mrs X back in Buckinghamshire or pay the costs of Mrs X’s support in York.
31. The CCG has refused to pay for Mrs X’s section 3 support since January 2020 until it has carried out a new assessment of Mrs X.
32. At the time I confirmed my investigation, this complaint was an ongoing issue and the CCG/Trust had not carried out an assessment of Mrs X. Once the CCG/Trust has decided how to support Mrs X under section 3, Mrs X can complain to the CCG if necessary. If Mrs X remains dissatisfied with the CCG/Trust’s response to her compliant, she can approach the Parliamentary and Health Service Ombudsman to consider her complaint. The Ombudsmen’s Joint Working Team will not consider this complaint because it concerns section 3, and not section 117.

Investigator’s decision on behalf of the Ombudsmen

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Investigator's decision on behalf of the Ombudsman