Summary: We found fault with the Trust; it did not allocate Mr Q a new care coordinator, did not conduct a S117 review or formally discharge him, and it was not clear with Mr P during the complaints process. We also found the Council did not understand the care package it was providing to Mr Q. This caused confusion to Mr P when he tried to clarify. We recommended an apology and service improvements to address this injustice.

The complaint

1. Mr P complains Cambridgeshire and Peterborough NHS Foundation Trust (the Trust), Peterborough City Council (the Council) and Cambridgeshire and Peterborough Clinical Commissioning Group (CCG) failed to provide his son, Mr Q, with the aftercare services he was entitled under Section 117 (S117) of the Mental Health Act (MHA) 1983. Specifically, Mr P says the organisations failed to arrange regular S117 aftercare reviews following his son’s discharge from hospital.
2. Mr P also complains the organisations failed to fully address his complaint.
3. Mr P says the failure to arrange regular S117 reviews led to delays in arranging care for his son when his existing care arrangements broke down in July 2019. Mr P says this placed his son at risk and caused them both distress and inconvenience.
4. Mr P wants the Council, CCG and Trust to acknowledge and apologise for their shared failure to provide his son with appropriate S117 aftercare. He would also like them to arrange regular S117 reviews for his son to ensure his care needs are being met.

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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 a single team has considered these complaints 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), 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. The Ombudsmen cannot question whether a decision is right or wrong simply because the complainant disagrees with it. We must consider whether there was fault in the way the organisation reached the decision. (Local Government Act 1974, section 34(3), as amended, and Health Service Commissioners Act 1993, sections 3(4)- 3(7))
9. 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

10. I considered the complaint Mr P made to the Ombudsmen and information he provided by email. I considered the information provided by the Council, Trust, and CCG in response to my enquiries.
11. I shared a confidential draft with Mr P, the Council, Trust, and CCG to explain my provisional findings and invited their comments. I considered their comments before making a final decision.

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What I found

Background

12. Mr Q has severe autism and learning and communication disabilities with no speech. Mr P is his father and carer. Mr Q was hospitalised and detained under Section 3 of the MHA 1983 in December 2016 and released in February 2017.

Analysis

What should have happened

13. Under the MHA 1983, when someone has a mental disorder and is putting their safety or someone else’s at risk they can be detained in hospital against their wishes. This is sometimes called ‘being sectioned’. It should be in the best interests of the person and they should not be detained if there is a less restrictive alternative.
14. Section 3 is to provide treatment and detention can last for a maximum of six months.
15. Before they discharge the person, a social care assessment should take place to assess if they have any social care needs.
16. S117 of the MHA imposes a duty on health and social services to meet the health and or social care needs arising from, or related to, the persons mental disorder. This is known as S117 aftercare.
17. S117 aftercare services must:
• meet a need arising from or related to the mental disorder for which the person was detailed; and
• have the purpose of reducing the risk of the person’s mental condition worsening and the person returning to hospital for the treatment for the mental disorder.
18. Section 33.7 of the Mental Health Act Code of Practice 2015 states Councils and CCGs should “maintain a records of people for whom they provide or commission aftercare and what aftercare services are provided.”
19. The CCG explained it commissions mental health services throughout Cambridgeshire through the Trust. For S117 aftercare, the CCG keeps responsibility through Case Management Reviews of individual placements and packages of care. It does this by completing a joint commissioning tool where it finds an individual's needs have changed. This ensures the individual receives the right care at the right time and in the right place.

Chronology of events

20. A note on Rio, the Trust’s electronic patient records system, shows S117 aftercare was discussed at the discharge planning meeting on 26 January 2017 and confirmed it would be in place on Mr Q’s discharge home. This is also noted in the discharge preparation paperwork from 6 February.
21. Mr Q left hospital in February 2017. The Trust’s Intensive Support Team (IST) took over his care. The Trust held a Care Programme Approach meeting in March 2017 and a follow up was scheduled for three months later. The Council also reviewed Mr Q in April 2017. The next Trust meeting took place in May 2017. At this meeting, Mr P and Mr Q sought a second opinion for Mr Q’s diagnosis. Mr P and Mr Q asked not to see the doctor who had previously been involved in Mr Q’s care, or anyone who had previously worked with him, and Mr P made a formal complaint about the care and treatment Mr Q received during detention.
22. The Trust discharged Mr Q from the IST in June 2017 but did not assign him a new care co-ordinator.
23. The Council reviewed Mr Q in September 2017.
24. In November 2017, Mr Q was transferred from the Trust to a social worker so the Council’s adult social care department could manage his care.
25. In May 2018, the Trust ended its involvement with Mr Q and Mr P because of their disengagement from the service. Mr P explained this was because they were only offering Mr Q medication with no other forms of help. It did not hold any discharge meetings or consider discharging Mr Q from S117.
26. The Council reviewed Mr Q in July 2018.
27. The Council conducted a S117 case review in September 2018 and identified Mr Q needed 20 hours of funded support. It continued to work with Mr P and Mr Q to support Mr Q’s continuing needs as they changed.
28. The Council reviewed Mr Q in June 2019.
29. In July 2019, the Council emailed the Trust to ask for clarification on the Trust’s involvement. It explained Mr P had told the Council the Trust had discharged Mr Q from S117 aftercare, but neither of them had been to any meetings about this. The Trust replied to the Council to explain it had discharged Mr Q after one year of non-engagement.
30. Further emails between the two organisations show the Trust believed it was the responsibility of the Council to conduct S117 reviews as it was leading his care. The Council explained disengagement does not mean discharge from S117 and is not in line with the Trust’s policy which says any discharge should include all parties. The Council asked the Trust to confirm if Mr Q had been officially discharged from S117. The Trust confirmed he had not and agreed it should arrange a S117 review meeting.
31. In October 2019, the Trust sent Mr Q a letter offering him a S117 review meeting. It also asked to meet Mr Q to review his needs before the meeting. Mr P and Mr Q declined both the review appointment and to attend the meeting. This was because they had already told the Trust they wanted no further involvement with its doctors.
32. Whilst discussions were taking place between the Council, the Trust and Mr P, the Council continued to hold care need reviews through its social care team and continued to support Mr Q. The Council reviewed Mr Q in July 2020.
33. The Trust asked to see Mr Q and offered him an appointment for February 2021. This appointment was to assess his mental health needs before a S117 review meeting could take place. Mr P told the Trust Mr Q did not want to see the doctor. The Trust agreed it would work with the Council to arrange a S117 review meeting soon.
34. The Trust wrote to Mr P in April 2021 and explained a doctor needed to assess Mr Q before a S117 review meeting could be booked. It offered Mr Q an appointment with a different doctor. Mr P and Mr Q attended an in-person assessment with an autism specialist.

Findings

35. During my investigation, I asked the Council if it records showed Mr Q was receiving S117 aftercare, which should have prompted reviews. It explained the doctors who are responsible for managing and supporting S117 aftercare and the Mental Health Administrator who looks after the register work for the Trust. It further explained “the Adult Social Care Department has advised they do not manage or keep the S117 register … and it is not the Council’s responsibility to maintain the register.”
36. While it may not be the Council’s role to keep the register, it should know if it was providing Mr Q with S117 aftercare, funded by the CCG. The records show the Council was fulfilling its duties and providing Mr Q with S117 aftercare, but it did not know this was the role it was fulfilling.
37. The Council caused confusion when answering Mr P’s complaint as it could not give him a clear answer, because it did not know. This is not in line with LGSCO guidance on effective complaint handling which states Council’s should be open and accountable. If the Council was unsure what care role it was providing, it should have checked before answering Mr P’s complaint. This would have prevented confusion for all parties and prompted action around booking a S117 review sooner. This is fault which caused an injustice to Mr P that could have been avoided.
38. The Trust has accepted it has not conducted any S117 reviews since Mr Q’s discharge from hospital. It explained this is because Mr P and Mr Q disengaged with the Trust and for reviews to take place it needed to do a mental health assessment on Mr Q.
39. When Mr Q stopped engaging with the Trust, it should have considered whether to discharge him from S117 aftercare. The Mental Health Act 1983 Code of Practice 33.20 states “the circumstances in which it is appropriate to end S117 after-care will vary from person to person and according to the nature of the services being provided. The most clear-cut circumstance in which after-care would end is where the person’s mental health improved to a point where they no longer needed services to meet needs arising from or related to their mental disorder.”
40. The Trust’s S117 policy states the Trust should assign a new care coordinator if a service user needs continuing support. The Trust did not assign a new care coordinator in 2017 despite the need remaining. This is fault. This became a problem to Mr P when he spoke to the Trust to ask about a S117 review. As there was no assigned care coordinator, Mr P did not receive answers to his questions and had to email different people. This is an injustice to him.
41. When Mr P and Mr Q disengaged from the Trust, it should have considered whether this was an appropriate time discharge Mr Q from S117 aftercare. It did not do this, it just stopped being involved with Mr P and Mr Q. This is fault. This led to an injustice to Mr P who did not know whether Mr Q was still receiving S117 aftercare services because the Trust did not provide him with any clarification.
42. However, Mr Q continued to receive a jointly funded care package from the CCG and Council under S117 aftercare. The CCG has provided evidence which shows Mr Q still receives funding for S117 aftercare to date. I found no fault with the actions of the CCG.
43. There is fault by the Trust when it did not consider discharging Mr Q when he said he would not work with them anymore. The Trust also did not communicate with the CCG and Council about his refusal to engage. However, this has not impacted on the care package Mr Q has received from the Council, which has continued to date. I have seen evidence of regular reviews by the Council of Mr Q’s needs and these needs were being met. Therefore, there is no injustice to Mr Q because of the fault by the Trust.
44. Mr P has an injustice in his own right. He has chased the organisations in the best interests of Mr Q and was forced to make complaints because he was not receiving clear answers. Had the Trust explained its mistake to him, he may not have felt the need to complain as he would have understood Mr Q’s care package was unaffected.
45. PHSO Principles of Good Complaint Handling states organisations should “be open and honest when accounting for their decisions and actions. They should give clear, evidence-based explanations, and reasons for their decisions. When things have gone wrong, public bodies should explain fully and say what they will do to put matters right as quickly as possible.” The Trust was not clear with Mr P, and he had no choice but to make a complaint to the Ombudsmen. This is an injustice to Mr P which the Trust could have avoided.

Summary

46. I have identified several faults which have led to an injustice to Mr P. During the complaint local resolution process, the Trust recognised it had made mistakes, apologised and told Mr P it would improve. It said it would:
• Address policy errors in its next policy review meeting
• Improve its case management system to ensure staff are aware when reviews are due
• Train staff in complaint handling
47. The Council admitted to Mr P that a S117 review was due and apologised for the delay. It offered to work with him to ensure this review took place soon.
48. I asked the Council to confirm whether this review had taken place. It confirmed it had not.

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Agreed actions

49. Therefore, the Ombudsmen recommended, and the organisations agreed, that within one month of the date of this decision the Council and the Trust would jointly write to Mr P to:
• Acknowledge their responsibility for the faults identified in paragraphs 13-45
• Apologise for the impact of the faults to Mr P, in terms of the avoidable frustration and distress caused
• Provide evidence to the Ombudsmen and Mr P the recommendations made in the local complaint resolution process have been completed
50. The organisations should also work with Mr P and Mr Q to arrange a S117 review meeting as quickly as possible and provide evidence of this to the Ombudsmen.

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Final decision

51. I partially uphold Mr P’s complaint. I found fault which led to an avoidable injustice to Mr P. The agreed recommendations will provide a suitable remedy.

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Investigator's decision on behalf of the Ombudsman