Summary: We found London Borough of Enfield, North London NHS Foundation Trust and North Central London Integrated Care Board failed to properly assess and review Miss X’s aftercare needs following her discharge from hospital in 2018. This caused Miss X significant uncertainty and distress. These organisations will apologise to Miss X for this fault, take remedial action and make a symbolic payment in recognition of the impact of these events on her.

The complaint

1. The complainant, Miss X, is complaining about the care provided to her by London Borough of Enfield (the Council), North Central London Integrated Care Board (the ICB) and North London NHS Foundation Trust (the Trust - formerly Barnet, Enfield and Haringey Mental Health NHS Trust).
2. Miss X is entitled to free aftercare services under section 117 of the Mental Health Act 1983. However, she complains that she has not received these services since being discharged from inpatient care in 2018. Miss X says she has been prevented from accessing services locally and has not had regular reviews of her care needs.
3. Miss X says this has been extremely distressing for her and that she has been left without proper care and treatment.
4. Miss X would like to have appropriate care and support in place to meet her needs.

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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, we 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. If we are satisfied with the actions or proposed actions of the bodies 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

9. In making my final decision, I considered information provided by Miss X and discussed the complaint with her. I also considered relevant information from the Council and Trust, including copies of the care and clinical records. I took account of relevant guidance and legislation. I shared a copy of my draft decision statement with all parties for comment and considered the responses I received.

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What I found

Relevant legislation and guidance

Mental Health Act 1983

10. The Mental Health Act 1983 (the MHA) allows that 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 known as ‘being sectioned’.
11. Section 3 of the MHA 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.
12. A person who has been detained under section 3 of the MHA is entitled to free aftercare services under section 117 of the same legislation. These services are intended to prevent a deterioration in the person’s mental health and reduce the risk of them requiring further admission to hospital. Responsibility for providing or arranging these services in Miss X’s case rests with the Council and ICB.

The Code of Practice that accompanies the MHA sets out that a person’s section 117 aftercare needs should be clearly recorded in their care plan and subject to regular review.

13. The Code of Practice also explains that local authorities and ICBs are required to maintain a record of all local people for whom they provide or commission aftercare. This should include details of what aftercare is being provided.

Background

14. Miss X had complex mental health needs. She had recorded diagnoses including severe depression, Emotionally Unstable Personality Disorder (EUPD) and Post Traumatic Stress Disorder (PTSD). Miss X had been under the care of the Trust’s Enfield Integrated Core Mental Health Team (the Enfield Team) since 2011.
15. In 2018, Miss X was detained under section 3 of the MHA due to a deterioration in her mental health. This meant she was entitled to s117 aftercare services on discharge.
16. Following her discharge from hospital, Miss X began to receive education and symptom management sessions through the Trust’s Complex PTSD pathway in August 2018. The Trust agreed to consider the possibility of trauma-focused therapy sessions once this work had been completed.
17. In September, Miss X was again detained under the MHA, before being discharged the following month. The Trust wrote to Miss X’s GP to explain changes to her medication.
18. In December, a consultant psychiatrist reviewed Miss X. He noted that she had attended six sessions of psychological therapy and would be attending a further 20 sessions of trauma therapy. However, the psychiatrist noted that Miss X had stopped taking her antipsychotic medication.
19. Miss X was detained again in May 2019 as she appeared to be experiencing psychotic symptoms and was considered to be at risk.
20. Miss X continued to experience psychotic symptoms and attended regular reviews with the Trust. This led to various adjustments in her medication. However, her condition remained unstable. This resulted in several further hospital admissions.
21. Between March and October 2021, Miss X underwent a course of eye movement desensitisation and reprocessing (EMDR). This is a psychotherapy technique used to treat the symptoms of PTSD. However, in February 2022, the treating psychologist advised Miss X she did not consider long-term therapy would be beneficial for her. This led Miss X to end her relationship with the psychotherapy team.
22. The Enfield Team undertook regular psychiatric reviews between September 2022 and March 2023. These reviews noted that Miss X’s mental health was stable, with no signs of low mood or psychotic episodes. Miss X also recommenced EMDR therapy.
23. In April 2023, Miss X decided that she no longer wanted to proceed with the EMDR therapy.
24. Miss X remained under the care of the Trust’s Enfield Team. Later that month, Miss X requested a medical review. The Enfield Team scheduled an appointment for her for June 2023. However, Miss X felt this was too long a delay.
25. In May 2023, Miss X contacted the Enfield Team to request her discharge and the cancellation of all upcoming appointments.
26. Early the following month, Miss X contacted the Enfield Team to request support. This led the Trust to transfer Miss X’s care to the North Core Mental Health Team (the North Team) due to the breakdown in her relationship with the Enfield Team.
27. The North Team offered to complete a medical review. It explained Miss X would first need to work with the team to complete a DIALOG+ questionnaire prior to an appointment. This is a form designed to identify key areas of need.
28. In June 2023, Miss X was admitted to hospital for back surgery. Following her discharge, Miss X was referred to the Council’s Occupational Therapy (OT) service due to her increased physical health needs. An OT visited Miss X to complete an assessment.
29. Miss X spoke to a member of the North Team in July 2023 to discuss the DIALOG+ questionnaire. There is some dispute as to what took place. The Trust said Miss X declined to proceed as she did not see the need for the DIALOG+. However, Miss X said the Trust officer did not explain the process and she was not confident to proceed. I was unable to find a note of this discussion in the Trust’s records.
30. In October 2023, the Council completed a social care assessment. This established that Miss X had eligible care needs under the Care Act 2014. However, Miss X declined any social care support services.
31. In January 2024, Miss X attended a section 117 review meeting with clinicians from the Enfield Team and North Team. This review meeting concluded Miss X would remain under the care of the North Team, with a medical review to take place in March. The review meeting also agreed that a clinician would discuss the possibility of further psychological support with Miss X.
32. However, Miss X’s relationship with the North Team subsequently deteriorated and the Trust transferred her care to the South Core Mental Health Team (the South Team) in May 2024.
33. Miss X attended a review meeting with the South Team in June 2024. Miss X subsequently recommenced EMDR later that year.

My findings and analysis

Section 117 aftercare services and reviews

34. Miss X complains that she was not provided with any section 117 aftercare services after she became eligible following a detention under the MHA in 2018.
35. In their complaint responses, the Council and Trust acknowledged Miss X had not been provided with a specific section 117 aftercare plan on discharge from hospital. Further, they accepted there was no evidence that specific section 117 reviews had been undertaken.
36. However, the Council and Trust said Miss X had been receiving treatment under its Complex PTSD pathway and that this included regular medical reviews and psychological treatment.
37. In response to my enquiries, the Council said Miss X had declined social care support on discharge from hospital. Nevertheless, it said the Trust continued to support Miss X through its mental health outpatient services and that she had an allocated care coordinator to assist her.
38. Section 33.14 of the Code of Practice says that “[a]fter-care for all patients admitted to hospital for treatment for mental disorder should be planned within the framework of the care programme approach…it is important that all patients who are entitled to after-care under section 117 are identified and that records are kept of what is provided to them under that section.”
39. The care programme approach (CPA) is an overarching system for coordinating the care of people with mental health conditions. It should be used for people who are at high risk of a deterioration in their mental health. This includes most people who are entitled to section 117 aftercare services.
40. Section 34.5 of the Code of Practice requires a care coordinator to be appointed “who has responsibility for co-ordinating the preparation, implementation and evaluation of the CPA care plan.”
41. The care records show Miss X became eligible for section 117 aftercare services in 2018, following a period of detention under section 3 of the MHA. However, the Council, Trust and ICB failed to put a section 117 aftercare plan in place for Miss X when she left hospital. Furthermore, the Trust did not arrange regular section 117 aftercare review meetings nor allocate Miss X a care coordinator as required by the Code of Practice.
42. This is fault. This fault is shared by the Trust (which provided Miss X’s day-to-day mental health care) and the Council and ICB (which had the statutory duty to provide or arrange section 117 aftercare services for Miss X).

Access to care

43. Miss X complains she was prevented from accessing care by the manager of the North Team. Miss X says she had been assured by a member of the team that she would receive a care coordinator but was subsequently informed she had been discharged from the service.
44. In the Trust’s complaint response, it noted Miss X had sent an email to an Enfield Team clinician in May 2023 requesting discharge from all care services and the cancellation of any upcoming appointments. The Trust said a clinician contacted Miss X’s GP to explain that she could be referred to the service again in future if necessary. The Trust said that, following further contact from Miss X, her care was transferred to the North Team. The Trust said there was no evidence Miss X had been prevented from accessing services.
45. The care records show Miss X has complex care needs. She has been under the care of the Trust’s mental health services since before her detention under the MHA in 2018. There is evidence of extensive contact between Miss X and local mental health services throughout this period.
46. In 2023, Miss X became aware that she may be entitled to section 117 aftercare. Miss X said she raised this with a consultant at a medical review in July 2023 and that the consultant would investigate this. The consultant’s clinic letter for the appointment does not mention this conversation. Nevertheless, there is evidence to show Miss X was querying her section 117 entitlement at appointments around this time.
47. The care records show there was some confusion initially amongst both health and social care professionals around Miss X’s entitlement to section 117 aftercare. This was not ultimately confirmed until October 2023, around three months after Miss X first began to raise concerns.
48. I recognise there were sometimes differences of opinion between Miss X and the professionals supporting her as to her care needs. This meant there were times Miss X did not receive services she felt she was entitled to. This caused tension between the North Team and Miss X and led the Trust to take action to limit her contact with the team.
49. However, there is no evidence to suggest these professionals deliberately attempted to prevent Miss X from accessing care. I found no fault by the Council, Trust or ICB on that point.
50. Nevertheless, there was a delay establishing Miss X’s entitlement to section 117 aftercare. This likely would not have occurred if there was a proper record of Miss X’s entitlement to aftercare. The failure to maintain a clear record is evidence of fault by the Council, Trust and ICB.

Injustice to Miss X

51. The evidence shows the Council, Trust and ICB failed to properly assess, and review Miss X’s section 117 aftercare needs. Miss X’s entitlement began following her discharge from hospital after her detention under section 3 of the MHA in 2018.
52. The impact of this on Miss X is mitigated to some extent by the extensive support she has received from mental health services from that period to the present. This support includes regular medical reviews and access to psychological therapy. I am unable to say whether Miss X’s care would have been substantially different even if her section 117 needs had been properly assessed and reviewed. Nor can I say whether her subsequent readmissions to hospital would have been prevented.
53. Nevertheless, this failure represents a missed opportunity over a significant period to explore whether Miss X had any wider needs arising from, or related to, her mental disorder. This has left Miss X with considerable uncertainty and caused her great distress.
54. This was exacerbated by the time it took to confirm Miss X was entitled to section 117 aftercare once she raised this as an issue in July 2023.

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Agreed actions

55. Within one month of my final decision statement, the Council, Trust and ICB will write a joint letter to Miss X apologising for the impact on her of their shared failure to:

• produce a clear care plan setting out her section 117 aftercare needs and how these would be met;
• carry out regular reviews of her section 117 aftercare in accordance with the requirements of the Code of Practice; and
• promptly establish her entitlement to section 117 when she raised this as a concern in 2023.

56. In addition, the Council, Trust and ICB will each pay Miss X £500 (a total of £1,500) as a symbolic recognition of the impact of this fault on her.
57. Within three months of my final decision, the Council, Trust and ICB will:

• If they have not done so already, work with Miss X to produce an up-to-date section 117 aftercare plan. This should set out Miss X’s section 117 aftercare needs and how these will be met. This plan should include input from all relevant professionals; and
• explain what action they will take to ensure Miss X’s section 117 aftercare provision is subject to regular review in accordance with the requirements of the Code of Practice.

58. The Council, Trust and ICB will provide us with evidence they have complied with the above actions.

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Final decision

59. I found fault by the Council, Trust and ICB with regards to their handling of Miss X’s section 117 aftercare entitlement.
60. I am satisfied the agreed actions I have set out above represent an appropriate and proportionate remedy for the injustice caused to Miss X by this fault.
61. I have now completed my investigation on this basis.

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Investigator's decision on behalf of the Ombudsman