Summary: Mrs H complained about the care provided to her son, Mr G, by London Borough of Bromley, NHS South East London Integrated Care Board and Oxleas NHS Foundation Trust. We found fault by these organisations for their handling of Mr G’s discharge from hospital. This caused Mr G and Mrs H distress and uncertainty. The organisations will act to put matters right and review their policies and procedures to prevent similar problems occurring in future.

The complaint

1. The complainant, Mrs H, is complaining about the care and support provided to her son, Mr G, by London Borough of Bromley (the Council), Oxleas NHS Foundation Trust (the Trust) and South East London Integrated Care Board (the ICB).
2. Mrs H complains these organisations failed to work together to put proper section 117 aftercare services in place for Mr G before his discharge from inpatient care in May 2022. She says Mr G’s aftercare provision should have included specialist accommodation to help meet his complex needs.
3. Mrs H says the failure of these organisations to provide Mr G with proper aftercare meant he was placed at risk of deterioration and readmission to hospital. In addition, she says these events were extremely stressful for her as she had to constantly chase the Council, Trust and ICB for assistance.
4. Mrs H would like the Council, Trust and ICB to acknowledge the failings in her son’s care. She would also like them to action to prevent similar problems occurring for Mr G and other vulnerable service users in future. Mrs H would like these organisations to pay a financial remedy. This should recognise the impact on Mr G of the failings in his care. It should also recognise she endured unnecessary stress and trouble pursuing support for him.

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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, 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. When investigating complaints, if there is a conflict of evidence, we 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. 
9. If we are satisfied with the actions or proposed actions of the organisations 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

10. I considered evidence provided by the Council, the Trust and the ICB. and relevant law, policy and guidance. I also considered information provided by Mrs H and discussed the complaint with her.
11. I shared a copy of my draft decision statement with all parties and considered the comments I received.

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What I found

Relevant legislation and guidance

Mental Health Act 1983

12. 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’.
13. 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.
14. 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. Specialist accommodation can be included in a person’s section 117 aftercare provision if it meets a need arising from, or related to, the person’s mental disorder.
15. Responsibility for providing or arranging these services in Mr G’s case rests with the Council and ICB.
16. The Code of Practice that accompanies the MHA sets out that professionals should clearly record a person’s section 117 aftercare needs in their care plan. The care plan should also be subject to regular review.
17. 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.

Care Programme Approach

18. The Care Programme Approach (CPA) is an overarching system designed for coordinating the care of people with mental disorders.
19. The Code of Practice explains that the CPA should be used for patients with complex needs who are at high risk of suffering a deterioration in their mental health. Section 34.8 of the Code of Practice says “[t]his would include most people who are entitled to after-care under section 117 of the [MHA].”
20. The Code of Practice sets out the importance of effective care planning as part of the CPA. It says the care plan “should be prepared in close partnership with the patient from the outset, particularly where it is necessary to manage the process of discharge from hospital and reintegration into the community.”
21. In addition, the Code of Practice requires that a person who is subject to the CPA should have an allocated care coordinator.

Background

22. In 2022, Mr G was living in supported accommodation.
23. In March 2022, Mr G attended the A&E department at a local hospital. Staff noted Mr G was behaving strangely and were concerned for his safety. Mr G was subsequently detained under section 2 of the MHA. In April, the hospital converted this to a section 3 detention.
24. In the meantime, Mr G’s accommodation evicted him. This meant he was at risk of homelessness on discharge.
25. Mrs H contacted the Council in April to enquire about arrangements for Mr G’s accommodation on discharge. The Council referred Mrs H to the Trust.
26. An Occupational Therapist (OT) reviewed Mr G later that month. The OT recommended that Mr G should have non-shared accommodation on discharge to support his mental health wellbeing. The OT also noted that Mr G would need supervision to take his medication.
27. The Trust then referred Mr G to the Council’s housing team.
28. Mr G attended a section 117 meeting on 10 May with members of the multidisciplinary team. A Community Mental Health Team (CMHT) manager noted that B&B accommodation would not be suitable for Mr G on discharge. The OT present told the meeting that Mr G could become overwhelmed when sharing communal spaces.
29. On the same day, Mr G’s responsible clinician rescinded his section, and he remained on the ward as an informal patient.
30. The Trust contacted the Council on 15 May to report that Mr G’s discharge was imminent and that he would require temporary accommodation.
31. The section 117 meeting reconvened the following week. This meeting heard that Mr G could be discharged to a B&B temporarily while the Council secured suitable housing. The meeting heard the Trust’s Home Treatment Team (HTT) would support Mr G until he had an allocated care coordinator.
32. Mr G was discharged to B&B accommodation in the Bromley area that day.
33. There appears to have been some confusion as the accommodation could not initially find a booking for Mr G. However, the Trust resolved the situation later that evening.
34. Later that month, the Council’s housing team secured temporary accommodation for Mr G in the Watford area. Mr G accepted the offer and moved into the accommodation shortly afterwards.
35. The Trust made a referral for Mr G to the local mental health team in Watford in June. However, by mid-July, Mr G had still not received contact from the local services. The service in Watford eventually completed the transfer of care in August.
36. In October, a consultant psychiatrist reviewed Mr G and suggested he receive a depot injection instead of his oral antipsychotic medication due to concerns about his compliance. The consultant noted Mr G refused this option and that his mental health seemed to be deteriorating. Following further input from the local community team and consultant, Mr G agreed to receive a depot injection.
37. Mr G moved into permanent accommodation in the Bromley area in August 2024 and his care transferred back to the Trust.
38. In January 2025, the Trust put a fresh care plan and crisis plan in place for Mr G.

My analysis and findings

Discharge process

39. Mrs H complained that the Council, Trust and ICB discharged Mr G into the community into unsuitable accommodation and without proper section 117 aftercare. She said this had left Mr G in an out of area placement and without access to care. Mrs H said Mr G was at increased risk of readmission, which is what section 117 aftercare services should prevent.
40. In its response to my enquiries, the Trust said there was no indication Mr G needed specialist mental health accommodation. Rather, it said it could meet Mr G’s care needs through mental health services in the community. The Trust said it had reviewed Mr G’s section 117 aftercare needs prior to his discharge at the meetings on 10 and 18 May 2022.
41. The Code of Practice places effective care planning at the heart of the CPA process. The Code of Practice says a person’s care plan should provide a comprehensive record of their needs and how these will be met. This includes physical and mental health needs, social care needs, accommodation needs and any action the person should take in the event of a crisis.
42. The Code of Practice emphasises the importance of involving the correct people in the care planning process. Central to the process is the patient and their representatives. In addition, Section 34.10 of the Code of Practice sets out that “[i]t is also essential that a suitable care co-ordinator is identified.”
43. The other professionals involved in care planning will vary from patient to patient. However, this may include (but is not limited to):

• the responsible clinician;
• professionals involved in the patient’s inpatient care;
• social care professionals;
• housing service representatives; and
• community mental health representatives.

44. By the point of the first meeting on 10 May, the multidisciplinary team was aware that Mr G was due to become homeless at the point of discharge. Despite this, there was no representative present from the Council’s housing service. This was significant as the OT present specifically noted that Mr G may become overwhelmed in communal spaces and recommended private accommodation. Further, the CMHT manager who had worked with Mr G in the community, cautioned against a B&B. The manager said time was needed to appoint a care coordinator to assist Mr G with securing appropriate accommodation.
45. Despite these concerns, the notes of the second meeting on 18 May, record that “[Mr G] can be discharged to Bed and Breakfast temporarily.” It is of concern that neither the OT nor the CMHT manager were present to provide further input. I found no evidence in the records to suggest that Mr G’s presentation had changed between the two meetings. It is unclear, therefore, why the decision was made that he could now be discharged to a B&B.
46. Again, there was no representative from the housing team at this meeting. The meeting notes record that “[the CMHT manager] is chasing housing and this may take some time.” This suggests there was no clear plan for Mr G’s accommodation on the day of discharge. This in turn meant there was no indication how long he would be required to remain in B&B accommodation.
47. Mr G’s stepfather, who was present at the meeting raised concerns about this. He also pointed out that Mr G still did not have a care coordinator. I found no evidence in the records of even an approximate timescale for one to be allocated.
48. It is similarly unclear whether the Council assessed Mr G’s social care needs prior to his discharge. I found no evidence of a social care assessment in the care records, and no social care representative appears to have been present at either of the discharge meetings.
49. I note the Trust did receive notification from Mrs H later on the day of Mr G’s discharge that he had been offered temporary accommodation in Watford. Nevertheless, the Trust does not appear to have made a referral for Mr G to mental health services in that area prior to his discharge.
50. Mr G’s discharge summary recorded that he was to be discharged with HTT support and that the CMHT would follow up on his accommodation. The discharge summary also noted that Mr G would make an appointment with his GP for a physical health check.
51. In summary, Mr G was discharged from hospital to temporary accommodation out of area:

• without an allocated care coordinator;
• with no clear plan for his long-term accommodation;
• with no settled plan for his mental health care in the community and
• with no assessment of his social care needs.

52. The evidence I have seen suggests this discharge process was contrary to the requirements of the Code of Practice, therefore. This is fault. The Trust bears some of the responsibility for this as the organisation that was providing Mr G’s day-to-day care. However, the fault is shared by the Council and ICB, which bore the statutory duty to provide, or arrange section 117 aftercare services for Mr G.

Injustice

53. I will now go on to consider the injustice caused to Mr G and Mrs H. In doing so, I must be clear that the Ombudsmen cannot determine what accommodation or services a person should receive. These are matters of judgement for the multidisciplinary team supporting that person. Rather, our investigation focused on whether the discharge was handled in accordance with relevant law and guidance. As I have explained above, my view is that this was not the case for Mr G.
54. However, it is important to note that there were some mitigating factors.
55. Mr G was discharged on 18 May, with planned support from the HTT. At that time, he was noted to be “bright in mood, pleasant on approach.”
56. Mrs H contacted the Trust the following day to report her concerns that Mr G had been discharged without support and would be going to temporary accommodation in Watford. The Trust duty officer advised Mrs H that the HTT would be completing a 72-hour follow-up with Mr G.
57. The HTT spoke to Mr G later that day. At that stage, he was in the process of moving to his temporary accommodation. The clinical notes record that he was “doing well”, was not at risk and was aware how to contact services in an emergency.
58. The HTT then spoke to Mr G again on 21 May to complete the 72-hour follow-up. He reported that his mood was “all right” and that he was looking forward to moving to his new accommodation.
59. On 25 May, the HTT completed a 7-day follow-up. Mr G reported that he was “doing well” and was “eating and sleeping well”. The HTT provided Mr G with the contact details for the CMHT in his new area and advised him to register with a GP as soon as possible.
60. There was then a delay of around two months before mental health services in Watford had any significant input into Mr G’s care. The case records show the Trust was chasing the equivalent service in Watford for progress.
61. I am satisfied that the Trust was providing Mr G with some support in the days immediately following his discharge, therefore.
62. Nevertheless, I consider it likely, on balance of probabilities, that the delayed transfer of care and subsequent problems with Mr G’s accommodation might have been avoided with more effective care and discharge planning.
63. Further, I consider the discharge placed Mr G at increased risk of deterioration. It also caused both Mr G and Mrs H significant distress and uncertainty.

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Agreed actions

64. Within one month of my final decision, the Council, Trust and ICB will each write to Mr G and Mrs H to apologise for the impact caused to them by their shared failure to:

• appoint a care coordinator to support Mr G through the care planning and discharge processes; and
• put in place a comprehensive care plan setting out Mr G’s health care, social care and accommodation needs and how these would be met in the community prior to his discharge from hospital.

65. In addition, The Council, Trust and ICB will each:

• pay £200 to Mr G; and
• pay £200 to Mrs H.

This is a total of £400 to be paid by each organisation.

66. This sum is intended to recognise the distress and uncertainty caused to Mr G and Mrs H by the fault I identified.
67. Within three months of my final decision, the Council, Trust and ICB will:

• review their section 117 policies and procedures to ensure they reflect the requirements of the Mental Health Act 1983 and the associated Code of Practice. These reviews should ensure there is clear guidance for staff around effective care planning and the importance of an allocated care coordinator for people with complex needs; and
• if they have not done so already, provide Mr G with an allocated care coordinator in keeping with the requirements of the Code of Practice.

68. The Council, Trust and ICB will provide us with evidence they have complied with the above actions.
69. I also considered whether to make any further recommendations about Mr G’s ongoing care. However, the Trust provided me with a copy of his most recent care plan from January 2025, following his return to the Bromley area. I am satisfied this shows Mr G does now have an appropriately detailed care plan in place. I did not make any additional recommendations to those above, therefore.

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Decision

70. I found fault by the Council, Trust and ICB with regards to their handling of Mr G’s discharge from hospital in May 2022. This caused Mr G and Mrs H significant distress and uncertainty.
71. The actions these organisations have agreed to undertake represent an appropriate and proportionate remedy for this injustice.
72. I have now completed my investigation on this basis.

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Investigator's decision on behalf of the Ombudsman