Summary: We found no fault with the support provided to Mrs X by Somerset Council, Somerset NHS Foundation Trust and NHS Somerset Integrated Care Board following the discharge of her son, Mr Y, from hospital. However, we did find fault with the way the Council and Trust handled Mr Y’s situation when he was threatened with homelessness and the impact this had on Mrs X. The Council and Trust will apologise to Mrs X and pay a financial remedy in recognition of this.

The complaint

1. The complainant, Mrs X, is complaining about the support provided to her by Somerset Council (the Council), Somerset NHS Foundation Trust (the Trust) and NHS Somerset Integrated Care Board (the ICB).
2. Mrs X complains that her son, Mr Y, was discharged to live with her without any proper consultation and without appropriate care and support in place. Further, Mrs X says professionals involved in Mr Y’s care shared inaccurate information about him that made the situation worse.
3. Mrs X says the lack of support resulted in Mr Y’s condition deteriorating. Mrs X says the situation placed great pressure on her and affected her housing situation and her relationship with neighbours. She says the situation ultimately led to legal action being taken against her in relation to Mr Y’s behaviour.

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The Ombudsmen’s role and powers

4. 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).
5. 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).
6. 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.
7. We cannot question whether an organisation’s decision is right or wrong simply because the complainant disagrees with it. We must consider whether there was fault in the way the decision was reached. If there was no fault in how the organisation made its decision, we cannot question the outcome. (Local Government Act 1974, section 34(3), as amended, and Health Service Commissioners Act 1993, sections 3(4)- 3(7))
8. 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(1), as amended)

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How I considered this complaint

9. I considered evidence provided by Mrs X and her daughter, Mrs B, and discussed the complaint with Mrs B. I considered relevant documents from the Council and Trust, including the care records. I also took account of relevant law, policy and guidance.
10. All parties had an opportunity to comment on my draft decision. I considered all comments before making a final decision.

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What I found

Relevant legislation and guidance

Mental Health Act 1983

11. Under the Mental Health Act 1983 (MHA), 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’.
12. 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 person’s 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 person’s mental disorder under section 117 cannot be charged for. This is known as section 117 aftercare.

Homelessness

13. The Housing Act 1996 is the main legislation setting out local authorities’ powers and duties in respect of housing and homelessness. This is accompanied by statutory guidance entitled ‘Homelessness Code of Guidance for Local Authorities’, which provides guidance for housing authorities.
14. Someone is homeless if they have no accommodation, or if they have accommodation, but it is not reasonable for them to continue to live there. (Housing Act 1996, Section 175)
15. Someone is threatened with homelessness if, when asking for assistance from the council on or after 3 April 2018:

• they are likely to become homeless within 56 days; or
• they have been served with a valid Section 21 notice which will expire within 56 days. (Housing Act 1996, section 175(4) & (5)

16. Under Section 213B of the Housing Act 1996, public authorities have a duty to notify a housing authority of service users they consider may be homeless or threatened with homelessness. Public authorities include health and social care organisations such as councils and Trusts.
17. Councils must complete an assessment if they are satisfied an applicant is homeless or threatened with homelessness. The Code of Guidance says, rather than advise the applicant to return when homelessness is more imminent, the housing authority may wish to accept a prevention duty and begin to take reasonable steps to prevent homelessness. Councils must notify the applicant of the assessment. Councils should work with applicants to identify practical and reasonable steps for the council and the applicant to take to help the applicant keep or secure suitable accommodation. These steps should be tailored to the household, and follow from the findings of the assessment, and must be provided to the applicant in writing as their personalised housing plan. (Housing Act 1996, section 189A and Homelessness Code of Guidance paragraphs 11.6 and 11.18)
18. If a council is satisfied an applicant is threatened with homelessness and eligible for assistance, it must take steps to help the applicant keep their home or find somewhere new to live. In deciding what steps to take, a council must have regard to its assessment of the applicant’s case. (Housing Act 1996, section 195)

Background events

19. Mr Y has complex mental health needs. He is entitled to aftercare services under section 117, having been previously detained under the MHA.
20. In October 2022, Mr Y was detained under section 2 of the MHA. This was converted to a section 3 detention later that month. Mr Y used periods of leave to visit family.
21. In early December, a social worker visited Mr Y to complete a social care assessment. Mr Y was clear that he wished to live independently with minimal support.
22. Shortly after this, the social worker spoke to Mr Y and Mrs X to discuss accommodation options for Mr Y. Mr Y said he wanted independent accommodation and a package of mental health care to support him in the community. The social worker discussed the possibility of Mr Y living with Mrs X. Both Mr Y and Mrs X thought this would not be good for Mr Y. The social worker advised Mrs X that she may need to provide formal notification that Mr Y could not live with her. The social worker said this would be a necessary step for Mr Y to access other housing options.
23. On 23 December, Mr Y went to stay with Mrs X for the festive period. He was due to return to the ward on 27 or 28 December.
24. On 29 December, Mr Y’s sister, Mrs B, spoke to a ward nurse on three occasions. The ward nurse also spoke to Mrs X and Mr Y. Mrs X and Mrs B felt Mr Y remained unwell and required ongoing inpatient treatment. However, Mr Y said that, while his mood was low, he felt otherwise well. The nurse concluded that Mr Y did not appear to be suffering from a mental illness. However, the nurse was unable to share further detail about Mr Y’s care as he had not consented to his personal information being shared with them.
25. Mr Y attended a review with a consultant psychiatrist on 4 January 2023. The review noted there was no clinical reason for Mr Y to remain in hospital. However, the review found work was ongoing to secure suitable accommodation for Mr Y.
26. Ward staff attempted to contact Mrs X and Mrs B on 9 January to invite them to attend a discharge meeting for Mr Y. Mrs B agreed to attend on behalf of the family.
27. The discharge meeting went ahead as planned on 11 January. The meeting heard Mr Y would continue to live with Mrs X until suitable accommodation had been identified. It was agreed the Council would support Mr Y to consider his housing options. In addition, the Council would contact Mrs X to offer her a carer’s assessment. The social worker present advised Mrs B that Mrs X would need to go on record to say that Mr Y could not live with her for him to become eligible for homelessness support.
28. Mrs B called the Trust on 16 January. She advised that Mrs X had agreed to a referral for a carer’s assessment.
29. On 18 January, the Trust convened a discharge meeting for Mr Y. He was unable to attend, but the meeting proceeded as planned. The meeting heard that Mr Y’s family remained unhappy with plans for his care and accommodation. Nevertheless, those present agreed Mr Y’s discharge could proceed and that he would be supported to find suitable accommodation. Mr Y was discharged later that day and continued to live with Mrs X.
30. A social worker and housing support worker visited Mr Y at home on 1 February. Mrs X and Mrs B were also present. They described concerns about Mr Y’s ability to cope without further support and his general wellbeing. The housing support officer explained that he would assist Mr Y to apply for housing.
31. The Council’s care records subsequently note that Mrs X contacted the Council to request a further MHA Assessment for Mr Y. However, Mrs X denies this.
32. A further professionals meeting was held on 8 March to discuss Mr Y’s care and support. This heard Mr Y was presenting as increasingly agitated. He had come into conflict with neighbours, who had reported concerns about his behaviour. The meeting heard that Mr Y was not considered a priority for rehousing as he was currently able to live with Mrs X. It was again noted that Mrs X would need to formally say that Mr Y could no longer live with her. However, the meeting heard Mrs X was unwilling to do so. The meeting agreed to discuss this further with Mrs X.
33. Shortly after this, Mrs X’s housing association began injunction proceedings to prevent him living with Mrs X due to his continued and problematic interactions with the neighbours.
34. In late May, Mr Y was arrested for making threats towards a neighbour. This led Mrs X to request a further Mental Health Act Assessment. The assessment took place later that night. The assessing professionals concluded that Mr Y did not meet the criteria for detention at that time.
35. However, in early June, a further Mental Health Act Assessment found Mr Y should be detained under section 2 of the MHA. This was subsequently converted to a section 3.

My analysis and findings

36. Mrs X complained that Mr Y had been discharged to live with her without any proper consultation and without having appropriate care and support in place. She said the professionals involved in Mr Y’s care also shared inaccurate information about him made the situation worse.
37. Mrs X said the lack of support meant Mr Y’s condition deteriorated and that he had to be detained again under the MHA. Mrs X said the situation placed great pressure on her and affected her housing situation and her relationship with neighbours. This ultimately led to her housing association taking legal action against her.
38. It is important to note that Mr Y at times withdrew his consent for information about him to be shared with Mrs X and Mrs B. This means that I, in turn, am limited in the amount of information I can share with them. For this reason, my consideration has focused on the impact of these events on Mrs X.
39. The clinical records show Mr Y has complex needs. However, he has received various diagnoses of the years. During the period my investigation considered, the people involved in Mr Y’s care (including the professionals, Mr Y’s family and Mr Y himself) had widely varying views on his care needs. This situation was made more complicated by Mr Y’s decision to withhold some information from his family.
40. At the point of Mr Y’s family leave in December 2022, the clinical records show the professionals involved in his care felt there was no clinical need for him to remain in hospital. Rather, Mr Y’s accommodation situation was seen as the main obstacle to his discharge.
41. One such significant difference of opinion developed shortly after Mr Y refused to return to the ward from his leave. Both Mrs X and Mrs B felt Mr Y was unwell and required further treatment in hospital. However, this view was not shared by the professionals supporting him. This was confirmed at the medical review on 4 January 2023 which found Mr Y did not need to be admitted.
42. Again, accommodation was identified as the main issue to be resolved. This was because all parties agreed it would not be a sustainable situation for Mr Y to continue living with Mrs X. To this end, professionals advised Mrs X to provide formal notice that Mr Y could not continue to live with her.
43. It is understandable that Mrs X was uncomfortable with the idea of doing this. Section 175 of the Housing Act sets out that someone is homeless if they have no accommodation, or if they have accommodation, but it is not reasonable for them to continue to live there. There is no requirement for a person to make a formal notification. This is a matter of discretion for the local housing authority.
44. Given the concerns of both professionals and the family, there is some evidence to suggest it was not reasonable for Mr Y to continue to live at the property by this point. In my view, this should have prompted a homelessness referral for Mr Y. This did not happen. This was fault by the Council and Trust.
45. By May 2023, Mr Y’s relationship with, and behaviour towards, Mrs X’s neighbours had deteriorated to such an extent that the housing association was pursuing an injunction. The evidence clearly shows that it was not reasonable for Mr Y to continue to live at the property by this stage. Again, neither the Trust nor the Council appear to have made a homelessness referral at this point. This is further evidence of fault.
46. This meant throughout this period, opportunities were missed to properly assess Mr Y’s housing needs and secure suitable accommodation for him. This was a significant oversight as the records show there was ongoing disagreement about Mr Y’s accommodation and the level of support he would need in the community. This continued to prove the main obstacle to progress.
47. I cannot say what the outcome of any homelessness assessment would have been. Nor can I say whether Mr Y’s further detention could have been prevented even with further housing intervention. Nevertheless, I recognise this situation caused Mrs X significant distress and frustration.
48. Mrs X and Mrs B were also concerned that Mr Y was not receiving the level of care he needed in the community. Mr Y’s situation was discussed at the multidisciplinary team meeting on 11 January. The meeting heard Mr Y’s key worker and social worker would continue to support him in the community However, Mr Y was clear he would accept only minimal mental health support.
49. The case records show there was tension between Mr Y and his family regarding his care needs and his mental health. In the meantime, Mr Y’s relationship with Mrs X’s neighbours continued to be problematic. Despite this, the professionals found no evidence of a deterioration in his mental health. The situation culminated in Mr Y’s arrest in May and detention the following month.
50. I recognise Mrs X and Mrs B were of the view that Mr Y should have been readmitted to hospital shortly after his refusal to return to the ward. The case records show professionals considered the possibility of a further detention extensively between December 2022 and May 2023 but decided this would not be appropriate as Mr Y was not suffering from a mental disorder. In the circumstances, it was appropriate for them to consider the least restrictive option for treating Mr Y. This is in keeping with one of the key principles of the MHA.
51. In summary, the evidence I have seen suggests this was a complex case. I am satisfied the professionals involved in Mr Y’s care and support made appropriate efforts to put care in place for him in the community and to support Mrs X, albeit this was not of the nature or level Mrs X and Mrs B felt was indicated. I find no fault by the Council, Trust and ICB in this regard.
52. However, the Council and Trust will take further action with regards to the handling of Mr Y’s homelessness situation and the impact on Mrs X of this. These actions are set out below.

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Action

53. Within one month of my final decision, the Council and Trust will write a joint letter of apology to Mrs X for the distress caused to her by their shared failure to make appropriate referrals for Mr Y to the local housing authority when he was threatened with homelessness between January and May 2023.
54. In addition, the Council and Trust will each pay Mrs X £400 (£800 in total). This is a symbolic recognition of the impact of these events on her.
55. The Council and Trust will provide us with evidence they have complied with the above actions.

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Decision

56. I found no fault by the Council, Trust and ICB with regards to the care they provided to Mr Y. However, I did find fault with the way in which the Council and Trust handled Mr Y’s situation when he was threatened with homelessness and the impact this had on Mrs X.
57. In my view, the above actions represent an appropriate and proportionate remedy for the injustice caused to Mrs X by these events.

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Investigator's decision on behalf of the Ombudsman