Summary: Mrs D complained about NHS South West London Integrated Care Board’s (the ICB’s) and London Borough of Wandsworth Council’s (the Council’s) response to her son’s, J’s, deteriorating mental health before and after he was detained under the Mental Health Act. We find fault that the ICB did not attempt to arrange a Care and Treatment Review earlier. And we also find fault that the ICB and the Council failed to fully assess J’s needs before deciding which elements of support they were responsible for providing. These faults caused Mrs D stress and frustration and left her with uncertainty about whether J missed out on opportunities to benefit from different support. The ICB and the Council have agreed to actions to address the injustice.

The complaint

1. J lives alone in specially adapted accommodation with 24-hour support. Before October 2023 NHS South West London Integrated Care Board (the ICB) was solely responsible for arranging and funding J’s care and support. In October 2023 professionals detained J under section 3 of the Mental Health Act 1983 (the MHA). Following J’s detention he became entitled to s117 aftercare. The ICB shared the responsibility to assess, arrange and fund any necessary s117 aftercare with the London Borough of Wandsworth Council (the Council). J stayed in hospital until February 2024.
2. J’s mother, Mrs D, complains:
1. The ICB failed to respond adequately to reports of a significant deterioration in J’s condition in September 2023 and, specifically, failed to arrange an urgent Care and Treatment Review (CTR) meeting.
2. During J’s inpatient admission (from October 2023 to February 2024) the ICB and the Council failed to work together and with J’s representatives. Mrs D said the ICB and the Council failed to produce a complete care plan or arrange adequate care and support for J before he returned home in mid‑February 2024.
3. Following J’s discharge and return home in February 2024, the ICB and the Council failed to work together and with J’s representatives. Mrs D complains the ICB and the Council’s earlier failure to produce a complete care plan or arrange adequate care and support continued during this time.
4. Neither the ICB nor the Council applied for community Deprivation of Liberty Safeguards (DoLS) before J left hospital in February 2024, on in the months after he returned home.
5. About the conduct of a social worker’s visit with J in May 2025.

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The Ombudsmen’s role and powers

3. 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).
4. 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).
5. 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.
6. 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. 
7. We cannot decide what level of care is appropriate and adequate for any individual. This is a matter of professional judgement and a decision that the relevant organisation has to make. Therefore, my investigation has focused on the way that the body made its decision.
8. 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))
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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What I have and have not investigated

10. The Ombudsmen will investigate issues (a), (b) and (c).
11. For issue (c) we will investigate events up to the end of April 2024 but no later. At this time Mrs D applied to the Court of Protection (CoP) for authorisation of community DoLS. The CoP remained involved in the case and took a broader interest in J’s needs and care, beyond the initial request for authorisation of DoLS. At times the CoP directed the Council and the ICB to take specific steps, including to produce a comprehensive care plan. Because of this broad involvement, it would be inappropriate for the Ombudsmen to consider Mrs D’s concerns about the ICB’s and the Council’s actions since the CoP became involved. To do so would risk stepping into the CoP’s role and authority.
12. The events from September 2023 to the end of April 2024 pre-date the CoP’s involvement. The CoP will not look back at historical events and give a view on whether there was any fault. The Ombudsmen will, therefore, investigate Mrs D’s complaints of fault during this period.
13. We will not investigate issue (d) because Mrs D was able to successfully approach the CoP to start the process of considering DoLS for J. The CoP reconstituted the case so that it became the ICB’s and the Council’s responsibility to present the case. As such, any outstanding injustice would relate to any avoidable time, trouble and frustration Mrs D was put to in approaching the CoP. This would not represent a significant enough impact to justify the Ombudsmen’s consideration of this issue.
14. We will not investigate issue (e) as any investigation would be likely to rest on a subjective view of differing reports of the social worker’s actions and manner. It is unlikely the Ombudsmen would be able to make a clear, evidence-based finding of fault leading to an injustice here. And, as such, the Ombudsmen will not investigate this issue.

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How I considered this complaint

15. I considered evidence provided by Mrs D, the Council and the ICB, along with records from South West London and St George’s Mental Health NHS Trust and Oxleas NHS Foundation Trust. I also considered relevant law, policy and guidance.
16. Mrs D, the Council and the ICB had an opportunity to comment on my draft decision. I considered all the comments I received before making a final decision.

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What I found

Legislation and guidance

The Mental Health Act 1983

17. Under s117 of the MHA local authorities and integrated care boards (ICBs) have a duty to provide or arrange free aftercare services for people who have been detained under s3 of the MHA.
18. S117 aftercare services are defined in the MHA as services which serve both of the following purposes:

• To meet a need arising from or related to the person’s mental disorder; and
• To reduce to risk of a deterioration of the person’s mental condition and, accordingly, to reduce the risk of the person needing another admission to hospital for treatment of that mental disorder.

19. The Department of Health produces the Mental Health Act 1983: Code of Practice (the Code) to accompany the MHA. This provides guidance for professionals on how to implement the MHA in practice.
20. The Code encourages local authorities and ICBs to “interpret the definition of after-care services broadly” (section 33.4).
21. Care planning for s117 aftercare should be via the Care Programme Approach (CPA). Under the CPA, the person must have a comprehensive care plan and a named care coordinator who is responsible for ensuring the care plan is prepared, carried out and reviewed. The care coordinator should use a CPA care plan to document aftercare plans. The care plan should specify the services funded through s117. The Code notes that care planning, including aftercare planning, requires a thorough assessment of the patient’s needs and wishes. It notes this is likely to involve consideration of a range of mental health, physical health and social care factors (section 34 of the Code). The care plan should specify that the person is entitled to s117 aftercare and detail which services will be s117 funded.

Care and Treatment Reviews (CTRs)

22. CTRs are for people with a learning disability and autistic people who have been admitted to a mental health hospital or who are at risk of admission. NHS England published Dynamic support register and Care (Education) and Treatment Review Policy and guidance (the CTR policy) in January 2023. CTRs are undertaken by commissioners and carried out by an independent panel of people. The aim of a CTR is to ensure that the person’s care and treatment is delivered in the least restrictive way. This includes ensuring that the person is not admitted to hospital unnecessarily or, if the person requires admission, to ensure that their stay is as short as possible. The role of CTRs is separate and distinct from that of approved mental health professionals, hospital managers and responsible clinicians. A CTR cannot decide whether someone should be detained under the MHA or, if they are already detained, whether that detention should end.
23. Section 13.2 of the CTR policy details that a range of people can request a CTR, directing them to a case manager or responsible commissioner. It notes that the commissioner’s “first response should be to address the concerns that led to the request as promptly and thoroughly as possible, including by arranging additional support if the concern relates to possible hospital admission”. The CTR policy states that such action could mean “potentially avoiding the need for a review”. It further notes there may be occasions when the commissioner decides a CTR “will not benefit the person”.
24. The CTR policy says that local areas “must have a process for requesting a C(E)TR; how decisions are reached and whether an appeal can be made where a request is denied; and how decisions are recorded and communicated to the person and their family”.
25. Section 14.1 of the CTR policy says that community CTRs “should be initiated where mental health hospital for a person is being actively considered or sought”. It says the CTR will help decide if the person’s needs could be met effectively and safely in the community through additional and/or alternative support and interventions. The policy encourages commissioners to consider a range of options and to work flexibly.
26. The same section also notes that “Where a person is at the point of ‘crisis’ action is urgent and it is unlikely a community C(E)TR can be set up quickly enough to direct this. However, even in urgent circumstances an assertive, fast and measured review needs to be undertaken to safeguard against the person being admitted unnecessarily to an inpatient service.”
27. Appendix 8 of the CTR policy gives information about a local area emergency protocol. It notes this is to be used “where there is no prior knowledge of the escalating risk of admission or the time to set up or hold a C(E)TR”. In these instances the lead commissioner should arrange a meeting with the intent of exploring treatment and support options that could help avoid a hospital admission.
28. Section 14.2 of the CTR policy details that, if a community CTR was not held, an inpatient CTR should be carried out within 28 days (20 working days).

Background

29. J was diagnosed with autism when he was a child and has other diagnoses including: language development disorder; borderline learning disability; dyspraxia (a developmental coordination disorder); obsessive compulsive disorder; and, pathological demand avoidance.
30. South West London and St George’s Mental Health NHS Trust’s (the Trust’s) learning disability service considered J did not meet its eligibility criteria; and, J did not have a severe mental illness which required support from a secondary mental health service. Further, while time-limited specialist autism-informed services are available, J was not under the ongoing care of specific autism service.
31. In late 2019 the NHS determined he was eligible for Continuing Healthcare (CHC). This meant the ICB was responsible for meeting all his health and social care needs. Around the same time J began living alone in specially adapted accommodation provided by the NHS. J had 24‑hour one-to-one support from care workers (referred to as “companions”) from Care Provider A, funded through a Personal Health Budget (PHB). The ICB also commissioned a consultant clinical psychologist to provide weekly support to J and his companions.
32. In addition, through a Council‑funded Education Health and Care Plan (EHCP), J had access to a full weekly timetable of activities.
33. In November 2022 a community CTR took place. It noted J’s PHB “should include the activities currently provided by education as part of his EHCP which is ending soon due to his age. This should support him to be part of the community and enable him to maintain his friendship peer groups in his activities.”
34. Following the CTR the ICB agreed an activity budget for J.
35. Correspondence from J’s GP in the middle of June referred to J’s behaviour escalating in the summer of 2023. A Community Mental Health Team (CMHT) accepted J as a patient around this time.
36. In early September 2023 J assaulted one of his companions. J went to the Emergency Department following this incident.
37. On the same day Mrs D emailed various members of staff at the ICB. Mrs D said J was in crisis but remained without access to a suitable service which oversaw his care and support. Mrs D asked for an urgent CTR and a Local Area Emergency Response meeting (the Local Area Emergency Protocol is raised when a person with a learning disability or an autistic person has been, or is likely to be, recommended for inpatient admission with little or no notice meaning a community CTR has not taken place). Mrs D said a consultant psychiatrist had seen J and said he thought an urgent CTR was appropriate as J was at high risk of admission. Mrs D said J had Post Traumatic Stress Disorder (PTSD) from a detention under the MHA ten years earlier. She said she was scared that there was to be a repeat of those events and said J would not survive another detention.
38. On the following day the ICB noted a view that it would be too risky for J to return home. As such, they asked Care Provider A to “stand down”. The ICB said it considered a MHA assessment would be appropriate. An Approved Mental Health Professional (AMHP) reviewed J in the evening and concluded that he did not have an acute mental illness and, instead, was presenting with behavioural symptoms in the context of autism. The AMHP said J did not need an inpatient admission. J went home the following morning.
39. Multi-disciplinary professionals meetings took place five and ten days later. They included staff from the Trust’s learning disability service and mental health services along with J’s psychologist. The meetings did not agree a firm plan. Staff decided they needed to contact the ICB to ask for information about J’s current needs. In subsequent correspondence the ICB advised that J’s care and support plan was in the process of being updated.
40. Toward the end of September Care Provider A emailed Mrs D and said J was “not in a good place right now”. They said he was disengaging and asking for help. They said they felt there needed to be a CTR. ICB staff replied and said another planning meeting had been arranged to take place in four days’ time.
41. The multi-disciplinary planning meeting decided the CMHT should complete an assessment to establish J’s current needs. It said a care plan would then be clarified with the learning disability team’s consultant psychiatrist’s input, and a crisis plan would be developed. The CMHT called Mrs D the same day and offered possible times for an assessment with the consultant psychiatrist. Mrs D said she had repeatedly asked the ICB for an emergency CTR and still felt this was required. Mrs D said she did not want J to be detained again. She said his recent attendance at the Emergency Department had traumatised him and caused him to retreat into himself.
42. On the next day an ICB manager asked a colleague to set up a CTR for J and suggested it could potentially be arranged for mid‑October. They noted Mrs D had requested a specific chairperson. The ICB manager said that, if possible, he would like them to explore that request with NHS England.
43. The following day J attacked one of his companions and Mrs D. Police took J to the Emergency Department, handcuffed him and detained him under s136 (a part of the MHA which allows the police to detain someone in a public place when they are experiencing a mental health crisis). A MHA assessment took place in the afternoon. It recommended J be detained under s2. In early October 2023 J went into a mental health hospital in another part of the country.
44. In the second half of October Care Provider A gave the ICB notice that it could no longer support J. It said this was due to recurring incidents of physical aggression toward staff and others. The ICB also told us Care Provider A’s decision “was influenced by the level and availability of specialist support required to maintain the package”. The ICB asked Care Provider A if it would be willing to extend the notice period beyond J’s undetermined discharge date, to help mitigate risks to continuity of care and allow more time to secure an alternative provider. Care Provider A would not agree to this. The ICB began looking for alternative providers.
45. Toward the end of the month the ICB identified Care Provider B as capable of meeting J’s needs and willing to support him. The ICB emailed Care Provider A and asked it to work with Care Provider B, as a priority, to transfer the staff who supported J.
46. At the end of October an inpatient CTR took place. The panel agreed a plan for Care Provider B to support J. The CTR noted the responsible clinician had detained J under s3 as he had reached the end of the s2 period and Care Provider B still needed time to recruit and embed staff.
47. On the following day the ICB emailed Mrs D. It noted J was now entitled to s117 aftercare. The ICB said, because of this, the Council would take the lead in arranging J’s discharge and his community support. The ICB said it was no longer responsible for managing J’s case. The ICB said it would contact the Council to make sure it was aware of J. It said it would also let the Council know about Care Provider B and its plan to transfer J’s previous companions to it.
48. During November Mrs D emailed the ICB (and the Trust) on several occasions and raised concerns about a lack of progress in arranging J’s discharge. Mrs D said J was very stressed about not knowing how much longer he would have to remain in hospital. The ICB reiterated to Mrs D that it was for the Council to determine how things would move forward, including whether it would commission Care Provider B. The ICB said it was continuing to exchange emails with the Council and would attend relevant meetings. Toward the end of November Mrs D emailed her MP. She raised concerns that, three weeks after the ICB said it was the Council’s responsibility to commission J’s care, there was still no agreement about funding. Mrs D said, because of this, Care Provider B “have not been engaged, and no recruitment can happen, nor transition planning”. Mrs D said because of these delays some of J’s companions (who had previously worked for Care Provider A and had hoped to transfer to Care Provider B) had left.
49. In early December 2023 the Council allocated a social worker to complete an assessment of J’s needs under the Care Act 2014 and s117. A few days later Care Provider B began to do some in-reach work with J. The Council completed a Care Act assessment which recommended that J’s needs continue to be met as they were prior to his admission in 2023, including access to the same weekly activities and with access to support from psychology, an occupational therapist (OT) and others.
50. In the days after this assessment the CMHT referred J to a Forensic Intellectual and Neurodevelopmental Disabilities team (FIND). FIND aimed to meet J and his existing network to support him to leave hospital and reestablish himself in the community.
51. Shortly before Christmas Care Provider B emailed the ICB and said it was having problems transferring staff from Care Provider A partly because they had not completed the necessary compliance work. It also said it was having trouble working collaboratively with Mrs D. Care Provider B said it felt the only option was to terminate all existing staff contracts and start again. It asked the ICB to present this proposal to J’s family so see if they would agree. A couple of days later Care Provider C, which Mrs D had identified, assessed J with the ICB’s agreement.
52. In early January 2024 Care Provider B told the ICB it could not support J’s package of care. On this basis, the ICB noted Care Provider C was now the preferred provider.
53. The ICB told us that during January it and the Council discussed their respective responsibilities for providing J’s care and support. It said the Council concluded most of J’s needs did not arise because of his mental health condition and, as such, were not entitled to support under s117. The ICB said the Council concluded some of J’s needs were eligible for support under the Care Act – including access to daytime activities. The ICB said it maintained a different view about the nature of J’s needs and their corresponding entitlement to support under the s117.
54. The Council agreed that it and the ICB “maintained different positions in relation to which elements of [J’s] support fell under S117 and which did not”. The Council said it considered (and still considers) “the majority of [J’s] needs do not fall under S117, as they are not related to his mental health or the reason for his admission under Section 3.” The Council said it met the ICB “on several occasions” in early 2024 to discuss this issue. However, it said they did not reach a consensus. The Council said “It was agreed that the ICB would continue to commission and fund the majority of [J’s] support, funding the care and support provision in his home. [And the Council] would fund the support for [J] to access daytime activities, such as access to day centre activities."
55. A multi-disciplinary team meeting in the middle of January noted a plan to discharge J at the end of the month. It was noted J was fit for discharge and was regressing while he remained in hospital. FIND said it would complete assessments and could work in partnership with Care Provider C. It was noted that both OT and psychology had been agreed in principle, but there would need to be some assessment about the level of input necessary.
56. Toward the end of January the Trust created a titled “Multiagency Approach to Care Plan/Interventions” for J. It proposed a range of support:

• Care coordination, risk assessments and crisis planning by the CMHT,
• Consultation from a learning disability consultant psychiatrist,
• FIND to provide psychological and OT input to J’s care provider for around three months,
• Day-to-day support from J’s care provider.

57. The care plan did not include any information about activities.
58. At the end of January J returned home on s17 leave. A s117 meeting took place on 8 February. During the meeting Mrs D continued to press for J’s previous activities to be re-started. An independent mental health advocate said two day centres (which J had previously attended) met his needs and should be considered as part of his care plan.
59. The ICB said at the time of J’s discharge it commissioned two-to-one 24-hour support, to be provided by Care Provider C. The ICB said that the MDT considered J’s needs could be safely met through existing commissioned services. It said there was no identified need for additional specialist OT or psychological input.
60. At the start of April a CPA meeting took place. It noted the ICB and the Council were still working out who was responsible for aspects of funding. The meeting also noted a care plan was still being developed for J.
61. In late April/early May Mrs D made an application was made to the CoP to ask the court to authorise Deprivation of Liberty Safeguards (DoLS) that arose from the care J received in his own home.

Analysis

Failure to arrange a CTR in September 2023

62. As briefly reference in paragraph 35, in June 2023 J’s GP wrote a letter warning that J’s mental health was getting worse and his behaviour more challenging. The GP said J’s difficulties were “significantly impacting on him currently, to the extent where they are jeopardising his care, future health and well being". The GP raised concerns J could “rapidly spiral downwards to the extent where he ends up inappropriately sectioned”. The GP sent this letter to various people at the ICB.
63. There was no request for a CTR at this point. But, in the context of the guidance noted at paragraph 27, this suggests the ICB did have “prior knowledge of the escalating risk of admission” in the middle of 2023.
64. As noted in paragraphs 37 to 42, there were requests for a CTR in early September 2023.
65. The ICB told us it considered the request for a CTR through multi-agency network discussions. The ICB said there was a “collective professional view” that proceeding with a CTR “would not add meaningful benefit at that specific point”. The ICB said the main priority was to ensure J was receiving direct input from appropriate specialist mental health professionals.
66. The ICB said its view was, “for a CTR to be meaningful and effective, there needs to be established specialist involvement in place to inform robust discussion, recommendations, and planning”. The ICB said this specialist involvement was only at an early stage in September 2023 so "the professional judgement was that the immediate focus should be on embedding the CMHT’s involvement” before arranging a CTR.
67. These events happened in the context of Mrs D’s long-running concerns about a lack of appropriate multi-disciplinary involvement and oversight of J's care. Specifically, Mrs D considers J’s care should be managed by the Trust’s learning disability team. I have noted that, in November 2022, a CTR also recommended this happen and that J’s clinical psychologist repeatedly gave his view this it would be appropriate as well. However, the ICB is not responsible for this service and could not force it to take responsibility for J’s care, and this investigation is not investigating the Trust. I mention this here as, from the available evidence, it appears unlikely a CTR or local area emergency meeting at this time would have led to the learning disability service accepting J as a patient.
68. As the ICB noted, in early September 2023, the CMHT had only recently taken on J’s care and was beginning to assess him. However, when the ICB learned of J’s attendance at the Emergency Department at the start of September professionals noted a clear view that he may need an inpatient admission. A clinical lead noted the ICB was requesting either a MHA assessment or a detailed explanation if this was not considered to be appropriate. ICB staff also noted significant concerns when they learned the AMHP had not recommended J be detained, and that J had left hospital.
69. As detailed in paragraph 23, the ICB is entitled to exercise its judgement about whether a CTR is required. However, in this context, given a clear concern about J being at risk of requiring an admission to hospital, it is difficult to understand why professionals felt the conditions for a CTR were not met, considering what the guidance referenced in paragraph 25 says. Either way, the ICB should have given Mrs D a clear answer to her request for a CTR with a complete explanation of the rationale. This did not happen and is fault.
70. If the ICB had decided to arrange a CTR in early September it seems probable one may have been arranged for the second half of the month. (When it sought to arrange one at the end of September it anticipated it could be done in just over two weeks.) I cannot do anything other than speculate about what a CTR panel would have concluded and recommended. Further, I do not know how long it would have taken to have implement any recommendations or how effective they would have been in the short term. In view of this I cannot say if a CTR at this stage could or would have prevented J’s admission to hospital. There are too many unknowns and variables to be able to do so.
71. However, the failure of the ICB to arrange a CTR, or provide a timely and comprehensive explanation about why it would not do so, did have an impact. It caused Mrs D stress and frustration and has left lasting uncertainty about whether more could have been done to prevent J’s detention in hospital. This is an injustice and I have made a recommendation to address this below.

Inadequate care planning during J’s inpatient admission; and inadequate care planning in the community from February to April 2024

72. Mrs D complains about a failure to ensure previous care staff were authorised to continue supporting J when he left hospital in February 2024. Mrs D said this meant J lost trusted companions and had to start with unknown staff he did not trust. Mrs D said J continues to miss these companions.
73. Mrs D also said there were extensive delays in arranging suitable and sufficient support for J following his discharge in February 2024. Mrs D said there was a failure to arrange any: psychology input; occupational therapy (OT) support; or, access to day services. Mrs D said the lack of psychological support caused a decline in J’s physical and mental health. Mrs D said J stopped eating and drinking and has been left with long-standing issues with a very restricted diet. In addition, Mrs D said this caused her avoidable worry. Further, Mrs D said the lack of psychological support meant J engaged in behaviour which was difficult for the family to manage and this caused further tension and stress.
74. In addition, Mrs D said the lack activities left J with literally nothing to do for months and he lost friendships, connections and activities. Mrs D said had the appropriate care been in place J’s life would have been better. Mrs D said this, in turn, put the family under financial pressure as she had to give up work. Further, Mrs D said it was emotionally draining to have to constantly fight for the care and support J was entitled to.
75. Before looking at the individual issues (of J’s preferred companions along with access to psychology and activities) I will look first at the interaction between the ICB and the Council when planning J’s discharge.
76. Under s117 of the MHA both the ICB and the Council had a responsibility for ensuring J’s needs for aftercare were met. It is important to highlight that the “tests” for eligibility for support under CHC, the Care Act and s117 are all different. Entitlement to support under s117 requires consideration of the tests set out in paragraph 18. It is possible for a person to be entitled to support under s117 and be eligible for additional support either via CHC or under the Care Act.
77. While both the ICB and the Council have told me there were ongoing discussions about respective responsibilities, I have seen very little in the way of contemporaneous evidence of these discussions. Nevertheless, given both organisations have provided similar accounts, I accept these discussions happened in the way they have been described.
78. However, these discussions were too soon. They appear to have taken place before a full s117 aftercare assessment had taken place, and before there was a clear, documented, and properly articulated s117 plan for J. Of note is an email from the ICB to Mrs D a couple of days after J was detained under s3. The ICB said then that it would be for the Council to manage J’s case, but this was before a s117 assessment.
79. During the s117 meeting in February an independent advocate “asked [why] there is no written document that clearly sets out [J’s] needs and how to achieve this in the community”. I have seen that the Council completed a Care Act assessment in December 2023 but, as above, this relates to different eligibility criteria. Both organisations’ rationales for why they considered some or all of J’s needs were (or were not) entitled to support under s117 should have been clearly documented at the time, after an appropriate assessment, and not just in “behind the scenes” communications.
80. This is fault by the ICB and the Council as they were prematurely trying to determine responsibilities for J’s care before he had been fully assessed. It is apparent from emails at the time that this situation caused Mrs D frustration and stress, which is an injustice to her.
81. I will turn now to Mrs D’s concerns about the transfer of J’s previous companions. Regardless of the discussions with the Council there is evidence to show the ICB put Care Provider A and Care Provider B in touch with one another, as mentioned in paragraph 45. The ICB also encouraged the care providers to prioritise this work. As noted in paragraphs 51 and 52, Care Provider B later raised concerns about issues with compliance and its working relationship with the family. These appear to have been the key reasons for its withdrawal. It was for Care Provider B to manage its own contracts with individual staff members, and to satisfy itself that regulatory duties had been met. In this instance, I have not found fault with the actions of the ICB or the Council.
82. Regarding psychology input, the ICB had funded weekly sessions for J with a clinical psychologist before his admission. In a report in late 2023 the psychologist noted J’s family asked for direct sessions with him to develop an understanding of J’s complex behaviour and to develop strategies and skills to help reduce his distress. The November 2022 CTR noted several services it considered essential for maintaining J’s welfare and wellbeing. This included psychology for ongoing assessment, advice and support. By August 2023 there were plans for the psychologist’s sessions to become less frequent. However, in an email to the ICB at the time, Mrs D said J’s need for these sessions (which had been ongoing for ten years) had not changed. She said the only thing that had changed was the psychologist’s capacity to provide weekly sessions.
83. In January 2024, while J remained in hospital, the CMHT said it could not offer any specialist psychology (or OT) input in relation to J’s “presenting behaviours that challenge as a result of his autism”. FIND said it would offer psychological input to Care Provider C to support their understanding and ability to deliver the interventions of J’s existing Positive Behaviour Support Plan. It said it would likely achieve this by offering various forms of support over three months.
84. In late January 2024 FIND spoke to J’s previous consultant clinical psychologist. He said “he considered clinical psychology input not to be necessary in the context of input from statutory services.” The psychologist said J did not require direct input from a clinical psychologist, but this had been the only clinical provision available to him and his family for the last four to five years.
85. Later, FIND noted J’s personal network wanted them to start weekly sessions with J, or recommend weekly clinical psychology be restarted. FIND noted ICB colleagues said they could commission this input but requested a clinical opinion on whether it was necessary first.
86. In its closing report, in August 2024, FIND said that, throughout its work with J, it had “not been able to identify a current need or wish from [J] for 1:1 psychological therapy”. FIND said J’s existing care provision should be able to help J move on from a context of autistic catatonia. It said that, if this did not happen, it might be beneficial to see if J “wishes and is able to engage in time-limited psychological therapy”.
87. Overall, I can see no evidence the ICB (or the Council) refused to arrange psychological support for J. The evidence shows they did consider it as a potential source of support. There is also evidence to show the commissioners allowed relevant professionals to lead the discussions about the type and level of psychological support that would be appropriate and helpful for J. As such, I have not found fault here.
88. In terms of daily activities the Council said it did not commission anything for J between February 2024 and April 2024 as he did not want to take up the offer of day activities. The Council said J’s social worker regularly talked to J about this.
89. Prior to J’s admission:

• An assessment in October 2021 (by an adult autism service) noted J had “in the past displayed a range of challenging behaviours, and continues to do so. These are limited by his current support and very full timetable which overall provides him with a high level of day-time scaffolding and support opportunities to develop his occupational, interpersonal and self-care skills. They occur nevertheless…” The psychiatrist said “In my opinion it is essential that such activities continue in order to optimise [J’s] quality of life but also in order to prevent a deterioration in behaviour and increase in challenging behaviours constituting a risk to self and others. In my opinion a decrease in this input would significantly increase the risk of admission to hospital”.
• In May 2023 J’s clinical psychologist wrote to the ICB and said it was important for J to have clear routines and structures to his day and week. They said they were aware that “when breaks in activities happen for example during holiday periods, there tends to be an increased risk of [J] becoming distressed or stuck in behaviours that can limit his opportunities or can pose a challenge [to] his well-being”.
• In June 2023 J’s GP wrote to various professionals. The GP said they knew “from past experience, without [psychological support and activities]…[J] can rapidly spiral downwards to the extent where he ends up inappropriately sectioned”.

90. During J’s admission:

• In mid-November 2023 an inpatient OT said a “scheduled activity timetable with activities of [J’s] current interest (using an interest checklist) could promote his intrinsic motivation and engagement. The activity timetable can be graded using new activities to explore (exploring stages) new interests and previous interests."
• In early December 2023 the Council social worker noted a plan for J to continue to access the activities he had used before his admission.
• In late January 2024 FIND noted that Mrs D “has asked for [J] to get back into the activities prior to him going into hospital. [J had] a very full programme, not sure how much he wanted to engage in this.” They noted an advocate had contacted the ICB about this and asked for funding for three days at one centre and two days at another.
• Also in late January 2024, Mrs D called FIND to ask when its OT input would start. She said the ICB had told her that J’s access to activities would be contingent on FIND’s OT clarifying if there was a continuing need for activities in the community. FIND clarified its plan (as per a multiagency approach document) and said its OT would not be involved in any funding decisions. Following this conversation FIND emailed various staff at the ICB and the Trust. FIND said its OT’s work “wouldn’t be focused on clarifying appropriateness of the activities [J] was accessing in the community at the time he went into hospital and that from our perspective he could be engaging with activities as he wished from the get-go”.

91. Following J’s discharge (initially on s17 leave):

• Mrs D asked the CMHT about restarting J’s activities. The CMHT told her that it’s initial plan was to get J used to those supporting him. Mrs D argued that waiting to get him forming relationships without having an activity would result to him sleeping in his bed all day. The CMHT said they would speak to the ICB about it. On the following day the CMHT told Mrs D the plan was for J to decide what activities he wanted to do and then to apply for funding for them.
• On 6 February 2024 FIND emailed the ICB and asked for an update about J’s activities. It said that, from records, “it appears that [J] has been accessing the day services and activities for a number of years and they provide him with structure and routine to his day…From a clinical perspective, [J] returning to his regular, familiar activities appear to be in his best interests based on information in previous reports”. In a meeting the following day the ICB said an advocate in the hospital had spoken to J about activities and he had not mentioned going to day centres. The ICB said Care Provider C would help J to identify the activities he wanted to do.
• During the s117 discharge meeting the ICB said funding for activities was not a problem but that it wanted the activities to be what J wanted.
• The CMHT visited J the day after the s117 meeting and spoke to him about what activities he wanted to do. They noted that an OT was due to assess J soon and would consider activities. The CMHT said, after this, it would contact J’s social worker to ask them to arrange funding for the activities. A social worker replied the next day and said the ICB continued to be responsible for deciding what care and support J needed, and for funding it. They said this included arranging any necessary activities.
• FIND staff visited J in the middle of February 2024 and asked if he wanted to return to two specific day centres. J said he did and was interested in new activities. In the days following this FIND staff met with staff from the two day centres to discuss J re-starting. FIND’s OT also told other professionals they supported J’s return to his previous activities. A couple of days later, during a professionals meeting, the ICB agreed to set up funding as soon as it got an idea on the specific number of days J would attend. The number of days was agreed at a meeting around a week later, at the end of February.
• In the middle of April 2024 the Council and the CMHT noted that J’s activities at two day centres had been reinstated but that J had not been attending them. Around this time Mrs D advised FIND that J was spending around 23 hours a day in bed.

92. Overall, there does seem to have been confusion about which organisation would be responsible for funding activities. It was around a full calendar month from the date J initially left hospital (on s17 leave) until the ICB agreed to fund J’s attendance at day centres (for a total of five days a week). As set out above, this happened because the commissioners wanted to base their decision on up‑to‑date assessments of J’s needs which took account of his wishes. There is evidence to show the clinicians from FIND considered this in a detailed way. This involved talking to J and talking to each of the services. I cannot criticise the ICB (which led this commissioning process) for wanting a robust assessment of J’s needs in this area.
93. However, as above, before J’s discharge FIND provided a clear view that did not object to him participating in activities from the outset. Further, as the bullet points in paragraph 89 set out, the “baseline” for J was that he had spent a significant amount of time at activities for a long time before his admission. Also, that professionals considered this was an important part of maintaining J’s wellbeing. In this context in is not clear why consideration of daily activities was not given more emphasis during J’s admission, as part of discharge planning. From the available evidence, it appears the main consideration of this began after J’s discharge. This is fault by the ICB and the Council. They both had a responsibility to produce a comprehensive s117 plan ready for J’s discharge.
94. As with the issue of the CTR, there is a great deal we do not know in terms of the impact of this. Crucially, we do not how well J would have engaged with the activities in the days and weeks after his discharge. And we do not know how effective and significant any given engagement would have been in helping J’s recovery. However, Mrs D has been left with a lasting sense of uncertainty about whether J missed out on an opportunity to benefit from earlier access to activities. This is an injustice to her.

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Agreed actions

95. Within one month of the final decision the ICB should write to Mrs D to acknowledge the fault I have identified in paragraphs 69, 80 and 93. The ICB should also acknowledge the impact these faults had on Mrs D and should apologise for this. The ICB should follow PHSO’s guidance on making an effective apology, found on its website.
96. Within one month of the final decision the Council should write to Mrs D to acknowledge the fault I have identified in paragraphs 80 and 93. The Council should also acknowledge the impact these faults had on Mrs D and should apologise for this. The Council should follow LGSCO’s guidance on making an effective apology (at part 2.2 of its Guidance on Remedies).
97. Within two months of the final decision the ICB should pay Mrs D £400 as a symbolic, tangible acknowledgement of the injustice its failings caused her.
98. Within two months of the final decision the Council should pay Mrs D £250 as a symbolic, tangible acknowledgement of the injustice its failings caused her.
99. Within three months of the final decision the ICB and the Council should both complete a review of their handling of J’s case: from the summer of 2023 to the end of April 2024 for the ICB; and, from the point of J’s detention under s3 until the end of April 2024 for the Council. The ICB and the Council should produce an action plan to address the faults this investigation found. The plans should seek to identify and implement specific and realistic ways of improving their processes to ensure they comply fully with national legislation and guidance.
100. The organisations should provide us with evidence they have complied with the above actions.

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Decision

101. There was fault by the ICB and the Council which caused an injustice to Mrs D. I have recommended actions to remedy the injustice.

Investigator’s decision on behalf of the Ombudsmen

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Investigator's decision on behalf of the Ombudsman