Summary: Mr B complained about the way an NHS Trust and Council assessed him to decide whether he should be detained under the Mental Health Act. He also complained about his care and support while he was waiting to be transferred to an in-patient “mental health bed”. We found fault by both organisations. The Trust did not properly inform Mr B about his legal rights and status under the Mental Health Act. The Council did not ensure the medical recommendations remained valid when it reassessed Mr B under the Mental Health Act. These failings caused Mr B avoidable distress and upset. The organisations have agreed to apologise, pay a financial remedy, and take actions to improve their services.

The complaint

1. Mr B complained about the way West Sussex County Council (the Council) and Sussex Partnership NHS Foundation Trust (the Trust) assessed him to decide whether he should be detained in hospital under the Mental Health Act 1983 (the MHA). He also complained about his care and support while he was waiting to be transferred to an in-patient “mental health bed”. He complained about:
1. Incorrect information: the mental health nurse and the first Approved Mental Health Professional (AMHP) provided incorrect and misleading information about powers under the MHA
2. Lack of explanation: The AMHP, and staff at Unit X, did not adequately explain Mr B’s status under the MHA while he was waiting for an in‑patient “mental health bed”
3. Delay in admission: there was an unreasonably long delay before he was admitted to an in-patient “mental health bed”, during which time he was held in a short-term mental health facility (Unit X) that was not appropriate to his needs
4. Medication risks: a doctor did not adequately explain the risks of Sertraline medication
5. Expired medical recommendations: the second AMHP did not realise the first Mental Health Act assessment’s medical recommendations had expired, which meant Mr B had to go through two MHA assessments on two subsequent days
6. Complaint handling: Mr B said his complaint was poorly handled by the Trust and Council. He said the responses were disjointed, failed to answer all his concerns, and did not lead to resolution of his complaint
2. Mr B said these events scarred him for life and caused unnecessary and significant trauma. He said he was incarcerated against his will for an additional two weeks and has lost all confidence in the NHS.
3. Mr B wants the organisations and individuals involved to acknowledge what went wrong and to be held accountable for their failings. He wants improvements in services to prevent similar issues in future for others, and a financial remedy to recognise the impact on his life.

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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). 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.
6. 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))
7. 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. 
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. I have considered information Mr B provided in writing and by phone. I also considered documents and comments on the complaint from the Council and the Trust, including Mr B’s medical records. I looked at relevant law, policies and guidance.
10. Mr B and the organisations had the opportunity to comment on my draft decision. I took into account all the comments I received before making a final decision.

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What I found

Relevant law and guidance

Mental Health Act 1983

11. The Mental Health Act 1983 (the MHA) is a law which allows people to be detained in hospital (“sectioned”) if they have a mental disorder and need to stay in hospital for assessment or treatment. A person can be sectioned if they are at risk of harm to themselves or others. Usually, three professionals need to agree that the person needs to be detained in hospital. These include an Approved Mental Health Professional (AMHP) and usually (but not always) two doctors who have been specially approved to carry out Mental Health Act assessments (Section 12 doctors). 
12. The AMHP is responsible for deciding whether to go ahead with the application to detain the person and for telling the person. They are also responsible for providing information about the proposed detention to the person’s Nearest Relative. Any admission to hospital under the MHA should be in the best interests of the person and they should not be detained if there is a less restrictive alternative. Local authorities are responsible for the actions of AMHPs.
13. The purpose of detention under section 2 of the MHA is for assessment of a patient’s mental health and to provide any treatment they might need. Patients can be detained under section 2 for a maximum of 28 days.
14. The Nearest Relative is a legal term in the MHA and refers to a person who has particular rights and powers related to a person’s care and treatment under the Act. The Nearest Relative might be a person’s husband, wife or civil partner, their child / parents, or another family member or friend.
15. An “informal” or “voluntary” patient means someone who has agreed to go into a psychiatric hospital voluntarily for assessment and/or treatment. This contrasts with someone who has been detained under the MHA, as this means they can be kept in hospital even if they do not want to or do not want treatment.
16. The Reference Guide to the Mental Health Act (The Reference Guide) is a piece of official guidance about how the MHA operates. The Mental Health Act Code of Practice (the MHA Code) provides guidance about how professionals should carry out functions under the MHA.
17. The Reference Guide includes information about the difference between being “detained” and being “liable to be detained”. When someone is “liable to be detained”, they could lawfully be detained but are not. This includes people who have been assessed under the MHA and the AMHP has recommended that they are detained, but there is no available mental health bed for them to be admitted / detained to.
18. The Equality and Human Rights Commission has published guidance on Your Rights When Detained Under the Mental Health Act in England (the EHRC guidance). It explains that the decision to detain someone in hospital because of a mental health condition takes away their human right to freedom, and it is very important that patients understand their rights and that decisions to detain are lawful.

Background

19. This section provides an outline of events leading to Mr B’s complaint. It is not intended to be a comprehensive account of everything that happened.
20. Mr B was taken to hospital by the police in July 2023 after becoming suicidal. He agreed to go to hospital voluntarily. In A&E a mental health nurse assessed him, discussed various support options, and decided to arrange a MHA assessment.
21. Before Mr B could be assessed, he left hospital against the advice of staff. The hospital reported him missing to the police, who located him and brought him back to hospital. Mr B was then detained under s136 of the MHA.
22. The next day, Mr B was assessed under the MHA. The AMHP and two doctors decided Mr B should be admitted to hospital under s2 of the MHA, for further assessment and treatment.
23. There were no available in-patient “mental health beds” at the Trust, so the AMHP could not apply for Mr B to be detained (“sectioned”) at that time. It was agreed that he would stay at the hospital under close supervision, until a bed in a specialist mental health unit became available.
24. Four days later, as there was still no in-patient “mental health bed” for Mr B, he agreed to be transferred to a short-term mental health crisis facility (Unit X), whilst waiting for a mental health bed to become available.
25. The AMHP and hospital staff made daily efforts to find a mental health bed for Mr B. Two weeks after the original MHA assessment, a bed became available on a mental health ward (Ward Y). An AMHP had to re-assess Mr B under the MHA to see if he still met the criteria to be detained.
26. The AMHP decided Mr B still met the criteria to be detained. However, the AMHP did not realise the two doctors’ recommendations from the original MHA assessment had expired and were no longer valid. As a result, Mr B had to have a further MHA assessment the next day with an AMHP and two s12 doctors. The outcome was that he should be admitted to hospital under s2 of the MHA for up to 28 days.
27. Mr B was admitted to Ward Y later that day. He was detained for 28 days, and agreed to stay in hospital voluntarily for a further week, before being discharged home.
28. Mr B complained to the Trust and Council about aspects of his care. As he remained unhappy after receiving their complaint responses, he complained to the Ombudsmen.

Analysis

a) Incorrect and misleading information about powers under the Mental Health Act 1983

29. Mr B said the mental health nurse who assessed him told him he would be injected with drugs without his consent and could be detained under section 2 repeatedly every four weeks. Mr B said this information frightened him. Mr B also said the mental health nurse told him he was free to leave the hospital at any time, but when he did he was brought back to hospital by the police and detained under s136 of the MHA.
30. The Trust said it was sorry the conversation with the mental health nurse had caused Mr B concern, and that the nurse was trying to make sure Mr B was told about the entire process so he understood what might happen.
31. I have looked at Mr B’s account and the records the mental health nurse made at the time. The nurse documented that Mr B was not engaging with the assessment or agreeing to ‘safety planning’ (a tool to help navigate suicidal feelings and urges). The nurse felt Mr B could not be safely discharged from hospital and needed a MHA assessment. The nurse said he explained the MHA assessment process to Mr B including that he could be admitted to hospital and treated without his consent. He said that at that point Mr B got up and ran out of the department and out of the hospital grounds.
32. I appreciate that Mr B found these conversations frightening and upsetting. There are also some differences between Mr B’s account and what the nurse wrote in the records at the time. I have not seen anything in the records about Mr B being told the section 2 detention could be repeated indefinitely. A section 2 detention can only be for a maximum of 28 days. If someone needs to stay in hospital for treatment after a section 2 detention, they are then detained under section 3. A detention under section 3 lasts for up to six months in the first instance.
33. In relation to what the nurse told Mr B about the possibility of being treated without his consent, there is nothing specific about this in the records. However, as the nurse was telling Mr B about the MHA and the processes involved, it is correct that a person can be treated without their consent when they are detained under section 2.
34. It is difficult to resolve conflicting accounts like this, when there is no additional evidence. Two people can come away from a conversation with different recollections or understanding about what has been said. It is also important to acknowledge that Mr B was mentally unwell at this time. The Trust and Council records refer to his mental state as “fraught” and him not being able to weigh up the pros and cons of admission to hospital to protect his safety. It is possible Mr B’s understanding and recollection of the discussion was impacted by this.
35. The MHA Code says effective communication with patients is essential, and patients should receive clear and unambiguous information about their rights and their care. Patients should be given important information about how the MHA applies to them, which includes information about the circumstances in which they can be treated without consent, and the circumstances in which they have the right to refuse treatment.
36. Having weighed up the evidence and reviewed the relevant guidance, I have not found fault in what the mental health nurse told Mr B about powers under the MHA. I appreciate that Mr B found the information distressing to hear, but I do not consider it fault that this information was provided.
37. Mr B said the AMHP also gave him misleading information. He said the AMHP told him the section 2 detention ‘could be up to 28 days but would be nowhere near that long’, when they must have known this would not be the case. Mr B complained the AMHP ‘extracted information and commitments’ from him and got him to share a lot of very personal information, when they were probably going to section him anyway, regardless of what he said.
38. The Council said the AMHP had spoken with Mr B about less restrictive options than detention under the MHA, and needed to get as much information as possible so he could make a fully informed decision about whether to recommend detention. The Council also said it can be difficult to be specific about the likely amount of time someone might be detained under the MHA because this depends on their progress once they have been detained. The Council said it had shared the learning from Mr B’s complaint with AMHP staff, to emphasise the importance of providing patients with clear and consistent information about the maximum timeframes for detention under the MHA.
39. I have looked at the AMHP’s records for these discussions with Mr B. The records say Mr B refused to engage with triage staff at the hospital and refused to talk with the AMHP about recent and past events leading up to him feeling suicidal. The AMHP spoke with Mr B’s mother, his Nearest Relative under the MHA, to get more information. There is nothing in the record about the AMHP telling Mr B about how long detention under s2 was likely to be for, and I cannot resolve this part of the complaint due to a lack of further evidence.
40. Referring back to the MHA Code, it is important that staff engage with and listen to patients, and explore all alternatives to detaining the patient under the MHA such as receiving treatment in the community from a crisis team. These conversations should include speaking with the patient about their views, wishes and feelings, the likely effect on them of detention under the MHA, and their capacity to consent to or refuse admission and treatment.
41. Having carefully considered the evidence and guidance, I have not found fault in terms of what the AMHP told Mr B about powers under the MHA. I also note the Council has shared learning from this complaint with the AMHP service, to improve practice.

b) Inadequate information about status under the Mental Health Act 1983

42. Mr B complained about not being adequately informed about his status under the MHA after his first MHA assessment. Mr B thought his detention / section had started straight away, and said he did not find out until four weeks later that the detention did not start until he had been reassessed and was admitted to Ward Y. He said he had frequently referred to himself as being “sectioned” and no-one had corrected him and explained that he was ‘liable to be detained’ rather than ‘detained’. [I have explained the difference between being “detained” and being “liable to be detained” in paragraph 17].
43. Mr B said it was a significant failing that he was not properly told about his legal rights during this period. He also felt the lack of clear information was intentional, so he would not try to leave the hospital / Unit X. Mr B said he felt misled about the move to Unit X, being led to think it was a way to avoid admission to a mental hospital ward, rather than as a temporary measure. He implied he might not have agreed to move to Unit X if he had fully understood his rights.
44. The Trust acknowledged there had been communication breakdowns and missed opportunities to inform Mr B of his status and rights under the Mental Health Act (MHA) after his original assessment and when he was transferred to Unit X. It said Mr B should have been told he was an "informal/voluntary patient" whilst waiting for a mental health bed to become available. 
45. The Trust apologised for these failings and said it planned to create an information leaflet for people “added to the bed waiting list with medical recommendations” but not currently detained. It said the leaflet would include information about the person’s rights and what process would need to be followed if they wanted to seek discharge before a bed had been allocated for their admission under the MHA.  
46. The Council and the AMHP involved in the initial MHA assessment provided some information to us as part of our investigation.
47. The AMHP said they told Mr B about the MHA assessment outcome and the plan to admit him to hospital under s2 of the MHA, but that this could not happen immediately due to a lack of available mental health beds. The AMHP said Mr B “would have been requested to remain informally within the health care facility…in the interests of his own health and safety” while waiting for a psychiatric ward bed to be available.  
48. The AMHP said Mr B would have been given a leaflet explaining his rights under the MHA. They said NHS staff were then responsible for regularly reinforcing Mr B’s understanding of the situation, including his voluntary status while awaiting a mental health bed.  
49. The Council said Mr B’s distress may have prevented him from fully retaining the information he was given about his status and rights. As outlined in paragraph 34, staff felt Mr B was “fraught” and not able to weigh up the pros and cons of admission to hospital to protect his safety. It is possible Mr B’s recollection of what he was told about his status under the MHA was impacted by this.  
50. I have looked at the Trust and Council records. The Trust records make several references to Mr B being “liable for s2 detention and on the bed list”, and to some discussions with him about this. There are also some references to him being an “informal patient”, although it is not clear what information Mr B was given about this.  
51. The Trust told us it had decided not to create an information leaflet for this scenario, as there are too many different situations and variables. However, it said the service has worked with staff to change the language used in this situation. Staff now use the phrase "informal with recommendations for detention" instead of "liable to be detained", to make the person’s MHA status clear when no inpatient mental health bed is available. 
52. Mr B was not properly told about his legal rights and status under the MHA, as outlined above. The MHA itself, and the MHA Code, set out the important information that patients must receive about their rights and their care. The evidence suggests Mr B was not provided with all this information, or at the right time. This is fault which led to an injustice to Mr B.
53. I have considered the impact of this fault on Mr B. He said he might have left the hospital if he had known he was not detained under the MHA. However, the Trust told us that if Mr B had left the hospital against medical advice, he would have been reported missing and is likely to have been returned to the hospital by police under s136 of the MHA. It is clear from Mr B’s records that staff felt he remained a high risk to himself, did not have insight into his mental health decline, and was unwilling to engage with coping strategies or services in the community.  
54. Notwithstanding the above, it is my view that Mr B suffered a significant injustice in terms of his avoidable distress at learning his legal and human rights were not properly observed or protected during this period.
55. In terms of wider service improvements, the Trust and Council have taken actions to address the identified faults. These include sharing learning from the complaint with staff to make sure patients are provided with clear information about their status under the MHA when they are not able to be admitted to a mental health bed straight away. The Trust also apologised to Mr B in its complaint response, which I consider appropriate.

c) Being held in a short-term placement not appropriate to needs whilst waiting to be admitted to a “mental health bed”

56. Mr B agreed to be transferred to Unit X, a short-term mental health crisis facility, (Unit X) while waiting for a mental health bed. He complained that Unit X is used as a “dumping ground” and should only be used for a day or two but he had to stay there for 11 days. He said there was no bed and he had to sleep in a chair, which worsened his mental health due to sleep deprivation.
57. The Trust’s website explains Unit X is a “mental health crisis assessment facility” for stays of up to 23 hours. In Mr B’s case, he stayed considerably longer, for 11 days. The Trust acknowledged this and explained that unfortunately some patients have to stay on Unit X for longer than 23 hours. The Trust apologised to Mr B that he had to stay on Unit X for an extended period.
58. The Trust and Council both referred to the national shortage of mental health beds in their responses to Mr B and to us. This is an issue that has also been highlighted by the Care Quality Commission and NHS England, including that many services struggle to provide enough mental health beds to meet demand. This can leave some patients in vulnerable positions in the community, and others being cared for in unsuitable environments for prolonged periods.
59. The Trust and the Council provided evidence about the daily efforts staff made to identify a mental health bed for Mr B. This included the AMHP duty manager and shift lead (two different members of staff) emailing the Trust bed managers daily to ask for an update on bed availability. The contacts between the AMHP service and Trust bed managers include information about specific concerns about patients and any increasing risks, if applicable.
60. Within the Trust, there are two daily meetings about bed availability, and this includes discussion about each person awaiting a bed and any risks or issues. In the interim, the team looking after the patient (if they are in a Trust facility rather than in the community) continue to review the patient and provide support and can raise any issues about change in need or risk so the system is as responsive as possible.
61. There is also provision in s140 of the MHA for mental health beds to be made available urgently for cases of special emergency / exceptional clinical need. This applies where a person is so unwell that failure to urgently admit them to hospital under the MHA could cause significant harm, trauma, or death. The Trust and Council work to a Pan-Sussex s140 Policy, where a s12 doctor carrying out a MHA assessment can flag that a patient needs a “special urgency inpatient bed”. In Mr B’s case, the s12 doctors did not consider he needed a special urgency bed.
62. The Trust said work is ongoing to improve issues relating to its mental health bed availability, within its “Patient Flow” programme of work. Also, in 2023 the Trust was purchasing 40 additional acute psychiatric beds, to increase capacity to meet rising demand. 
63. I have considered whether it was fault that Mr B had to stay on Unit X for 11 days until a mental health bed became available for him. The MHA and the MHA Code do not set out specific timeframes within which a person should be admitted to a mental health bed after an MHA detention. The medical recommendations completed as part of a MHA assessment are valid for a period of 14 days. 
64. Considering the widely reported national issues about a shortage of mental health beds and the increasing demand for them, I do not consider it fault that Mr B was not admitted to a mental health bed until 14 days after his original MHA assessment. I have no doubt that this period was very distressing for Mr B, and being cared for on Unit X as an interim measure was far from ideal. However, it is clear from Mr B’s records that he was felt to be at considerable risk to himself and staff felt he could not be safely cared for in the community while waiting for a mental health bed.
65. The Trust has outlined the actions it is taking to improve mental health bed availability. Whilst this will not change things for Mr B, it is a positive step towards addressing some of the difficulties this case has highlighted.

d) Inadequate explanation about risks of Sertraline medication

66. Mr B complained a doctor on Unit X didn’t properly inform him about the possible side effects of Sertraline medication, particularly some of the longer-term effects. He said he took the medication under duress, and only agreed to take it because he thought he was already detained under the MHA. He said his decision was influenced by what the mental health nurse had said about powers to give forced medication.
67. The Trust said the doctor could not recall this specific incident but had reflected on the issues Mr B raised. The doctor said he committed to ensuring the purpose of each conversation with patients and medication side effects are clearly discussed. The Trust explained that complaints about doctors are also reported to the Medical Directorate and considered during the medical revalidation process, which ensures doctors are up-to-date and fit to practise.
68. As well as looking at Mr B’s account and the doctor’s response, I examined Mr B’s medical records. The entry about Sertraline is very brief, saying: “He has never been on regular medications but is open to therapy and starting medications. I offered him sertraline and explained the SE [side effects]. He wanted me to write the name of the medication down because he wanted to discuss with his sister.”
69. The records show that Mr B then agreed to starting Sertraline medication after discussing it with his sister, a GP.
70. There is not enough evidence to reach a view on the level or quality of the doctor’s explanation to Mr B about possible side effects of Sertraline. The medical record says side effects were explained but does not go into any more detail. I would not expect a doctor to list every possible side effect in detail in the patient record.
71. Mr B said he might not have agreed to take Sertraline if he had known he was not detained under the MHA at that point. As outlined earlier in this decision, Mr B was unclear about his status under the MHA at the time Sertraline medication was discussed. However, records show that Mr B took time to discuss the medication with his sister, and then informed the team at Unit X he was willing to start taking it. This indicates Mr B felt he had some degree of input into the decision on whether to start the medication.
72. Taking everything into account, I find no fault with how the doctor explained the risks of Sertraline medication to Mr B.

e) MHA medical recommendations expired

73. As outlined at paragraph 26, when Mr B was re-assessed under the MHA two weeks after the original assessment, the AMHP did not realise the medical recommendations from the s12 doctors had expired or were about to expire. This meant Mr B had to go through a further MHA assessment the next morning. He complained this was very distressing and should have been avoided.
74. In its complaint response the Council said the AMHP involved should have realised a full re-assessment under the MHA, including two s12 doctors, was needed at this point. The Council apologised to Mr B for the distress and upset this fault caused, through him having to go through two MHA assessments within 24 hours. The Council explained it had shared learning from the complaint with staff, and several additional checks were now in place to prevent a similar error in future.
75. The Council told us the issue had been discussed directly with the AMHP concerned. It also said every AMHP shift lead now checks the date of medical recommendations and this is confirmed in the AMHP handover/allocation meetings which happen twice each day. The date of expiry of the medical recommendations is included in the written handover information.
76. It was fault that the AMHP did not realise the s12 medical recommendations had expired / were about to expire, and the Council acknowledged this and took action to address it.
77. I have considered the impact of this fault on Mr B. He said it was very distressing to go through two MHA assessments in such a short timeframe, and to have the uncertainty about when he would be admitted to hospital under the MHA on top of all the delays and uncertainty he had already experienced.

f) Poor complaint handling

78. Mr B said the Trust and Council handled his complaint poorly. He said the responses were disjointed, failed to answer all his concerns, and did not lead to resolution of his complaint
79. The Trust has acknowledged some of the complaint issues were not addressed initially, and has apologised for this. It explained that in September 2024 the Trust introduced a new Complaints and Patient Advice and Liaison Service policy. It said this involves more extensive scrutiny of formal complaint responses at three different levels within the Trust.
80. Through our investigation we identified that Mr B’s complaints about the doctors who carried out the s12 MHA assessments had not been answered by either the Trust or Council. It appears each organisation felt the other was responsible for answering this part of the complaint, and the upshot of this was the complaints remained unanswered when Mr B complained to the Ombudsmen.
81. When a complaint involves both NHS and social care responsibilities, the organisations should co-operate to ensure the complainant receives a comprehensive and coordinated response addressing all the key issues. The organisations must also provide relevant information to each other as part of the complaint investigation and management process. (Local Authority Social Services and National Health Service Complaints (England) Regulations 2009).
82. The NHS Complaint Standards also emphasise the importance of providing a through response to issues raised, and liaising with other organisations where appropriate.
83. It is fault that some of Mr B’s complaints were not addressed at all and some were passed between the Trust and Council due to a lack of clarity or understanding about which organisation was responsible for dealing with complaints about s12 doctors involved in a MHA assessment. We have now agreed a route for Mr B’s complaints about the s12 doctors to be answered.
84. Mr B was caused additional frustration and inconvenience as a result of the failings in how his complaint was handled.

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Agreed actions

85. We take the individual circumstances of each complainant into account when recommending remedies. For injustice such as avoidable distress, harm or risk, we usually recommend a symbolic payment to recognise the impact of the fault on the complainant. Distress can include uncertainty about how the outcome might have been different and can include lost opportunity.
86. Where there has been avoidable distress, our financial recommendation to remedy this is usually between a total of £300 to £1,000. This depends on the severity of the injustice, the vulnerability of those affected and whether the injustice is over a prolonged period.
87. I proposed and the organisations agreed to take the following actions, to remedy the injustice caused to Mr B by their faults.

The Trust

88. Within a month of our final decision, the Trust should:

• write to Mr B to apologise for the impact of the faults identified in this decision. These faults relate to explanation about his status under the MHA, and complaint handling
• pay Mr B a symbolic payment of £600 to recognise his avoidable distress and upset.

89. Within three months of the final decision, the Trust should also consider the lessons learned from this complaint. It should write to Mr B and set out the action it has already taken, and any further planned action, in relation to:
• providing clear information to patients about their status under the MHA when they cannot be admitted to a mental health bed straight away
• ensuring people receive a thorough and comprehensive response to all the key issues in their complaint
• ensuring complaints about s12 doctors under the MHA are routed to the appropriate organisation to investigate and respond to.
90. The Trust should provide us with evidence it has complied with all of the above actions.

The Council

91. Within a month of our final decision, the Council should:
• write to Mr B to apologise for the impact of the faults identified in this decision. These faults relate to not realising medical recommendations under the MHA had expired, and complaint handling
• pay Mr B a symbolic payment of £300 to recognise his avoidable distress and upset.
92. Within three months of the final decision, the Council should consider the lessons learned from this complaint. It should write to Mr B and set out the action it has already taken, and any further planned action, in relation to:
• ensuring s12 medical recommendations have not expired / are about to expire when a repeat MHA assessment is carried out by an AMHP
• ensuring complaints about s12 doctors under the MHA are routed to the appropriate organisation to investigate and respond to.
93. The Council should provide us with evidence it has complied with all of the above actions.

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Final decision

94. I partly uphold this complaint. I found fault with both the Trust and the Council in some aspects of Mr B’s care and support, and in handling his complaint. These faults caused Mr B avoidable distress and upset. The organisations have agreed to our actions which will provide a suitable and proportionate remedy for Mr B.

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Investigator's decision on behalf of the Ombudsman