Summary: We found fault by a Council, Trust and ICB concerning the discharge planning for Miss E, a young woman with complex needs. We also found fault with the failure of these organisations to arrange proper Section 117 aftercare for Miss E. The Council, Trust and ICB will apologise for this, provide appropriate care and make a financial payment to recognise the impact on Miss E and her family.

The complaint

1. The complainant, who I will call Ms D, is complaining about the care and treatment provided to her daughter, Miss E, by Birmingham City Council (the Council), Birmingham and Solihull Mental Health NHS Foundation Trust (the Trust) and Birmingham and Solihull Integrated Care Board (the ICB).
2. Ms D complains that:

• the Trust and Council failed to plan for Miss E’s discharge in an effective and timely manner as required by the Mental Health Act Code of Practice;
• the Trust, Council and ICB failed to put appropriate aftercare services for Miss E under Section 117 of the Mental Health Act 1983;
• the Trust failed to appoint a care coordinator with the necessary skills and experience to support Miss E with her complex needs; and
• the Trust failed to investigate her complaint in a timely and comprehensive manner.

3. Ms D says the delayed discharge had a significant impact on Miss E’s mental health. She says the lack of proper support in the community meant Miss E resumed unhealthy coping strategies that placed her at greater risk. In addition, Ms D says these events affected her relationship with Miss E and caused her great distress and frustration.

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The Ombudsmen’s role and powers

4. The Ombudsmen investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, the Ombudsmen 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. If the Ombudsmen are satisfied with the actions or proposed actions of the bodies that are the subject of the complaint, they can complete their 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

7. In making my final decision, I considered information provided by Ms D and discussed the complaint with her. I also considered relevant information and records from the Council, Trust and ICB. In addition, I took account of relevant legislation and guidance.
8. I considered comments from all parties on my draft decision statement.

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What I found

Relevant legislation and guidance

Mental Health Act 1983

9. The Mental Health Act 1983 (the MHA) allows that, when someone has a mental disorder and is putting their safety or someone else’s at risk, they can be detained in hospital against their wishes. This is sometimes known as ‘being sectioned’.
10. A person can be detained under Section 3 of the MHA for the purpose of providing treatment. This section empowers doctors to detain a patient for a maximum of six months. Clinicians can renew a Section 3 detention for another six months.
11. Before the person is discharged, a social care assessment should take place to assess if they have any social care needs that should be met.

Section 117 aftercare

12. People who have been detained under certain sections of the MHA (including Section 3) are entitled to free aftercare services on discharge. This is known as Section 117 aftercare.
13. Section 117 of the MHA imposes a duty on the relevant local authority and Integrated Care Board to meet the health and social care needs arising from, or related to, a person’s mental disorder. The purpose of this support is to prevent a deterioration in the person’s mental health that may lead to further inpatient admissions.

Care Programme Approach

14. The Care Programme Approach (CPA) is the process by which mental health services assess a patient’s needs, plan how to meet them and ensure they are met.
15. Under ‘Refocusing the Care Programme Approach’ (Department of Health, 2008), people under CPA should have a comprehensive assessment of their health and social care needs. They should have a care coordinator, as well as a care plan to show how their needs will be met. This care plan should be reviewed by a multi-disciplinary team (MDT). When a patient is in hospital, their care coordinator is the key person responsible for arranging the care and support they will need on discharge.

Background

16. Miss E is a young woman with complex physical and mental health needs. She has an eating disorder, with anxiety and depression. She also has problems with substance misuse. In 2020 she was receiving treatment in a specialist eating disorder unit. The Trust provided this treatment through a private inpatient facility.
17. In September 2020, an AMHP acting for the Council arranged a Mental Health Act Assessment at the request of the inpatient unit. The assessment found Miss E was showing only limited engagement with her care. The assessment decided that Miss E should required detention under Section 3 to allow for a more structured approach to her care.
18. Between November 2020 and January 2021, clinicians noted Miss E was engaging well with her care and was making good progress towards her recovery. The care records show that, by January, the MDT had begun to plan for her discharge.
19. However, in February, Miss E suffered a stroke. This caused her significant speech difficulties. Following a period of treatment in hospital, Miss E was discharged back to the eating disorder unit for further assessment.
20. A CPA review meeting in May heard that Miss E had regained her weight and no longer needed care on an eating disorder unit. However, the meeting noted she was engaging in self-harming behaviours, including misuse of alcohol. At that stage, the MDT was planning to transfer Miss E to an alternative placement managed by the same private provider (Placement A).
21. Later that month, the Trust allocated Miss E a care coordinator.
22. In early June, Ms D raised concerns that Placement A may not be suitable for Miss E.
23. In June, the responsible clinician held a Section 117 meeting. Miss E and Ms D attended, along with the care coordinator. The meeting recognised that Miss E was keen to return home with support. However, the meeting agreed she would need a rehabilitation. The meeting heard the ICB would need to provide funding for a placement.
24. Ms D continued to raise concerns about the suitability of Placement A. She asked the care coordinator to explore alternative placements.
25. By August, the care coordinator had not identified a suitable placement that was willing to accept Miss E. Ms D and Miss E suggested the possibility of a supported living placement as an alternative. The care coordinator said this would mean Miss E would need to access psychotherapy in the community via the local Community Mental Health Team (CMHT). However, she advised there was a significant waiting list for this service.
26. Miss E was admitted to hospital again in September, having suffered several seizures. The clinical team expected Miss E to return to the eating disorder unit when her treatment was complete. However, she was reluctant to do so.
27. The case records show there was some dispute about what placement would be suitable for Miss E. Miss E was keen to enter a supported living placement. However, the MDT felt her recent physical ill health may mean an acute hospital ward or rehabilitation placement would be more suitable. The eating disorder unit reported that staff were struggling to cope with Miss E’s challenging behaviours and that the unit may not be suitable for her. The MDT ultimately decided that supported accommodation would offer the best means of meeting Miss E’s complex care needs.
28. The clinical team and Ms D eventually persuaded Miss E to return to the eating disorder unit. Miss E returned to the unit in early October.
29. On the same day, the care coordinator submitted a funding application to the ICB with supporting clinical documentation from an Occupational Therapist (OT), Speech and Language Therapist (SALT) and a psychologist.
30. Later that month, the care coordinator contacted Miss E’s social worker to request an updated social care assessment for her.
31. In late October, Miss E told her care coordinator she would proceed with a move to Placement A as there was a lack of alternative options. An MDT meeting discussed this on 26 October and again at a CPA review the following day. The CPA review agreed that Miss E did not want to move to Placement A and decided to continue searching for suitable supported accommodation or a rehabilitation placement.
32. Throughout this period, Miss E took unescorted leave and stayed with Ms D. However, she continued to struggle with substance misuse. Wards staff often noted Miss E returned to the ward intoxicated.
33. In early November, the Council reallocated Miss E’s case to another social worker. By this point, Miss E had begun to refuse her medications and was requesting a transfer to an acute hospital bed.
34. In the meantime, Miss E continued to receive regular reviews from the local Brain Injury Specialist Clinic (BISC). In late November, Miss E’s care coordinator established that Miss E was on the waiting list for SALT.
35. Later that month, Miss E and Ms D wrote to the Trust to advise that Miss E was intending to discharge herself home if the multidisciplinary team had not identified suitable alternative provision by 10 December. They asked the multidisciplinary team to put appropriate care and support in place for Miss E in the community. This was a notice period of four weeks.
36. A further CPA review meeting in early December heard that Miss E’s decision to discharge herself was against clinical recommendations and that professionals had not yet had a chance to arrange support. The team agreed Miss E would go on extended leave and return to the unit once per week for review until her discharge could be finalised.
37. However, in the following days Miss E was twice admitted to hospital having taken overdoses of sedative medication. Miss E refused to return to the eating disorder unit and asked to be transferred to an acute mental health ward. There were no available beds and Miss E was discharged back to Ms D’s address.
38. At a CPA review meeting on 17 December, Ms D raised concerns that Miss E was not receiving psychotherapy, which was an assessed need. A psychologist at the meeting explained that complications arising from Miss E’s stroke would make it difficult for her to engage with therapy. The meeting heard that Miss E would benefit from input from a neuropsychiatrist. This is a clinician who treats psychiatric and behavioural symptoms of patients with neurological disorders.
39. The care coordinator identified a specialist eating disorder supported living placement (Placement B). It was agreed that Miss E would remain living with Ms D while the care coordinator applied for funding. She came under the care of the Trust’s Home Treatment Team (HTT).
40. The ICB initially arranged a funding panel for 24 December. However, it later postponed this to 6 January 2022. Placement B offered Miss E a move-in date of 10 January.
41. On 31 December, Miss E and Ms D wrote to the care coordinator to express concerns about the suitability of Placement B following a visit to the premises.
42. On 5 January, Ms D told a care meeting that she was supporting Miss E to purchase her own flat. Ms D and Miss E felt Miss E would be able to cope in her own accommodation with community rehabilitation support and psychotherapy.
43. During this period, Miss E’s condition remained volatile. She was attending a crisis day service. However, professionals often noted she was low in mood and continued to self-harm. On 13 January, Miss E’s care coordinator noted that she would refer Miss E for art therapy sessions to help her establish structure to her days.
44. Later that month, Miss E disclosed to the HTT that she had been sexually assaulted the previous year when on leave from the eating disorder clinic.
45. A psychologist from the HTT contacted Miss E on 19 January to offer her a psychological therapy session. Miss E said she had benefited in the past from Dialectical Behavioural Therapy (DBT – a talking therapy aimed at helping people to understand and cope with difficult feelings). Miss E also said the symptoms she experienced following her stroke made group therapy sessions difficult. The psychologist arranged for Miss E to have two individual sessions with an assistant psychologist focusing on DBT skills. These sessions took place on 24 and 25 January.
46. On 8 February, Miss E’s sister told a Trust clinician that Miss E was pregnant as a result of the sexual assault. However, Miss E later suffered a miscarriage. This caused Miss E understandable distress and led to an increase in her alcohol misuse.
47. Ms D contacted the care coordinator on 28 February. She reported that Miss E had experienced two hospital admissions in recent days. Ms D said Miss E needed an urgent mental health assessment, appropriate accommodation and psychological therapy.
48. The care coordinator advised Ms D that she continued to search for a suitable rehabilitation placement. The care coordinator said one out of area placement may be suitable and would allow a multidisciplinary team (including a psychologist) to support Miss E. In the meantime, she said she had referred Miss E for art therapy.
49. On 7 March, Ms D sent a detailed email to the care coordinator reiterating her concerns. Ms D said the out of area placement would not be suitable as this would take her away from her local community and support network. Ms D said Miss E continued to go without support to meet her assessed Section 117 care needs, including psychotherapy.
50. An Occupational Therapist from the BISC assessed Miss E. She concluded Miss E would be suitable for psychological therapy and that her stroke symptoms should not preclude this. The OT said Miss E would begin to access BISC services (including SALT) in early April.
51. On 11 March, a psychologist who had previously worked with Miss E contacted the care coordinator to query why she was not receiving therapy. He recommended a reassessment of her needs and ongoing trauma and DBT provision.
52. Miss E was admitted to hospital again on 16 March, having been found unresponsive at a train station. She was transferred to a mental health inpatient unit.
53. A consultant psychiatrist from the mental health unit discussed Miss E’s case with a psychologist. The psychologist explained that she had referred Miss E for 1:1 DBT sessions. However, she concluded that Miss E was not ready for trauma therapies. The psychologist explained that Miss E would also be able to attend weekly drop-in sessions while she was an inpatient.
54. The care coordinator contacted the ICB to explore funding options for Miss E’s care package. She explained that Miss E had been due to start SALT with BISC prior to her admission but would now have to wait until her condition had stabilised. She asked whether it would be possible to fund SALT via a personal health budget. The ICB advised this would be unlikely as Miss E could access SALT via mainstream services.
55. In subsequent correspondence with the ICB, the care coordinator explained that Ms D had been required to secure private SALT for Miss E due to limited available services in the community. She queried whether the ICB would reimburse Ms D if the SALT was determined to be an assessed clinical need. The ICB advised this would be a management decision.
56. On 29 April, a psychologist from the HTT documented that was not open to the HTT DBT service as she had declined to engage in group sessions. The HTT psychologist noted that Miss E had attended a trauma counselling session on the ward and should not be pursuing more than one psychological therapy. She noted that she would discuss the case with the inpatient psychologist.
57. The inpatient psychologist subsequently noted that she would review Miss E and there should be further discussion about her psychological needs.
58. The inpatient psychologist reviewed Miss E on 11 and 18 May. The psychologist explained that Miss E should only engage with one psychological therapy at a time and suggested that this should be art therapy, for which a referral had already been made. Miss E agreed to attend art therapy in the community.
59. A social worker completed a Care Act Assessment on 30 May. This found Miss E would need support with her meals and nutritional needs and to access community resources.
60. On 31 May, Ms D told a Section 117 review meeting that she was concerned Miss E still did not have proper support in place in the community.
61. Miss E was discharged on 1 June.
62. On 7 July, the multidisciplinary team held a Section 117 panel meeting to agree a package of support for Miss E. The meeting agreed the ICB would fund three 30-minute care visits per day on a short-term basis. The ICB also agreed to provide SALT funding from July to the end of September, when BISC SALT would begin. The meeting heard that a local brain injury charity was also considering a referral for two to three hours of outreach support per week.
63. Miss E further discussed her concerns about the prospect of art therapy during a session with the HTT psychologist. Miss E said she thought she would receive some sort of trauma therapy. However, the psychologist explained the HTT were concerned this may destabilise her.
64. On 14 July, the art therapy service decided to delay commencement of the therapy until Miss E’s therapeutic goals had been clarified.

My analysis

Discharge planning and support

65. Ms D complained that the Trust and Council failed to plan for Miss E’s discharge in an effective and timely manner as required by the Mental Health Act Code of Practice. Ms D pointed out that Miss E had first been admitted in May 2020 and sectioned in September 2020. She left hospital in December 2021, before being readmitted in April 2022 and finally discharged in June 2022.
66. In its complaint response, the Trust admitted there had been shortfalls which contributed to Miss E’s discharge. The Trust said confusion surrounding what would be a suitable placement for Miss E had been a significant factor.
67. Section 33.10 of the Mental Health Act Code of Practice (the Code) sets out that the Section 117 duty begins when a person leaves hospital. However, it emphasises that aftercare planning needs to begin “as soon as the patient is admitted to hospital.”
68. Section 33.14 of the Code goes on to say that “[a]fter-care for all patients admitted to hospital for treatment for mental disorder should be planned within the framework of the care programme approach.” The Code describes the CPA as “an overarching system for coordinating the care of people with mental disorders”. It requires the appointment of a care coordinator.
69. Section 34.6 says the CPA should be used “to assess, plan, review and coordinate the range of treatment, care and support needs of those people…who have complex needs.” Section 34.7 clarifies that this includes people who need “multi-agency support”, “active engagement”, intense intervention” or “support with dual diagnosis”.
70. The clinical records contain evidence of what appear to have been multidisciplinary CPA review meetings from 2020 onwards. This suggests Miss E’s care was being managed under the CPA. However. she did not have a care coordinator as required by the Code.
71. This is contradicted by an entry in the records from 20 April 2021. This entry says a doctor on the eating disorder unit contacted the local Community Mental Health Team (CMHT) for advice as to whether Miss E should be treated under the CPA. The doctor also queried whether Miss E required a care coordinator. It was this contact that eventually led to a care coordinator being appointed in May 2021.
72. The records suggest the clinical team began to plan Miss E’s discharge from December 2020, by which point her condition had stabilised. The complexity of her needs means the discharge planning should have been managed within the CPA framework from the outset in accordance with the Code. This would have allowed Miss E to have an allocated care coordinator to maintain oversight of her needs and how these would be met in the community. Instead, there was a delay of around four months before this happened. I can see no good reason for such a significant delay. This was fault by the Trust.
73. This caused Miss E and Ms D unnecessary frustration and contributed to Miss E’s delayed discharge.
74. It is important to recognise that Miss E has very complex physical and mental health needs. Miss E suffered a stroke in February 2021. This exacerbated the situation as it extended her recovery time and meant her care needs changed. This made it harder to identify a suitable placement.
75. By May 2021, the clinical team had established that Miss E no longer needed care in an eating disorder unit. However, there appears to have been some dispute as to Miss E’s diagnoses and what sort of discharge placement would be most suitable for her. The care records show the care coordinator was considering both inpatient rehabilitation and supported living placements.
76. The evidence I have seen suggests the multidisciplinary team missed an opportunity at this stage to establish a clear picture of Miss E’s needs and how these could best be met in the community. This meant there was a lack of clarity that contributed to the delay in her discharge. This had still not been resolved by December 2021, when Miss E returned home on leave to live with Ms D.
77. This was fault by the Trust, Council and ICB which shared the responsibility for establishing Miss E’s care needs and providing, or arranging, services to meet them.
78. I cannot say when Miss E would have been discharged, even if the discharge planning had been appropriate. This is because the complexity of her needs meant there was limited provision available in the community to meet them. Furthermore, the care records suggest Miss E’s condition fluctuated. This caused further complications for the multidisciplinary team.
79. Nevertheless, I am satisfied that more effective discharge planning would have reduced the delay. This delay caused Miss E and Ms D understandable distress and frustration.
80. Miss E subsequently experienced a period crisis resulting in several hospital admissions and attendance. The multidisciplinary team recommended Miss E return to the eating disorder unit as an inpatient. She was reluctant to do so and so it was agreed Miss E would return to live with Ms D with crisis support from the HTT.
81. In late December, Miss E and Ms D visited a supported living placement that had offered Miss E a place. They subsequently wrote to the care coordinator to express various concerns about the suitability of the placement.
82. In the meantime, the care coordinator made a referral to a specialist mental health home care agency to explore whether it could support Miss E at home. The care agency agreed to consider the referral.
83. Over the following months, Miss E’s condition fluctuated, with regular crisis episodes. This assault Miss E suffered in December 2021 exacerbated this situation. This made it challenging for the multidisciplinary team to identify a suitable placement for her as her condition remained unstable. Miss E continued to receive limited support from the HTT and a crisis day centre.
84. In late February 2022, Miss E advised the care coordinator that she had made an offer on a flat in the local area. Miss E said she hoped to live independently with rehabilitation support and psychotherapy.
85. That month, the home care agency declined the referral because it concluded Miss E needed more time to recover from her recent traumas.
86. Miss E identified three clinics specialising in caring for patients with a dual diagnosis of eating disorder and alcohol addiction. However, a psychiatrist gave her view that Miss E was using alcohol as a coping mechanism and that she was not dependent upon it.
87. In March, Miss E was admitted to hospital again. She was then moved to a mental health inpatient bed on a short-term basis. The care coordinator visited Miss E on the ward in April. The care coordinator suggested sourcing an alternative home care agency to support Miss E at home to help manage any risk to her. However, Miss E appears to have been reluctant to have support staff supervising her in her own home. Rather Miss E said she would prefer support with her daily life skills.
88. The care coordinator subsequently arranged for a social worker to carry out a Care Act Assessment in late May. This found Miss E would benefit from support to access her local community. In addition, the social worker found Miss E would need support to manage her nutritional needs.
89. The multidisciplinary team discussed Miss E’s care at a Section 117 meeting on 31 May. Ms D and Miss E were also present. Ms D expressed concern that Miss E would resume drinking alcohol to excess if she returned home without support. However, the responsible clinician advised that this was not a reason for Miss E to remain an inpatient. Furthermore, he said carer workers in the community would be unable to prevent Miss E from drinking alcohol and that she must take some responsibility for this.
90. Miss E was discharged the following day with support from the HTT.
91. Miss E’s decision to effectively discharge herself in December 2021, while understandable, placed greater pressure on the professionals supporting her. At that stage, only very limited community support was in place from the HTT and a local crisis day centre.
92. It is also necessary again to acknowledge Miss E’s extremely complex needs. This made it very challenging to identify suitable support either via a residential placement or care in the community.
93. Nevertheless, the fact remains that at the point of discharge in both December 2021 and June 2022, Miss E remained in receipt of only very limited short-term support from the HTT. This was not an adequate substitute for the structured rehabilitation support that was an assessed Section 117 need. This also needs to be considered alongside the fact that Miss E was similarly not receiving psychotherapy or SALT. I have commented further on these below.
94. The failure to put rehabilitation support in place for Miss E represents fault by the Council, Trust and ICB.
95. Again, I am unable to say whether the course of Miss E’s care would have been different if she had received appropriate rehabilitation support. Nevertheless, I consider the absence of this support is likely to have contributed to Miss E’s unsettled presentation following her discharge in December 2021. This caused Miss E and Ms D significant distress.

Section 117 aftercare - Psychotherapy

96. Ms D complained that the Trust, Council and ICB failed to put appropriate aftercare services in place for Miss E as required by Section 117 of the Mental Health Act 1983.
97. The care records show Miss E had been receiving DBT prior to suffering a stoke in February 2021. She was noted to have responded well to that therapy. The documented plan was for Miss E to proceed to trauma therapy following completion of the DBT.
98. Following Miss E’s stroke, the therapy ceased. The clinical records suggest this is because the communication problems caused by the stroke made it difficult for Miss E to engage with therapy.
99. In June 2021, a s117 review meeting heard that, after a period of rehabilitation, Miss E would commence with Eye Movement Desensitisation and Reprocessing therapy. This is known as EMDR (a psychotherapy to help a person recover from past experiences that may be affecting their mental health). Furthermore, the meeting agreed that Miss E would be supported in this process by the SALT team. This was due to happen in Placement A. However, Miss E ultimately did not move to that placement.
100. Over the following months, there remained a significant disparity of views between the professionals involved in Miss E’s care as to whether she would benefit from psychological therapy and, if so, what kind. This issue was raised repeatedly by Ms D.
101. It is concerning that even in July 2022, a psychologist documented the need to “explore with [Miss E] her difficulties/therapeutic aims”. This was over a year after the Section 117 review meeting in June 2021 that identified psychotherapy as a key component of Miss E’s care.
102. Miss E was eventually discharged in June 2022 without any psychotherapy in place.
103. The evidence suggests there was a clear need to carry out a holistic assessment of Miss E’s psychotherapy needs. This should have considered the impact of Miss E’s stroke on her ability to engage with therapy, as well as the subsequent effect of the traumas she suffered in 2021 and early 2022. I found no evidence of such an assessment in the clinical records. This was fault by the Trust. This fault is shared by the Council and ICB, which shared the duty to provide or arrange Section 117 aftercare services for Miss E.
104. I consider the failure to provide Miss E with appropriate psychotherapy services had an adverse impact on her recovery. This caused Miss E and Ms D significant distress and uncertainty.

Section 117 aftercare – Speech and Language Therapy

105. Miss E initially received some sessions of SALT following her stroke in February 2021. However, this was a short-term service that ended in April., Ms D paid for Miss E to have a weekly session of SALT from a private therapist.
106. A Section 117 meeting in June 2021 agreed Miss E would require SALT input to support her to engage with psychotherapy. This was also reflected in her care plan.
107. Miss E’s care coordinator submitted a funding application to the ICB later that month. However, she did not include all the required supporting documentation. The care coordinator subsequently contacted Miss E’s social worker to arrange this. The care coordinator and social worker completed the form in early September.
108. In October 2021, the ICB declined to fund SALT for Miss E on the basis that she could access this through mainstream community services.
109. In the meantime, Miss E was assessed by the BISC service to see whether she would be suitable for SALT in the community. The assessor noted a clear need for SALT and agreed the service would provide this but advised there was a waiting list.
110. The BISC service agreed that Miss E would begin SALT in April 2022. However, Miss C’s hospital admission delayed this.
111. The BISC service rescheduled the SALT to begin in October 2022. In July 2022, the ICB agreed interim funding to cover the cost of Miss E’s private SALT sessions until she could commence the BISC sessions.
112. The care records show that Miss E had an assessed need for SALT. The Code makes clear that Section 117 aftercare is intended to meet a need “arising from or related to” a person’s mental disorder. The Code says ICBs and councils should interpret the definition of aftercare broadly.
113. I am satisfied, based on the records I have seen, that Miss E’s assessed need for SALT was related to her mental health. This is because she required this support to help her engage with psychotherapy. Therefore, Miss E’s SALT should have been included within her Section 117 provision.
114. Despite this, Miss E was still not in receipt of SALT by June 2022, a year after this had been identified as an ongoing need at the Section 117 meeting. The care records suggest there was limited SALT provision available in the community. When it was not possible to secure SALT provision in the community, the Council and ICB should have secured interim funding to pay for Miss E’s SALT (as they later did in July 2022). This is because Section 117 aftercare services are to be provided free of charge. The failure to do so was fault by the Council and ICB.
115. This meant Ms D was required to pay for SALT privately. This caused her financial hardship and added to her frustration. This also caused Miss E further distress.

Care coordinator

116. Ms D complained that the Trust failed to appoint a care coordinator with the necessary skills and experience to support Miss E with her complex needs. Ms D said the care coordinator’s communication was poor. She also said the care coordinator lacked understanding of relevant law and guidance and was unfamiliar with local provision.
117. In its response to the part of the complaint, the Trust said the care coordinator was able and competent to perform this role and was well supported within the team. Nevertheless, the Trust recognised there had been problems with communication. It recommended a communication plan setting out what communication between the care coordinator should look like.
118. It is not for the Ombudsmen to comment on a professional’s skills or qualifications. However, I recognise Ms D’s wider concerns about the complexity of Miss E’s care and her view that the care coordinator struggled to manage the case effectively.
119. I think it is important to recognise that the care coordinator was not acting as an individual but as part of a wider multidisciplinary team. This meant she was able to seek advice and guidance from other health and social care professionals to inform her search for suitable provision for Miss E. The care records show she sought input from relevant services and acted on the advice she was given. This sometimes resulted in periods of delay as the care coordinator was required to wait for responses to her queries.
120. More generally, the care records show the care coordinator made extensive efforts to identify suitable provision for Miss E. This was evidently very challenging due to the complexity of Miss E’s physical and mental health needs and her fluctuating presentation.
121. As I have explained above, I consider there was significant delay on the part of the Council, Trust and ICB in terms of arranging Miss E’s discharge and putting in place appropriate Section 117 aftercare services to meet her needs.
122. While the care coordinator was an important part of Miss E’s care provision, she was only one member of the wider multidisciplinary team. The care records suggest the failure to provide Miss E with the care she required was a collective one, rather than the result of action or inaction by any one individual. I have addressed this fault above.
123. The Trust has acknowledged that communication was not always as effective as it could have been. Again, I consider this to have been a collective failing.

Complaint handling

124. Ms D said the Trust failed to investigate her complaint in a timely and comprehensive manner. Miss E said it took seven months for the Trust to respond to her complaint. Furthermore, Ms D said the Trust made no reference to key legislation and guidance when addressing her complaints.
125. Ms D first complained to the Trust in September 2021. She received a response in February 2022, around five months later.
126. The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 (the ‘complaints regulations’) place a duty on health and social care providers to investigate complaints properly and in a way that will resolve them efficiently. There is also a duty to cooperate when a complaint is made to one organisation and contains material relevant to another.
127. Section 9 relates to the duty to cooperate to address complaints that concern more than one responsible body. It states that, in these circumstances, the responsible bodies must co-operate in handling the complaint. This includes a shared duty to: establish who will lead the complaint process; share relevant information; and provide the complainant with a coordinated response.
128. Furthermore, the complaints regulations set out expectations for the handling of health and social care complaints. Section 14 of the regulations require an organisation to provide a response within six months.
129. I am satisfied the Trust responded to the complaint within the six-month timescale and I find no fault in this regard.
130. Ms D remained dissatisfied and complained again in early February. The Trust provided a further response in March, a little over a month later.
131. The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 (the complaints regulations) set out expectations for the handling of health and social care complaints. Section 14 of the regulations require an organisation to provide a response within six months. I am satisfied the Trust responded to the complaint within this timescale and I find no fault in this regard.
132. With regards to the standard of the Trust’s complaint responses, I share Ms D’s view that it would have been helpful if the responses had made proper reference to key guidance (such as the Code of Practice), particularly given Ms D had referred to specific guidance in her complaints. I also accept the responses did not address Ms D’s complaint to her satisfaction. Nevertheless, I do not consider they fell so far below an acceptable standard as to warrant a finding of fault, albeit I do not agree with the Trust’s position on some points.

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Agreed actions

133. Within one month of my final decision:

• the Council, Trust and ICB will write a joint letter to Ms D and Miss E apologising for the injustice caused to them by Miss E’s delayed discharge and their shared failure to put appropriate Section 117 aftercare services in place for her in the community;
• the Council, Trust and ICB will each pay Miss E £500 in recognition of the distress and uncertainty this fault caused her. The recommended payment reflects the fact that the injustice arising to Miss E occurred over a protracted period and caused her significant distress and uncertainty;
• the Council, Trust and ICB will each pay Ms D £500 in recognition of the distress and uncertainty this caused her. Again, the recommended payment reflects the fact that the injustice arising to Ms D occurred over a protracted period and caused her considerable frustration and uncertainty; and
• the ICB will reimburse the private SALT fees incurred by Ms D for the period June 2021 to June 2022. This is the period during which Ms D was paying for private SALT despite this being an assessed Section 117 need.

134. Within three months of my final decision:

• if they have not done so already, the Council, Trust and ICB will arrange a multidisciplinary Section 117 review meeting to discuss Miss E’s aftercare needs. This should be informed by input from all relevant professionals and should arrive at a consensus between all parties as to Miss E’s current needs and how these will be met in the community;
• the Council, Trust and ICB will formulate a communication plan to ensure Miss E and Ms D are kept informed about Miss E’s care;
• the Trust will explain what action it will take to ensure relevant staff have a clear understanding of the Care Programme Approach and how this should be applied for patients with complex needs. This includes ensuring that service users on the CPA have an allocated care coordinator to arrange annual review meetings;
• the Trust will explain what action it will take to ensure relevant staff have a clear understanding of the Personal Health Budget process and how this applies to people who are entitled to Section 117 aftercare; and
• the Trust will ensure that all relevant staff have a clear route of escalation in the event that relevant professionals are unable to secure the care provision set out in a service user’s care plan.

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

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Final decision

136. I found fault by the Council, Trust and ICB with regards to the care they provided to Miss E. This had a significant impact on Ms D as Miss E’s main carer.
137. In my view, the actions I have recommended above represent a reasonable and proportionate remedy to the injustice I have identified.
138. I have now completed my investigation on this basis.

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Investigator's decision on behalf of the Ombudsman