Summary: Ms X complains about delays by the Council and the Trust in completing an autism assessment for her child and for not fast‑tracking their assessment. We found fault with the initial referral, but the Trust has already remedied this. We also found fault with the triage panel meeting that led to some delay. We did not find fault by the Council and the Trust with how they considered Ms X’s fast‑track request. However, fault with a panel meeting led to some uncertainty about whether this could have been considered sooner. We have recommended the Trust and the Council take actions to address the faults and apologise for the distress caused to Ms X.

The complaint

1. Ms X complains about the London Borough of Wandsworth (the Council) and St George’s University Hospitals NHS Foundation Trust (the Trust). She says failings with the referral process for an Autism Spectrum Disorder (ASD) assessment for her child, Y, led to delays of over 18 months.
2. Ms X has said the delays have meant Y has not received enough support, and they have struggled with social skills and increased anxiety. She says Y was suspended and removed from school. Ms X says the lack of support has impacted the whole family.
3. Ms X says she would like answers about what should have happened and what went wrong in the process leading to the delays. She also wants Y to receive adequate support, apologies for the failings and compensation for distress and loss of time.

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The Ombudsmen’s role and powers

4. The Local Government and Social Care Ombudsman and Health Service Ombudsman have the power to jointly consider complaints about health and social care. (Local Government Act 1974, section 33ZA, as amended, and Health Service Commissioners Act 1993, section 18ZA).
5. We investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, we consider whether it has caused injustice or hardship (Health Service Commissioners Act 1993, section 3(1) and Local Government Act 1974, sections 26(1) and 26A(1), as amended).
6. If it has, they may suggest a remedy. Our recommendations might include asking the organisation to apologise or to pay a financial remedy, for example, for inconvenience or worry caused.  We might also recommend the organisation takes action to stop the same mistakes happening again.
7. We cannot 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. 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 from Ms X, the Council and the Trust, including Y’s relevant health and social care records. I have also considered the relevant law, guidance and policies.
10. Ms X, the Council and the Trust will had an opportunity to comment on a draft of my decision. I fully considered their comments before reaching my final decision.

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What I found

Relevant law and guidance

Autism diagnostic pathway

11. When the events complained about happened, there was a local pathway in place for referral for autism assessment for children under 8 years old.
12. The Children’s Development Clinic at the Trust referred the child to the Emerging Needs Pathway (ENP). The Council managed the ENP and aimed to provide appropriate support for children and families while they are waiting for a clinic appointment. The ENP team at the Council were responsible for gathering information to pass cases to a Specialist Communication Disorder (SCD) Triage Panel. The SCD decided whether to list a child for a Multidisciplinary Assessment (MDA) based on the information presented to it.
13. The National Institute for Health and Care Excellence has guidance (CG128): “Autism spectrum disorder in under 19s: recognition, referral and diagnosis”. This says that once it has been decided to carry out an autism diagnostic assessment, a report from the school should be sought if one has not already been made available.

Fast Track

14. The Council and the Trust had a locally agreed process for fast-tracking a referral to an MDA. To consider fast-tacking a referral, a multi-professional clinical review would take place. There is no set criteria for the clinical review, but the multi‑professional panel would consider a child’s circumstances at the point their case is presented. This includes the severity and complexity of their needs, and the extent this is affecting their ability to manage their daily life and access their educational placement. Specific examples can include (but not limited to), issues around safeguarding, exclusion from school and evidence of no support for a child with significant needs requiring a specialist placement.

Brief Background

15. In August 2022 St George’s Hospital (part of the Trust) considered Y may need an assessment for autism. It said it would send a referral to the ENP at the Council. The hospital discovered it had not sent the referral and so sent this in November 2022.
16. In May 2023 Y was excluded from school. Y started at a new school in September 2023.
17. The SCD discussed Y’s case in June 2023. However, it did not have a parental or school report available, so it asked the ENP team to get this information to consider at a future panel meeting.
18. The SCD discussed Y’s case again in August 2023. It had received a parental report and some information from school, but there was still no school report. It however agreed to put Y on the waiting list for an MDA.
19. In November 2023 Ms X asked the Trust to fast-track the referral. A multi‑professional panel considered Ms X’s request, but they did not consider Y met the criteria.
20. The MDA was scheduled for May 2024.

My findings

Referral to ENP

21. The Trust should have referred Y to the EMP in August 2022, however an administrative error meant it did not send the referral. When it became aware of the error, the Trust acted quickly and emailed the referral to the EMP. The Council confirmed receipt in November 2022. There was fault by the Trust in not sending the referral initially which led to a 2-3 month delay in EMP receiving this.
22. The Trust’s complaint response accepted this fault and it apologised to Ms X. In its response to our enquiries, the Trust has also explained that it has since made changes to its administrative process. A central team now sends referrals rather than individual secretarial staff as was the case previously. This should prevent any oversights by individuals in future. I consider this is a reasonable and proportionate outcome to this part of the complaint. However, there was potentially a knock-on effect with the time taken to navigate through the overall pathway. I have addressed this in the issues below.

SCD

23. The Council accepted there was a long waiting time for the SCD to consider cases and this reflected the national picture. The SCD considered Y’s case in June 2023. A lack of information presented to the SCD panel meant it could not make a decision. The SCD asked the EMP to get the information so it could consider Y’s case again at a future panel.
24. At the SCD panel meeting in August 2023, the information it needed from Y’s school was still not available. In response to our enquiries, the Council has explained that schools close in July and August so there was little time to get reports and it relies on schools completing the reports in time.
25. The Council told us it was not usual practice to provide school reports to the SCD, but it would get these if requested. However, the Trust advised us that it would expect the EMP to include school reports in the information provided to the SCD panel. There is no specific policy about the information the SCD need, but NICE guidance is that a school report should be sought. This difference of opinion between the services highlights a lack of clarity with its policy/process and the information needed for an SCD panel. I consider this is fault.
26. The SCD however agreed to put Y on the waiting list for an MDA even though it had not received the school report. It also backdated the decision to May 2023 so the delay did not to disadvantage Y’s progress on the MDA waiting list.
27. Had the fault not happened and all the relevant information been available at the June 2023 panel meeting, it may have resulted in an earlier decision by the SCD. The Trust backdated Y’s place on the waiting list so this did not cause an injustice in relation to Y’s waiting time for assessment. However, an earlier decision and/or information in the school report may have affected the considerations to fast‑track an MDA.

Fast-track

28. Ms X contacted the Council by email in November 2023. She expressed her view that Y’s needs were not being met and asked if Y’s MDA could be fast-tracked. Her email also noted Y’s school wanted to complete 1-2 cycles of support, before completing an Education, Health and Care Needs Assessment (EHCNA).
29. The Council and the Trust considered Ms X’s request at a multi-professional panel meeting. The panel considered Ms X’s request, but noted Y’s new school was working to provide support and Y was not at risk of exclusion. The panel did not consider Y’s needs indicated the MDA should be fast-tracked and Y have an assessment ahead of other children already on the waiting list.
30. Although there is no set guidance for meeting the fast-track criteria, this is set relatively high and is for children with complex needs who are not receiving support. The records show the Trust and the Council considered Ms X’s request. Although Y’s case was complex, the panel saw evidence Y was receiving support and was attending school. The panel used professional judgement based on the relevant information to reach its decision. The Council also explained this decision to Ms X in writing and provided advice to seek support from the Autism Advisory Service should she wish to access extra help. This was not fault.
31. However, as noted in the previous issues, there were delays with referral to the ENP and with the SCD panel accepting Y onto the waiting list for MDA. Although Y’s place on the MDA waiting list was backdated, it is possible the SCD panel could have made a decision sooner had it not been for the fault.
32. Y was excluded from school in May 2023, shortly before the SCD panel first considered the referral. Had the SCD panel been able to make a decision at this point, or sooner, the information available would have been different. Y was not in education from May 2023 and was not receiving support. This different picture may have led the panel to consider Y met the criteria to be fast-tracked.
33. Ms X may have also requested a fast-track sooner if Y was on a waiting list at the point exclusion from school happened and support was not in place. I acknowledge however this is speculative. The different circumstances may not ultimately have changed the outcome. The Trust and the Council may have decided it needed to review Y’s progress following his placement at the new school in September, before they considered a fast‑track decision. There is uncertainty about whether earlier intervention could have led to an earlier assessment and this has caused an injustice to Y and Ms X. This is likely to have contributed to inconvenience and distress.

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Agreed actions

34. We would usually recommend service improvements and/or review of local procedures to address the fault identified. However, the Council and the Trust have confirmed that along with the local Integrated Care Board, they are already reviewing the local autism diagnostic pathway. This should lead to the introduction of a new pathway later this year. The aim of this is new pathway is to simplify the process and reduce waiting times. Our recommendations have taken this ongoing work into consideration.
35. The Trust and the Council have agreed the following actions within one month of the date of our final decision statement:
• Apologise to Ms X for the confusion about what information the ENP should provide for the SCD panel and for the distress caused by the delayed decision and uncertainty.
36. The Trust and the Council have agreed the following actions within three months of the date of our final decision statement:
• Ensure any new policy/procedures for the autism diagnostic pathway that is implemented provides clarity about what information should be included for multi-professional panel meetings and who is responsible for this.
• Share details of the new pathway with Ms X (if she would like this information) once it is agreed.
37. The Council and the Trust will provide us with evidence they have complied with the above actions.

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Final decision

38. There was fault with the Trust’s initial referral to the ENP. The Trust has already accepted this, apologised to Ms X and made service improvements.
39. There was fault by the Council and the Trust with the SCD panel not having the necessary information to reach a decision. This delayed a decision by up to two months. However, the injustice was remedied by backdating the decision date. There is an area-wide review of the autism diagnostic pathway, but we recommended actions to ensure these issues are avoided in future. The fault has also led to some uncertainty about whether a fast-track referral could have been considered earlier and whether the outcome could have been different. We recommended the organisations acknowledge this and apologise for the distress caused by the uncertainty.
40. The Council and the Trust have agreed to the actions above. I have therefore completed my investigation.

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Investigator's decision on behalf of the Ombudsman