Summary: We find no fault with the care provided to a young woman with complex care needs by the Council and Trust.

The complaint

1. The complainant, who I will call Mrs F, is complaining about the care provided to her daughter, Miss G, by Leicester City Council (the Council) and Leicestershire Partnership NHS Trust (the Trust). She says these organisations have not worked together to meet her daughter’s needs.
2. Mrs F says the Council failed to provide her daughter with appropriate care and support and was unresponsive to her requests for help. Mrs F complains the Council also failed to adequately safeguard her daughter as a vulnerable adult.
3. In addition, Mrs F says there has been inadequate input from the Trust’s mental health and autism teams. Furthermore, she says the Trust discharged her daughter from its services despite an agreement made at a meeting in September 2022 that she would receive extra support.
4. Mrs F says these failings have led to Miss G becoming increasingly isolated and withdrawn and that this has caused her mental health and general wellbeing to deteriorate significantly. She says this has affected Miss G’s relationship with her family.

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The Ombudsmen’s role and powers

5. 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). The Local Government and Social Care Ombudsman investigates complaints about adult social care providers (Local Government Act 1974, sections 34B, and 34C, as amended). The Health Service Ombudsman investigates complaints about ‘maladministration’ and ‘service failure’ in the delivery of health services (Health Service Commissioners Act 1993, section 3(1)).
6. 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).
7. 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 acts to stop the same mistakes happening again.
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))

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How I considered this complaint

9. In making my final decision, I considered information provided by Mrs F and discussed the complaint with her. I also considered relevant documentation from the Trust and Council, including the care and safeguarding records. I took account of relevant legislation and guidance. In addition, invited comments from all parties on my draft decision statement and considered the responses I received.

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What I found

Relevant legislation and guidance

Care Act 2014

10. Sections 9 and 10 of the Care Act 2014 require councils to conduct an assessment of any adult who appears to need care and support. The assessment must be of the adult’s needs and how they impact on their wellbeing and the outcomes they want to achieve. It must involve the individual and where appropriate their carer or any other person they might want to be involved.
11. An assessment should be conducted over an appropriate and reasonable timescale taking into account the urgency of needs and a consideration of any fluctuation in those needs. Councils should let the individual know of the proposed timescale for when their assessment will be conducted and keep the person informed throughout the assessment process.

Mental Capacity Act 2005

12. The Mental Capacity Act 2005 (the MCA) applies to people who may lack mental capacity to make certain decisions. It is accompanied by a Code of Practice (the MCA Code) which sets out steps organisations should take when considering whether someone lacks mental capacity.
13. Both the MCA and the Code start by presuming individuals have capacity unless there is proof to the contrary. The Code says all practicable steps should be taken to support individuals to make their own decisions before deciding someone lacks capacity. The Code says people who make unwise decisions should not automatically be treated as not being able to make decisions. Someone can have capacity and still make unwise decisions.
14. The Code says, at paragraph 2.11, there may be cause for concern if somebody repeatedly makes unwise decisions exposing them to significant risk of harm or exploitation. The Code says this may not necessarily mean the person lacks capacity, but further investigation may be required.

Mental Health Act 1983

15. Under the Mental Health Act 1983, 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’.
16. Before a person can be sectioned, a Mental Health Act Assessment (MHAA) must first be completed. The MHAA is arranged by an Approved Mental Health Professional (AMHP). The AMHP is accompanied by two doctors, one of whom must have special experience in the diagnosis or treatment of mental disorders. These doctors will assess the person’s mental state and make recommendations as to whether that person should be detained.
17. The AMHP is responsible for deciding whether to go ahead with the application to detain the person and for telling the person and their nearest relative about this. Admission should be in the best interests of the person, and they should not be detained if there is a less restrictive alternative.

Background

18. Miss G has complex needs, including a diagnosis of autism spectrum disorder. Miss G had an allocated social worker and Community Psychiatric Nurse (CPN) from the local Community Mental Health Team (CMHT).
19. In January 2022, Miss G was living in supported housing with a package of support. However, Mrs F and Miss G were unhappy with the support as they said this was not meeting Miss G’s needs. They asked the Council to source an alternative provider.
20. Throughout that month, Mrs F continued to contact the Council and Trust to report her concerns about Miss G’s mental health.
21. On 30 January, professionals completed an MHAA. This found Miss G did not need to be detained under section. However, the professionals recommended an urgent review of Miss G’s care package.
22. On 4 February, Miss G’s social worker visited her to discuss her support. Miss G explained the level of support she hoped to receive. Miss G agreed the current support would remain in place until a new provider could be found.
23. Miss G was initially receiving support from the Trust’s Specialist Autism Team (SAT). However, in February, the SAT wrote to Mrs F to explain that Miss G was not engaging with their service and that they would no longer see her directly.
24. The Council secured an alternative support provider in May. However, by July, Miss G’s relationship with her allocated support worker had broken down and a new one had to be allocated.
25. During this period, Mrs F continued to report concerns about Miss G’s mental health. She said Miss G was withdrawing from support and her family and was becoming increasingly destructive in her behaviours.
26. In August, the support package provider served notice. This left her without support. Miss G’s social worker began searching for a new provider.
27. Mrs F contacted the social worker again soon after the meeting to report her concerns. She said Miss G needed consistent support to maintain her mental health and access activities in the community. In addition, Mrs F said the Council was not properly supporting Miss G with budgeting and that this left her vulnerable to exploitation.
28. Mrs F raised further concerns about Miss G’s mental health. By this point, Miss G was not engaging with any support or with her family.
29. In December, a multidisciplinary team meeting agreed the SAT would lead on Miss G’s care to support her to engage with professionals. Miss G declined any input from that service. The situation was further complicated as Miss G would not speak to any professionals.
30. A further multidisciplinary team meeting in January 2023 heard that the SAT and CMHT would be discharging Miss G as she had declined to engage with them.
31. In April, a personal assistant began to support Miss G. However, this relationship quickly deteriorated, and Miss G refused to work with the personal assistant.
32. A social worker spoke to Mrs F the following month. Mrs F reported that Miss G’s behaviour had changed completely and that she may be experiencing psychosis. The social worker recorded that Mrs F wanted Miss G to be treated with medication for her mental health problems. The social worker advised Mrs F that Miss G would need to see her GP. However, Mrs F reported that Miss G refused to do so.
33. The new social worker visited Miss G at her home later that month. Miss G said she did not want any care agencies involved in her care and wanted to be left alone. Miss G asked the social worker to leave. The social worker advised that the adult social care team would close the case, but that Miss G could return to the service in future if she wished.
34. Mrs F continued to raise concerns about Miss G’s behaviour. This led the Council to rase a safeguarding alert in July. The safeguarding enquiries noted that Miss G’s decision to disengage from her support would likely increase her isolation and potentially make her more vulnerable. However, the enquiries found Miss G had capacity to make decisions about her care, even if these were sometimes unwise. The investigation did not identify any mental health concerns.
35. Later that month, the Council discharged Miss G from its adult social care service.

My analysis and findings

Care between January and February 2022

36. The case records show that Miss G has complex needs that make managing her care challenging for the professionals supporting her. Specifically, Miss G often chooses not to engage with her care and support.
37. In January 2022, Miss G was receiving a package of care linked to her supported living placement. Miss G was reluctant to work with female support workers and insisted on male workers. Furthermore, she had developed a good working relationship with one specific support worker. The care provider was unable to guarantee that Miss G would always be supported by the same worker. This led Miss G’s relationship with the care provider to deteriorate.
38. The case records show Mrs F had also begun to raise concerns about Miss G’s mental health. Mrs F described Miss G apparently responding to voices and visual hallucinations and said her mood was unstable. This led Mrs F to contact the crisis team for help.
39. Miss G’s CPN visited her on 19 January, but Miss G would not admit her or speak to her. The CPN visited again the following day. The CPN recorded that Miss G reported hearing the voices of family members even though they were not there. The CPN also noted that Miss G was “tearful, distressed and at times overwhelmed”. Miss G declined medication.
40. A multidisciplinary team meeting discussed Miss G’s care on 25 January. The meeting agreed the CPN would continue trying to assess Miss G’s mental health and offer support.
41. Miss G’s engagement with mental health professionals remained limited and the professionals agreed an MHAA would be the best way to proceed. They noted Mrs F’s view that Miss G may find this process upsetting and would not react well to an inpatient environment.
42. The MHAA took place on 30 January. Mr and Mrs F were also present. The AMHP noted that Miss G was “noticeably anxious and stressed” and seemed confused about her diagnosis. The AMHP concluded that Miss G’s distress appeared to be related mainly to the ongoing problems with her care package. The MHAA concluded that Miss G did not need to be detained.
43. The following day, a multidisciplinary team meeting discussed Miss G’s care again. The meeting agreed the social worker would review Miss G’s care provision urgently as her mental health was at risk of further deterioration if her care situation did not improve. In the meantime, it was agreed the SAT would try to support her with her autism care needs.
44. The social worker visited Miss G on 4 February to discuss her care needs. Miss G told the social worker she felt too many people were involved in her care and that she felt “pulled in different directions”. Miss G said she would like visits from two male support workers three to four times a week to help her access the community. Miss G agreed to receive support from the current care provider until an alternative had been identified.
45. The SAT made several attempts to visit Miss G and to engage her in support for her autism needs. However, Miss G did not respond well to these interventions. The SAT concluded Miss G was not presently able to engage with its service. However, the SAT offered to support Mr and Mrs F to help them gain a better understanding of Miss G’s diagnosis.
46. This was an understandably upsetting period for Miss G and Mrs F. Nevertheless, the care records show that the professionals supporting Miss G during this period were responsive to her needs and those of her family. Miss G received regular contact from both social care and health services. However, Miss G’s engagement with these services was limited and she refused various means of support (such as medication).
47. It is clear from the records that Mrs F was concerned about Miss G’s mental health. When Miss G’s limited engagement made it difficult for the CPN to properly assess her mental health, the professionals involved arranged an MHAA. The evidence I have seen suggests the professionals appropriately explored less restrictive alternatives before taking this course of action. This was in keeping with the requirements of the Mental Health Act 1983.
48. The MHAA process identified that Miss G’s mental health symptoms were related to her concerns about her care package. The records show the Council was already taking action to find an alternative provider, albeit this was not a simple process due to Miss G’s complex needs.
49. In summary, I am satisfied the Council and Trust were taking appropriate action to support Miss G during this period and I found no fault in this regard.

Care between March and September 2022

50. In March, a further multidisciplinary meeting heard that Miss G’s needs appeared to be related mainly to her autism and social circumstances. The meeting agreed the CPN’s role in Miss G’s care appeared limited as she did not have a primary mental health need.
51. In the meantime, the social worker identified two potential care providers (Care Provider 1 and Care Provider 2). Staff from Care Provider 1 visited Mrs F and Miss G at home. Mrs F felt the care workers did not understand autism and would not be suitable to support Miss G.
52. Later that month, staff from Care Provider 2 visited Mrs F and Miss G. Mrs F said Miss G struggled to communicate with the visiting care workers and that this provider would also be unsuitable.
53. The social worker identified two other potential providers. However, one did not respond to her enquiries and the other had no capacity to provide care in Miss G’s area.
54. In early April, the social worker identified another possible care provider (Care Provider 3). A manager from this provider visited Mrs F and Miss G. He said the company may be able to support Miss G, but this would likely be from female support workers. Miss G agreed to this. However, Care Provider 3 was ultimately unable to accommodate the care hours Miss G required.
55. Mrs F continued to raise concerns about Miss G’s mental health. The CPN continued to visit Miss G at home. She noted her condition appeared stable, although Miss G could sometimes become “tearful and frustrated”.
56. In May, the social worker identified a further care provider (Care Provider 4). Miss G was unwilling to engage with a visit from this care provider. However, Mrs F felt the care provider may be suitable. As Care Provider 4 would only be able to provide limited support hours, Mrs F arranged for a family friend to provide some additional support hours as a personal assistant. Care Provider 4 started supporting Miss G that month.
57. Also in May, Miss G’s CPN visited her at home. However, Miss G would not engage and asked the CPN to leave. Mrs F raised further concerns about Miss G’s mental health, which she said had deteriorated significantly.
58. The social worker and supported living worker visited Miss G on 15 June. However, she was not willing to engage with the visiting workers and told them she no longer wanted input from adult social care or support workers.
59. Miss G did not attend a review meeting with a consultant psychiatrist on 16 June. This was rearranged for 30 August.
60. Mrs F contacted the CPN on 12 July to say that she felt Miss G was showing psychotic symptoms. She said Miss G was shouting and swearing at family members and accusing them of following her. Mrs F also reported that Miss G was unwilling to see a doctor.
61. That day, Care Provider 4 contacted the social worker to explain that Miss G’s behaviour was becoming more difficult to manage and that had been rude about her support worker in front of him.
62. The CPN attempted to visit Miss G on 13 July, but she would not admit her or speak to her.
63. Miss G became increasingly aggressive to her support workers and eventually stopped engaging with them. On 18 July, Care Provider 4 advised the social worker that there had been a “significant change” in Miss G’s presentation.
64. Mrs F spoke to the social worker again on 21 July. She reiterated her belief that Miss G was experiencing psychotic episodes and said Miss G’s personal assistant was no longer prepared to work with her.
65. On 2 August, Care Provider 4 served notice due to Miss G’s deteriorating relationship with her support workers. This left Miss G without any support. The social worker began searching for a new care provider immediately.
66. On 12 August, Mrs F contacted the SAT. She said Miss G was “in a really bad way – withdrawing, swearing, property destruction and feels needs reviewing by adult mental health”.
67. Miss G again failed to attend a review meeting with a consultant psychiatrist on 30 August.
68. The care records suggest Miss G initially responded well to the support provided by Care Provider 4 and her condition appeared relatively stable. However, as Miss G’s engagement reduced, it became increasingly difficult for the professionals supporting her to thoroughly assess her care needs. This was particularly true with regards to Miss G’s mental health as she had stopped engaging with the CPN and failed to attend two psychiatric reviews. Nevertheless, the professionals working with Miss G at that time concluded there was no evidence of acute mental illness.
69. This was evidently a very difficult period for Miss G and her family. However, I am satisfied the Council and Trust were working together to provide care to meet Miss G’s needs and to support her to engage with this care. They achieved only limited success due to Miss G’s decision not to engage with professionals. Miss G was considered to have capacity to make decisions about her care and so was entitled to refuse support. I found no fault by the Council and Trust here.

Care between September 2022 and July 2023

70. A multidisciplinary team meeting discussed Miss G’s care again on 1 September. The meeting heard the Trust would allocate a new CPN to Miss G’s case as her relationship with the current CPN had broken down. The professionals present agreed Miss G’s presentation was linked to her autism and that there had not been a deterioration in her mental health. However, they acknowledged this had been difficult to assess thoroughly as Miss G had stopped engaging with professionals. The team agreed Miss G had capacity to make decisions about her care but that this should be kept under review.
71. On 9 September, the Trust held a meeting to discuss Mrs F’s concerns. Mr and Mrs F were present. The meeting agreed the SAT would work with Miss G to support her to engage with her care.
72. By mid-September, Miss G was also refusing to engage with her social worker. This led the social worker to request that the case be reallocated. Mrs F raised concerns that Miss G would be unlikely to work with anyone at that time. The social worker said the Council could not force Miss G to accept support and could only encourage her to do so.
73. In early November, the newly allocated CPN attempted to visit Miss G at home, but she would not admit her. A similar visit from the new social worker was also unsuccessful. By this point, Miss G was not engaging with any professionals and had also largely stopped engaging with Mr and Mrs F. The social worker and CPN discussed the possibility of a further MHAA. They concluded this would not be in Miss G’s best interests and would likely be upsetting for her.
74. On 15 November, a multidisciplinary team meeting discussed Mrs F’s concerns that Miss G was becoming increasingly isolated and vulnerable. The meeting agreed the SAT would continue to work with Miss G. However, the SAT attended Miss G’s property twice and she did not answer the door. They also arranged a meeting at a local café, but Miss G did not attend.
75. There was a further multidisciplinary team meeting on 13 December. The SAT explained it would discharge Miss G as she had declined any input from the service.
76. In the meantime, the new social worker was attempting to secure a personal assistant to support her. However, Mrs F was concerned the standard hourly Council rate would not be enough to secure somebody with sufficient skills and experience. Mrs F was also worried that she would not be able to manage the role of employer to the personal assistant.
77. On 17 January 2023, the Trust discharged Miss G from its services as she was not engaging with the offered support.
78. In February, Miss G resumed limited engagement with the adult social care team. She said she wanted to move to a house with a private garden as she was uncomfortable using the shared garden at her current accommodation. Miss G was reluctant to discuss any other aspects of her care.
79. Miss G began to employ a personal assistant in April using her direct payments. However, the relationship quickly deteriorated, and Miss G refused to accept support from the personal assistant. Mrs F told the social worker that she remained concerned about Miss G’s mental health.
80. Shortly after this, Miss G’s social worker went on secondment and the Council reallocated the case. The social worker spoke to Mrs F on 9 June. Mrs F reported that Miss G’s behaviour was deteriorating and that she was becoming increasingly aggressive and abusive. In addition, Mrs F said Miss G was unable to manage her money and was continually overspending.
81. The social worker visited Miss G on 15 June with the supported living worker. The social worker noted that Miss G appeared “tearful and upset”. She was reluctant to engage with the social worker, repeatedly asking her to leave. Miss G said she did not want any support and would not consider medication. Miss G again said she wanted to move into a house with a private garden. The supported living worker advised that Miss G would need to look at the private rental market.
82. The social worker subsequently explained to Mrs F that there was not much more the adult social care team could do if Miss G was refusing support.
83. Due to Mrs F’s continued concerns, the Council raised a safeguarding alert. The safeguarding enquiries found there had been no evidence of acute mental illness when the social worker visited Miss G on 15 June. As a result, the enquiry concluded that an MHAA was not indicated. The enquiry noted that Miss G’s decision to withdraw from her care left her at risk of isolation and was unwise. However, the enquiry found Miss G “demonstrated capacity to make her own choices”.
84. Later that month, the Council discharged Miss G from its adult social care service. The Council advised her she could contact the service again if she decided to engage.
85. The care records show it was becoming increasingly challenging for the professionals to support Miss G due to her refusal to engage with her care. Indeed, Miss G was clear that she did not want support from any of the agencies involved in her care, other than in helping her to identify alternative accommodation.
86. The professionals working with Miss G had to have regard to the MCA Code when considering whether Miss G had capacity to make decisions about her care and treatment. The MCA Code sets out that a person should be presumed to have capacity to make decisions unless an assessment has found otherwise. The MCA Code is clear that a person should not be treated as lacking capacity simply because they make an unwise decision, or one that a carer or professional disagrees with.
87. The evidence I have seen suggests the professionals working with Miss G did not have any concerns about her ability to make decisions during this period, albeit they thought her decision to refuse care was unwise. The case records show health and social care professionals made numerous attempts to engage with Miss G without success.
88. As I have explained above, it was difficult for clinical professionals to thoroughly assess Miss G’s mental health. However, the social worker who visited her on 15 June found no evidence of psychosis. As a result, she concluded an MHAA was not indicated and would likely be very upsetting for Miss G. Furthermore, the social worker was satisfied Miss G was eating and drinking appropriately, looking after her appearance, and keeping her home clean and tidy.
89. I recognise how distressing Mrs F found these events. However, taking everything into account, I am satisfied the Council and Trust took appropriate action to support Miss G. It was ultimately her decision to refuse this support. I found no fault with the care provided during this period.

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Final decision

90. I found no fault by the Council or Trust with regards to the care and support they provided to Miss G. I have now completed my investigation on this basis.

Investigator’s decision on behalf of the Ombudsmen

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Investigator's decision on behalf of the Ombudsman