Summary: Ms M complains about the way her son’s care was managed by the Trust after he left hospital in June 2021. We will not investigate this complaint because the organisation has already admitted fault in several areas of Mr N’s care. It has investigated several times, provided five written responses, improved its service and trained its staff to ensure the faults do not happen again. Further investigation by the Ombudsmen would not achieve anything more.

The complaint

1. Ms M complains about the care and treatment provided to her son, Mr N, by South London and Maudsley NHS Foundation Trust (the Trust), Croydon Council (the Council) and NHS South West London Integrated Care Board (the ICB). Mr N was detained under the Mental Health Act 1983 at Bethlem Hospital in April 2021. Ms M complains he was not given enough support which he should have had as part of S117 aftercare.
2. Specifically, Ms M complains;
• Mr N left hospital with oral medication. Ms M told the hospital Mr N had a history of not taking his medication so should have a depot prescription, this was ignored.
• The discharge planning was poor; they did not meet the care coordinator before discharge and Mr N did not have a care or crisis plan. Ms M was not involved in the planning even though her son went to her address from hospital.
• The Hospital did not tell the local authority of discharge. Ms M did not live in the Trust’s area, so he was discharged knowing his care coordinator would not visit him.
• When challenged during the local resolution of her complaint, Ms M feels the Trust have been dishonest. They have placed too much emphasis on the support her son has received after his second hospital discharge when she believes he would not have relapsed had he received the care he needed after the first discharge.
3. When her son’s mental health started to decline, Ms M had no one to turn to for help. She called 111 and 999, but no one came to help them. She and her partner became ill with the strain. Mr N was arrested and imprisoned and she believes this would not have happened had he been taking his medication and receiving the support he should have from the Trust.
4. Ms M feels the Trust should make a financial payment to recognise the damage done to her and her son.

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The Ombudsmen’s role and powers

5. We have the power to jointly consider complaints about health and social care. Since April 2015 a single team has considered these complaints acting for both Ombudsmen. (Local Government Act 1974, section 33ZA, as amended, and Health Service Commissioners Act 1993, section 18ZA)
6. The Ombudsmen provide a free service but must use public money carefully. They may decide not to start or continue with an investigation if they believe:
• it is unlikely they could add to any previous investigation by the bodies.

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How I considered this complaint

7. I considered all the information provided to us by Ms M and the complaint responses from the Trust.
8. I considered the Ombudsman’s Assessment Code.

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What I found

Background

9. Mr N was detained at first under section 2 and then section 3 the Mental Health Act 1983 at Bethlem Hospital in April 2021.
10. Section 117 of the MHA states a person may be eligible for aftercare services, if they are intended to meet a need that arises from or relates to a mental health problem and reduces the risk of the person’s mental health condition getting worse.
11. Anyone who may have a need for community care services is entitled to a social care assessment when they are discharged from hospital to establish what services they might need. Section 117 of the Mental Health Act imposes a duty on health and social services to meet the health/social care needs arising from or related to the person’s mental disorder for patients who have been detained under specific sections of the Mental Health Act (e.g. Section 3). Aftercare services provided in relation to the person’s mental disorder under S117 cannot be charged for. This is known as section 117 aftercare.
12. The ICB shares a statutory duty with the Council to provide, or arrange, s117 aftercare services for eligible service users in the area. In Mr N’s case, the Trust had authority to manage his aftercare on behalf of the Council and the ICB.

The complaint

13. Mr N left hospital in June 2021 and went to his mother’s address, problems with his mental health started shortly after.
14. Ms M made her first complaint to the Trust in early August 2021. The complaint contained the first three points listed at paragraph 2. The Trust responded to the complaint on 7 April 2022. It apologised for the delay in responding.
15. It explained as this was its first-time treating Mr N it was reasonable to start on an oral medication, as under the Mental Health Act 1983 Code of Practice, this was the least restrictive choice. It said it had considered the information from Ms M, but Mr N had capacity to decide on his own care. He told staff he would take his medication and was doing so willingly when in hospital.
16. It also explained Mr N had withdrawn his consent for the hospital to share information with Ms M, this meant she did not get updates about how his treatment was going. Ms M was also not as involved as she wanted to be in the discharge planning for Mr N. The Trust explained the clinical decisions taken were in Mr N’s best interest and with his input. It considered what she told them, but it did not have reason to put this above its own assessment of Mr N. Mr N was left hospital with a 48-hour follow-up call which is advised in guidance.
17. The Trust accepted the discharge could have been better. It also recognised how distressing what happened next was for Ms M. It said it would work with the charity MIND “to recruit personal independent coordinator support to improve patient and family experience.” The letter ends with an apology for Ms M’s experience and adds the Trust has taken learning from the investigation and will use it to support clinical staff and improve patient care.
18. Ms M was not happy with this response and replied with further concerns in early August 2022. The Trust provided another response in 30 November 2022.
19. The Trust again apologised for the time taken to respond and thanked Ms M for meeting with them to discuss her concerns. It advised Ms M to appeal Mr N’s conviction. It repeated what was in the letter of 7 April 2022 about giving Mr N oral medication and about Mr N withdrawing his consent to share information with her.
20. It explained that while it would have been good practice for Ms M to speak to the treating consultant, this is not always possible. It has taken learning from her complaint; the ward Mr N was on now has a support group for families and carers to improve engagement, with three staff acting as leads.
21. Ms M was still unhappy with the response and sent a further email of complaint in early December 2022. The Trust responded on 15 August 2023, it explained to reply due to the length of time passed it had reviewed Mr N’s clinical records and the previous complaint correspondence.
22. In this letter, the Trust identified several more areas of fault. It found;
• There was no formal capacity assessment recorded for Mr N when medication was discussed with him. The notes suggest he did have capacity, but it should have been recorded formally.
• Ms M’s concerns about Mr N not taking medication were not recorded in his notes, despite these issues being discussed with the clinical staff during the discharge process.
• The decision to issue oral antipsychotics was correct in line with the Mental Health Act 1983 Code of Practice, but depot medication should have been discussed with Ms M and Mr N when she raised concerns.
• Ms M was not told how Mr N would get more medication when he ran out. The Trust were managing this and his GP was told not to prescribe. Mr N was told he needed to speak to the Trust to get more medication, but Ms was not.
• Staff placed too much reliance on Mr N being open and honest with Ms M about his care. When this did not happen Ms M did not know what to do or who to get help from.
• Mr N had substance abuse issues. He spoke to a dual diagnosis nurse once, but he was not well enough to engage. He should have been able to speak to the nurse again when he was well enough, but this did not happen.
23. The Trust ended by saying “our investigations also show that Mr [N’s] discharge fell below the standard I would expect and that this caused significant difficulties when you tried to access support. As a Trust we did not provide Mr [N] or you with adequate information about his care plan on discharge or on a crisis plan for you which should have linked you to a support service.” It further added “I acknowledge that the lack of planning around Mr [N’s] discharge had a detrimental impact on both you and your partner’s mental health and wellbeing and I am so sorry for this.”
24. The author of the letter offered to meet with Ms M to personally apologise her experience. They offered a further written apology and said the ward is “working to develop a discharge pack which will contain details of the Community Team and a care plan which will also include details of appropriate local crisis support.”
25. Ms M did not accept the explanations the Trust had given. She felt the Trust were being misleading by changing their answers from one letter to the next. She wrote to the Trust again in early September 2023.
26. The Trust responded to this letter on 30 October 2023. It repeated its previous responses about Mr N’s medication. It explained Mr N had also been referred to the home treatment team, this was refused because there was nothing to suggest Mr N would not take it. It added that after his second hospital stay, he was discharged on depot medication because there was previous history to support that he may not take oral medication. The Trust also added further information about the support from the care coordinator. It said they had kept regular contact with Mr N via telephone as they could not visit in person due to being out of area. However, Mr N stopped answering and then blocked the care coordinator’s calls.
27. The Trust apologised for the confusion about Ms M’s address being outside the Trust’s area, and then further confusion as Mr N’s GP was in Croydon. It again accepted she should have been given information of support services local to her address, rather than this just being given to Mr N.
28. Ms M again raised the same concerns with the Trust. She said the Trust were being unclear and placing too much on what it did later in Mr N’s care. She added this did excuse the damage done by the first hospital discharge.
29. The Trust provided a fifth and final response letter on 9 January 2024. It did not add anything new to the information in its previous letters. It again apologised for how distressing the experience had been for her.

Summary

30. I have considered what action the Trust has taken. The Trust has investigated Ms M’s complaint several times over a number of years. It accepted it got things wrong, apologised, improved its service, taken lessons to improve its service and acknowledged it cannot remedy the distress the experience caused Ms M.
31. In investigating the complaint multiple times, the Trust has admitted it got things wrong in the first complaint investigation and sought to remedy this by being open and honest with Ms M about its mistakes.
32. Ms M has explained she wants the Trust to accept had it acted differently, Mr N would not have been arrested, convicted and imprisoned. This injustice is not something we could ever link to action or inaction by the Trust as we could never know what other factors influenced Mr N’s actions which led to his arrest. An Ombudsmen investigation of the same issues is unlikely to achieve any more.

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Final decision

33. We will not investigate this complaint as an Ombudsmen investigation is unlikely to achieve more.

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Investigator's decision on behalf of the Ombudsman