Summary: We have found fault by an NHS Trust, a Council and an NHS ICB for not allocating a care coordinator to someone who is entitled to one. The situation has caused avoidable uncertainty and distress. The organisations have agreed to provide an apology and small financial payments and to take steps to find a bespoke solution and work to resolve the wider issues.

The complaint

1. In May 2022 the Ombudsmen completed an investigation of:

• Cambridgeshire and Peterborough NHS Foundation Trust (the Trust),
• Peterborough City Council (the Council), and
• NHS Cambridgeshire and Peterborough Integrated Care Board (the ICB).

2. The Ombudsmen investigated a complaint from Mr X about a failure by the three organisations to provide his son, Mr Y, with the aftercare services he was entitled to under section 117 (s117) of the Mental Health Act 1983 (the MHA).
3. The Ombudsmen found fault and recommended the organisations should arrange a s117 review for Mr Y.
4. In November 2023 the Ombudsmen completed another investigation of the Trust, the Council and the ICB. It investigated Mr X’s complaint that the organisations had failed to complete the recommended s117 review of Mr Y.
5. The investigation noted that a mental health assessment completed since the Ombudsman’s last involvement found Mr Y needed a care coordinator. The Ombudsmen found fault that the organisations still had not completed a s117 review meeting. It also found fault that they had not allocated a care coordinator to Mr Y.
6. The Ombudsmen recommended that, by the end of January 2023, the organisations should appoint a care coordinator for Mr Y and arrange a s117 review meeting.
7. Mr X complains that, as of the end of August 2024, the organisations had failed to allocate a care coordinator to Mr Y.

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The Ombudsmen’s role and powers

8. 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).
9. 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).
10. 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.
11. 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)
12. 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.

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How I considered this complaint

13. I have considered Mr X’s written complaint along with information from the Trust, the Council and the ICB. I have considered relevant legislation and guidance.
14. I shared an initial confidential version of this draft with Mr X, the Trust, the Council and the ICB and considered the comments they made on it. This led to changes and a revised draft, which I also shared for comments. I considered all the comments I received in response.

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What I found

National legislation and guidance

The Mental Health Act 1983

15. Under the MHA, 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. Section 3 of the MHA empowers doctors to detain a patient for a maximum of six months at a time.
16. The Department of Health produces the Mental Health Act 1983: Code of Practice (the Code) to accompany the MHA. This provides guidance for professionals on how to implement the MHA in practice.
17. Under s117 of the MHA local authorities and integrated care boards (ICBs) have a duty to provide or arrange free aftercare services for people who have been detained under s3 of the MHA.
18. S117 aftercare services must meet a need arising from, or related to, that person’s mental condition. The aim of aftercare services is reduce the risk of the person’s mental condition worsening and thereby reduce the risk of further hospital admissions.
19. The Code encourages local authorities and ICBs to “interpret the definition of after-care services broadly” (section 33.4).
20. The Code also says that:

• “After-care for all patients admitted to hospital for treatment for mental disorder should be planned within the framework of the care programme approach” (section 33.14).
• The Care Programme Approach (CPA) “requires the clear identification of a named individual who has responsibility for co-ordinating the preparation, implementation and evaluation of the CPA care plan” (section 34.5).
• “…It is…essential that a suitable care co-ordinator is identified. For patients who have been or continue to be subject to provisions in the Act, this is likely to be a different person from the responsible clinician, but need not be” (section 34.10).
• “Professionals with specialist expertise should…be involved in care planning for people with autistic spectrum disorders or learning disabilities” (section 34.21).

The Care Programme Approach (CPA)

21. The CPA is an overarching system for coordinating the care of people with mental disorders. It requires close engagement between professionals, service users and their carers. It has four main elements:

• Systematic arrangements for assessing the health and social needs of people accepted into specialist mental health services.
• The formation of a care plan which identifies the health and social care required from a variety of providers.
• The appointment of a key worker to keep in close touch with the service user and to monitor and co-ordinate care.
• Regular review and, where necessary, agreed changes to the care plan.

22. The Department of Health issued guidance in March 2008: Refocusing the Care Programme Approach (the CPA guidance). This noted an aim of ensuring “renewed focus on delivering a service with the individual using the services at its heart…where bureaucracy does not get in the way of the relationship between the service user and practitioner.”
23. The CPA guidance said:

• “Services should be organised and delivered in ways that promote and co‑ordinate helpful and purposeful mental health practice on fulfilling therapeutic relationships and partnerships between the people involved…The quality of the relationship between service user and the care co-ordinator is one of the most important determinants of success” (page 7).
• “The care co-ordinator has a pivotal role in helping an individual navigate complicated care systems and provide continuity…” (section 5).
• “The role of the (new) CPA care co-ordinator should usually be taken by the person who is best placed to oversee care management and resource allocation and can be of any discipline depending on capability and capacity. The care co-ordinator should have the authority to co-ordinate the delivery of the care plan and ensure that this is respected by all those involved in delivering it, regardless of the agency of origin…” (section 6).

24. In 1999 a policy booklet was produced: Effective Care Co-ordination in Mental Health Services – Modernising the Care Programme Approach. This summarised that the principle of the CPA approach was “getting people to the right place for the right intervention at the right time.”
25. Information available of the English NHS website for people being treated under CPA notes: “You’ll have a CPA care co-ordinator (usually a nurse, social worker or occupational therapist) to manage your care plan and review it at least once a year.”

The Community Mental Health Framework

26. In September 2019 NHS England, NHS Improvement and the National Collaborating Centre for Mental Health published: The Community Mental Health Framework for Adults and Older Adults (the Framework).
27. The Framework:

• Proposed “replacing the CPA for community mental health services, while retaining its sound theoretical principles based on good care coordination and high-quality care planning” (section 2.2).
• Noted an intent to subsume “the important aspects of the CPA for community mental health services, including care planning and care coordination, and reframes them in a system that will work for everyone…” (section 3.2.2).
• Said “For people with more complex problems, who may require interventions from multiple professionals, one person will have responsibility for coordinating care and treatment. This coordination role can be provided by workers from different professional backgrounds” (section 3.2.2).

28. In March 2022 NHS England issued a position statement on the CPA. This said the CPA had been superseded by the new Framework approach. The position statement noted:

• “Care co-ordination is important work and has often been under-appreciated as a function which should provide high-quality care to service users, often with an outmoded and historically resource-constrained system. While many service users find care co‑ordination valuable – and while care co-ordination may form a significant part of the overall support that someone with a severe and complex mental health problem receives – care co-ordination is not a meaningful intervention in and of itself” (paragraph 10).
• “…Service users and carers should…have clarity as to who they can contact via having a named key worker; in most cases we expect this would be the existing care co-ordinator for people already under their care of services…best practice would be a key worker who can form a therapeutic alliance with the service user…” (paragraph 12).
• “…ensuring that all care and support plans are genuinely co-produced, personalised – and Care Act-compliant and integrated with Mental Health Act section 117 plans where necessary – should be a key aim of all new models…” (paragraph 15).

29. The position statement also noted:

• “There will be people with a learning disability and people who are autistic who access mental health services and would be entitled to the same offer as everyone else accessing those services. Services therefore need to be provided in accessible ways and with the required reasonable adjustments. Services should ensure that the changes set out in this Statement are applied for specialist learning disability and autism pathways where people are receiving assessment, care and treatment for their mental health and behaviours that challenge” (paragraph 24).

Local policy and commissioning arrangements

Local s117 policy

30. The Trust has a s117 policy. It was written in July 2017 and developed in partnership with the Council, Cambridgeshire County Council, Peterborough City Council and Cambridgeshire and Peterborough Clinical Commissioning Group (which the ICB replaced).
31. Appendix 1 provides definitions of the terms used within the policy. For “Care Coordinator” it says: “A health care provider who has been assigned a caseload of clients and has the responsibility of organising the care provided.”

Cambridgeshire and Peterborough Joint Strategic Needs Assessment – Health of Adults with a Learning Disability – 2023

32. In 2023 the Council and Cambridgeshire County Council completed a joint health needs assessment about the health needs of adults with a learning disability living in their areas. This noted that:

• “There is a discrepancy in the…agreement between [the Council] and [the ICB], between the scope of delegation of functions from the ICB and the service specifications for the individual clinical specialties with regards support for patients with mental illness. The scope of the delegated functions includes patients experiencing mental illness as well as challenging behaviour, but the service specifications for health services provided by [the Council] only reference challenging behaviour. This creates a gap in support from LD nursing before service users meet the threshold for the Intensive Support Team” page 174, bullet point 3).
• “There are no dedicated care coordinator roles for specialist LD health services in Peterborough” (paged 174, bullet point 6).
• “Peterborough is missing a number of key roles and services entirely (…care coordinators…)” (page 174, last bullet point).

Local services

33. In email communication the Trust noted that “In Peterborough the only service we have available for patients with [Mr Y’s] level of need is an [outpatient clinic] run by the consultant who also works in [in the inpatient unit where Mr Y was detained under the MHA and which he will no longer engage with]…”

Relevant chronology of events

34. This investigation has looked at events from November 2023 to August 2024.
35. The Ombudsmen completed its previous investigation in November 2023. It noted that the organisations still had not completed a s117 review meeting despite the Ombudsmen’s previous recommendation. The decision recognised that Mr Y’s “case is complicated by his unwillingness to work with certain Trust clinicians. However, this does not adequately explain such a significant delay”. The Ombudsmen recommended several actions, including that, within two months of the decision, the Council, the Trust and the ICB would:

• Appoint a care coordinator for Mr Y, and
• Arrange a s117 review meeting for Mr Y.

36. The organisations arranged a s117 review meeting for a week later. A few days before the scheduled meeting the Trust, the Council and the ICB discussed who might act as a care coordinator for Mr Y at the meeting.

• The Council said it could not do this because it would be outside of the current policy. The Council noted the policy said the care coordinator needed to be a health professional. The Council also said that, from a practical perspective, a social worker would not have access to the necessary information from mental health systems.
• The Trust said it could not allocate anyone to act as Mr Y’s care coordinator as it would be outside of its contracted services. It said this was because Mr Y was not receiving any treatment or being monitored by any of its secondary mental health services.

37. The scheduled s117 review meeting took place. Mr Y’s responsible clinician (who is based outside of Mr Y’s area) agreed to act as the care coordinator during the meeting, as a temporary arrangement. The meeting agreed that Mr Y remained entitled to s117 aftercare. It noted Mr Y could benefit from counselling and talking therapies.
38. Later that day the ICB told the Council it would look into allocating an ICB nurse to act as Mr Y’s care coordinator on a temporary basis. It said this would be until a new policy had been agreed or until further clarity had been provided about the care coordinator role.
39. During December the Council contacted Mr Y’s responsible clinician and noted concerns about a deterioration in Mr Y’s mental health. The Council asked how Mr Y could access the support suggested during the s117 review. The responsible clinician said they were acting as Mr Y’s care coordinator on a temporary basis. They said Mr Y needed access to local services. He said the Trust, the Council and the ICB needed to identify such services.
40. During the second half of December the Council contacted the ICB to ask how the recommendations of the s117 meeting would be taken forward. It also asked for an update on the plans to allocate an ICB nurse to act as Mr Y’s care coordinator.
41. At the end of January 2024 the ICB told the Council that the Trust would offer a care coordination service for people eligible for s117 who also have a learning disability. It said this would include Mr Y.
42. The Trust arranged for a clinical psychologist and an art therapist to see Mr Y in early March.
43. Around the same time, the Trust emailed the Council and the ICB and said:

• There was a service for people with the level of need Mr Y had. However, it said the consultant who led this service worked in the mental health service that Mr Y would not work with.
• It had offered Mr Y care coordination from a specialist doctor. It said Mr Y would not accept this because the doctor had an element of supervision by the same consultant.
• Mr Y’s responsible clinician could not remain as Mr Y care coordinator in the long-term because they were not local to him.

44. In summary, the Trust said it felt it had offered a care coordinator and reasonable alternatives but Mr Y had declined all of its offers.
45. At the end of April 2024 the Council and the ICB met to discuss the ongoing lack of care coordinator for Mr Y. The ICB said it was waiting to hear more from one of its staff about the arrangements for care coordination for people living in Peterborough with a learning disability.
46. In the middle of May 2024 another s117 review meeting took place. Mr Y’s responsible clinician again acted as the care coordinator for the purpose of the meeting. The meeting confirmed that Mr Y was still eligible for s117. One of the actions was for Mr Y’s s117 aftercare to be transferred to the locality.
47. Around the same time the Trust acknowledged to the Ombudsmen that Mr Y remained without a care coordinator. It said:

• The Council had referred Mr Y to a specific service but:
• Mr Y did not meet its criteria; and,
• The team did not offer care coordination.
• Mr Y continued to refuse to work with a particular mental health service.
• Mr Y did not meet the criteria for any of its community mental health teams for care coordination because he would not take medication or be actively treated.

48. The Trust said it could not act outside its standard operating procedures when there is “quite a waiting list” for care coordination for people who met the threshold. As such, the Trust said Mr Y was not on a waiting list as it had not been able to identify a suitable team.
49. In early July 2024 the Council wrote to the Trust and the ICB to ask for a meeting to resolve things. In the middle of the month the Trust replied and said it was the Trust’s view that Mr Y had been assessed and did not have a clinical need for a care coordinator. It said there was no health requirement for Mr Y.
50. The Trust also said that, even if Mr Y’s clinical presentation changed, there was still no commissioned service in Peterborough which would allow the Trust to provide a care coordinator for him.
51. Further, the Trust said it had offered support outside of commissioned services – through a doctor-led review and an outpatients contract. The Trust said Mr Y had declined this because of the association with a particular service.
52. In response to our enquiries the Council said:

• The Trust’s contract with the ICB did not include care coordination services for people living with a learning disability who do not receive a secondary mental health service. The Council said this created a gap in provision. It said it was for the ICB and the Trust to resolve this. The Council said the current local section 117 policy did not differentiate between those open to a secondary mental health service and those who have their needs reviewed within primary care.
• An ASC practitioner could not take on the role as it would be outside of the current policy.
• The ICB’s suggestion of an ICB nurse did not go ahead because of capacity within the service.
• It was involved in a project group, led by the ICB, to review the current s117 policy and procedures. The Council said the aim was to produce a more multi‑agency approach to monitoring, review and discharge. The Council said this would include situations where the person is not receiving any support from one of the Trust’s secondary mental health services but remained eligible for s117. It said it would include a pathway to be referred back to the Trust for support if the person’s needs change. The Council said this review was being “impacted by the clarity needed in respect of the commissioned services between the Trust and the ICB”. It said, as such, it remained ongoing.

53. In its response to our enquiries the ICB said it understood that the Trust “had agreed to take on the care coordination role (through a named clinician) for all adults with learning disabilities who are subject to s117”.
54. The ICB also said that it recognised “that it is not helpful for patients that there is a dispute between [the Trust] and the ICB in relation to the perception of what is commissioned for s117 case management.” The ICB said that, in order to resolve this, senior ICB and Trust officers had been working “to find a way forward”. The ICB said they expected “to take a business case through the ICB internal guidance processes in December which will make it much clearer for patients around offers of case coordination.”

Analysis

55. Two reviews of Mr Y’s needs have taken place since the Ombudsmen’s last involvement. This is positive. There is also evidence in the papers I have seen that the organisations have been mindful of the need to resolve this issue. The evidence also shows the Council was proactive in contacting the ICB on various occasions in an effort to move the situation forward. I have noted that Mr Y’s responsible clinician took on the title of ‘care coordinator’ during those meetings. However, I have not seen evidence to show they undertook any work beyond those meetings which would constitute a meaningful fulfilment of that role. Rather, it seems their practical involvement largely ended when the meetings did. While the meetings recommended some support which could be helpful for Mr Y, the responsible clinician said it would be others to identify and arrange specific services for him.
56. Guidance around mental health care has long recognised that people with mental health needs will often have needs in other areas of their lives as well. The guidance has been clear for many years that the individual needs of each specific service user should be at the front and centre of any care plans intended to improve their quality of life. They have recognised that, as a key part of this, there needs to be someone who will coordinate the person’s care.
57. CPA guidance was not prescriptive about who should take on this role. The key was to ensure that:

• the service user had a clear, personal plan,
• the actions in that plan were followed in a timely manner, and,
• the person was regularly reviewed with a focus on measuring the outcomes of any work being done.

58. Guidance noted that effective co-ordination was key to achieving a helpful, trusting relationship with the service user and promoting their engagement.
59. The introduction of the Framework, to replace the CPA, has not fundamentally changed this position. It is a new approach but it still aims to ensure the person is kept front and centre, and to try to minimise bureaucracy. The aim is to help the person get the right support from the right place at the right time. It also aims to avoid situations where a person cannot get the support they need because of the way services are set up and administered. This seems particularly relevant to Mr Y’s case; there is a stark contrast between the aims and what is happening for him. Importantly, the Framework does not suggest the removal of the care coordinator role. It continues to see this as a crucial part of delivering successful care.
60. In Mr Y’s case, he has been negatively impacted by two issues which are outside of his control. These issues are preventing him from getting a service he is entitled to and which national guidance stresses is a key component of successful care planning.
61. The first is that the local s117 policy is written more restrictively than national guidance. Specifically, that it says a care coordinator needs to be a “health care provider”. National guidance does not limit the role in this way and leaves it open for social workers to take on the role. It is fault that the policy is overly restrictive. All of the parties who took part in its development, including the Trust, the Council and the ICB, hold some responsibility for this.
62. If this were not the case there would have been an option of allocating a social worker to act as Mr Y’s care coordinator. The Council has noted a practical reason why this may not have been realistic: that its practitioners do not have access to the digital records of mental health services.
63. However, guidance highlights that the care coordinator does not need to be someone who is the most involved in the person’s day-to-day care. Rather, they need to have the authority to bring together the people involved in the person’s care and lead the process of hearing the key stakeholders’ views. They do this to lead to the production of an agreed plan and they make clear arrangements to keep its success under review.
64. The second issue is that Mr Y is not receiving any support from any of the Trust’s secondary mental health services and the ICB does not commission the Trust to provide a “standalone” care coordinator service for people in Mr Y’s situation.
65. Within this local commissioning picture, the Trust has offered possible care coordinators to Mr Y. It is, however, understandable that Mr Y chose not to engage with the suggested clinicians. He has said that his experience detained as an inpatient was traumatic and he links this to the personnel involved.
66. The ICB said it understood that, following a meeting between senior staff, the Trust had agreed to provide a care coordinator for Mr Y. The Trust said it does not recognise this position. Further, from the evidence available to me, the Trust has been clear that it has not been able to do this.
67. Mr Y has been left in a position where the wording of inter-agency policies and procedures are preventing him from getting an aspect of support he is entitled to. In other words, the type of bureaucratic barriers the Framework highlighted. It is likely to take a substantial amount of time to update the relevant commissioning arrangements and policies.
68. In this situation the Trust, the ICB and the Council will need to work out an interim solution for Mr Y before local policies and commissioning issues are resolved.
69. The definition of s117 aftercare is very loosely defined. It leaves commissioners with considerable scope to act creatively to fund any particular service, support or activity that may help the person to remain out of a mental health hospital. In this context, it does not seem unrealistic for the organisations to consider the use of a bespoke, individually-funded route to commission a care coordinator outside of usual secondary mental health services. I have not seen any evidence to suggest this has been considered or discussed. This is fault.
70. In the simplest of terms, the organisations have failed to adhere to the Ombudsmen’s last recommendation. Mr Y remains without a care coordinator. He should have one.
71. It is not possible to say what would have happened in Mr Y’s life if a suitable care coordinator had been offered and allocated to him before the end of January 2024. It is possible that, even with a care coordinator, Mr Y would have found it difficult to engage with the services offered to him. It is also possible that care coordination would not have proved to be as successful as hoped.
72. However, equally, I cannot ignore what the guidance (built on considerable research) says about the importance of building an effective and trusting relationship between the service user and a keyworker. Also, about what it says about the importance of effective coordination of services to ensure a person’s care is as suitable as possible. Mr Y may well have been able to build a relationship with a care coordinator which, in turn, could have increased his engagement. I cannot discount this as a possibility.
73. In short, even on balance, I cannot do anything more than speculate on what the impact of the faults in Mr Y’s case might be. But this leaves uncertainty. And that uncertainty, in and of itself, is an injustice to Mr Y and to Mr X.

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Agreed actions

74. Within one month of the final decision the Trust, the Council and the ICB should write to Mr X and Mr Y to acknowledge the failings identified in this decision statement. They should also apologise for the distress this has caused both Mr X and Mr Y, through avoidable uncertainty. In providing these apologies the organisations should take account of the guidance we publish on apologies. This is contained within our guidance on remedies at section 3.2; (see Guidance on remedies - Local Government and Social Care Ombudsman).
75. Within two months of the final decision the Trust, the Council and the ICB should:

• each pay Mr X £200 (i.e. £600 in total) to act as a symbolic, tangible recognition of the avoidable uncertainty he has been caused about whether his son has lost out on support which would have been beneficial, and
• each pay Mr Y £200 (i.e. £600 in total) to act as a symbolic, tangible recognition of the avoidable uncertainty he has been caused about whether he has lost out on support which would have been beneficial to him.

76. Within three months of the final decision the Trust, the Council and the ICB should ensure a care coordinator is appointed for Mr Y. This may not be possible through ‘standard’, regularly commissioned services and protocols. If it isn’t, the organisations should work together, with staff with appropriate levels of authorisation, to agree how they will fund, procure and case-manage a solution.
77. Within three months of the final decision the Trust, the Council and the ICB should provide the Ombudsmen with an action plan about how it will address and resolve the commissioning/policy issues the Joint Strategic Needs Assessment and this case have highlighted. This should include information about how it will identify any others impacted by the same issues.
78. Within three months of the final decision the Council should invite the relevant scrutiny committee to:

• consider the policy and commissioning issues this case has highlighted,
• consider identifying wider lessons learned about effective joint working with the Trust and the ICB, and
• monitor the Council's progress in addressing these issues (with the Trust and the ICB).

79. Within one month of the final decision the ICB should advise the relevant NHS England oversight department/team of this case, noting the specifics of Mr Y’s case and the wider learning points. The ICB should keep NHS England updated, including by sending it a copy of the action plan requested above.

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Decision

80. I found fault on the part of the Trust, the Council and the ICB. They have collectively, through inadequate policies and commissioning arrangements, failed to allocate a care coordinator to Mr Y. The organisations have agreed to take action to address the impact of this fault. I will complete 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