Conflicting information and appropriateness of discharge
15. Ms O complains about the conflicting information held and provided by the Trust. She says their complaint response of 26 March 2019 states that she disengaged, whilst her records say she was discharged. Ms O became aware of this discrepancy following the SAR she made for her records.
16. The assessment notes made on 27 July 2017 by the practitioner state under the proposed treatment plan ‘as patient refused to engage in assessment and hung up … discharged back to GP and update’. The letter to her GP dated 27 July 2017 confirms this stating ‘[patient] has now been discharged from our service.’ Ms O has told us that she has no recollection of hanging up and states she did not refuse to engage in the assessment. It is therefore clear to us that the practitioner discharged Ms O from the Healthy Minds service, but the notes indicate this was because she did not complete the assessment in full, because in the assessor’s view she disengaged from it.
17. Ms O was referred by her GP to the IAPT team, who has its own protocols and service standards. Telephone triages are completed by psychological wellbeing practitioners, who are not registered clinicians under the Health and Care Professions Council. They are asked through IAPT to do assessments which can then lead to therapy being initiated. IAPT guidance states that ‘a good assessment should accurately identify the presenting problem(s), make an informed clinical decision about the person’s suitability for the service, determine the appropriate NICE-recommended treatment and step in collaboration with the person, and identify the correct outcome measure to assess change in the problem(s).’ Guidance also recommends that the assessment is completed in full and ‘a clear outline of the person’s presenting problems’ and ‘an exploration of any adverse circumstances’ be discussed.
18. IAPT guidance 5.1.1. states that components of a good assessment should include ‘a clear outline of the person’s presenting problem(s)’. The practitioner acknowledged they did not read the doctor’s referral. They cannot therefore have been fully aware of Ms O’s presenting condition and the grounding for the assessment. If the practitioner had read the referral first, it would have been clearer that Ms O was not referred for anxiety or depression but rather symptoms associated with PTSD. IAPT does not test for PTSD and had the practitioner read the referral, it may have been evident that this kind of assessment was not appropriate for Ms O. Whilst we cannot say whether they would have continued to complete the assessment, it is likely that if they had, the discussion would have been easier as they would have understood why Ms O was presenting as ‘aggressive’ or uncooperative.
19. We considered whether it was appropriate to discharge Ms O with the assessment incomplete, or whether further action should have been taken first. There is no specific guidance available so we took clinical advice about what good clinical care and treatment would consist of. Ms O’s records indicate she was allocated for IAPT assessment based on the contents of the GP referral. As we have discussed, the referral mentions symptoms akin to PTSD rather than anxiety and depression. Our adviser indicated that based on the referral, Ms O would have been better suited to a face to face assessment, rather than IAPT which would not test for the symptoms she was experiencing. However, the assessment did go ahead and was not completed in full, with certain key elements such as the risk assessment not being completed, as per IAPT guidance.
20. In the absence of a complete assessment, our adviser indicated that it would have been appropriate to offer Ms O a face to face appointment to complete the assessment. This would then have highlighted to the Trust that the IAPT assessment would not have picked up on her symptoms and could have allowed her needs to be more thoroughly considered. But this did not happen.
21. As we have already explained, the IAPT protocol does not test for PTSD. As this was followed in full by the practitioner it is unsurprising that Ms O felt the questions were not applicable to her. Both sets of notes refer to her not meeting the scores for further assessment for depression and anxiety, but Ms O did express clearly during the call that she felt they were asking the wrong questions. Our adviser said that Ms O’s psychological distress was not picked up by the assessment as the questions were not for her condition. Based on the practitioner’s notes, the adviser said it appears that the practitioner rigidly followed the IAPT protocols which caused the difficulties.
22. The failing we have identified is therefore not that the practitioner rigidly followed the protocol, but that Ms O was not offered a follow up appointment when the initial assessment broke down. Both IAPT guidance and the independent clinical advice we obtained confirm that IAPT does not test for PTSD and therefore Ms O would have been better suited to a face to face assessment.
23. The Trust’s complaint response of 26 March 2019 explains that the assessment scores for anxiety and depression “are only part of the picture and the clinical interview determines the remainder”. The IAPT assessment evidently did not go well and the conversation between the practitioner and Ms O broke down which meant that the clinical interview was not completed in full. This is not in line with IAPT guidance which states that the minimum data set should be completed with a clear understanding of the presenting problems and a risk assessment. No follow up was offered to Ms O, despite the assessment not being completed and Ms O’s clear unhappiness and distress during the call.
24. The Trust explained that the practitioner discussed the call with her manager and said that Ms O said she did not want to continue with the service but based on the contemporaneous notes there is no indication this was the case. Rather she asked for her GP to be informed that her scores were too low to have an offer of further support made. Both sets of notes refer to her not meeting the scores for further assessment for depression and anxiety, but Ms O does express clearly that she felt they were asking the wrong questions. The notes also indicate that Ms O said to the practitioner that even if the scores were too low “the need was still there”. Ms O was evidently upset and unhappy with the outcome and she knew that as she was being discharged, she was not going to get the help she needed. Given that Ms O was evidently in distress and seeking help, it was even more important she should have been offered a follow up appointment.
25. In summary, Ms O disengaged on the telephone because she felt the questions were not applicable. While we are not critical of the assessor for asking these questions in line with the correct protocol, following review of IAPT guidance and the independent advice we received, we feel that it was not appropriate to discharge her at that time. Therefore, we find a failing in this area and we shall discuss the impact of this on Ms O.
Impact
26. Ms O says that as she was wrongly discharged from the service, she has had to pay privately for therapy to treat her PTSD. She tells us that the Trust chose not to compensate her based on her disengaging from its service when she was in fact discharged.
27. As we have discussed, there is clear evidence that the conversation between the practitioner and Ms O on 27 July 2017 was difficult, and Ms O became frustrated and disengaged because she felt she was being asked questions which were not appropriate to her. However, there are two pieces of evidence, as discussed above, that say she was discharged from the Trust. This may have been because she disengaged during the assessment, but regardless the fact remains that the Trust did discharge her without her assessment and clinical interview being completed, without any offer of a follow up face to face appointment and without a risk assessment being completed. IAPT guidance states that a risk assessment should be completed as part of the assessment process.
28. In considering the impact that this had on Ms O, we assessed the reasonableness of her actions following the conversation with the practitioner. We note that Ms O’s first appointment with the private therapist was on 20 July 2017, before the assessment with the Trust. Ms O also advised us that she had subsequent appointments with the therapist on 27 and 28 July, following the assessment. As part of the investigation, we asked Ms O to explain her approach. She said that “I had begun to think I had a degenerative condition; I literally couldn't think and was frequently extremely upset. My assessment had already been delayed as I'd had a phone call from the practitioner delaying the appointment due to her childcare needs. I had no idea when I might be offered therapy and had already waited nearly 6 weeks. I was feeling desperate by this time and in a state of constantly wondering when I might be able to get help. In moments of crisis I was using voluntary phone lines.”
29. Ms O also explained that she had phoned the private therapist on the recommendation of a friend in April to enquire but the cost was expensive, and they had no capacity to take on new patients. She states that she was very upset and an incident involving her son had triggered her own “unresolved multiple and complex trauma”. She further adds that “by July, not knowing when or what the NHS would offer - I responsibly and desperately sought support for my own emotional safety and wellbeing, and to ensure as far as possible that I could keep working. Had an NHS offer of therapy been made I would have accepted it immediately. I note from my diary that after the appointment with the practitioner I saw the private therapist that afternoon and the following day too - such was my distress exacerbated by the appointment.”
30. From this account, we have established that Ms O did not go back to her GP to seek further advice on any other NHS options that were available to her, but sought private treatment as she felt she needed immediate help. Ms O has made it clear in her complaint to the Trust and to us, that the cost of private treatment was expensive to her and that she only sought private treatment as she thought she had no other option.
31. The Trust have stated that they could have offered PTSD treatment, but the assessment scored for anxiety and depression. It is not apparent from the records whether PTSD was considered at all in the assessment nor treatment options considered or discussed with her. The letter to the GP clearly states that Ms O did not meet the service threshold due to her scores being too low but there is no reference to her clinical needs as stated in the referral from her GP.
32. We considered whether Ms O’s reaction was reasonable given the evidence in her records of how the assessment went. Unfortunately, we do not have a full understanding of her needs at that time as these were not assessed. Ms O could have returned to her GP to discuss the outcome and seek advice before she sought private treatment and she could also have complained to the Trust at that time. However, we can understand why Ms O felt that there was no help available to her from the NHS following the assessment and the subsequent letter to her GP which confirmed her discharge from the service.
33. Whilst it is not clear why Ms O did not discuss other options with her GP, we can understand from her account that she was in a desperate position and felt helpless following the assessment. She was already aware of the option for private therapy and had made an enquiry, and the fact that she saw the therapist later in the day after the assessment, and the following day is testament to the distress she was in and that she felt she needed immediate help. Therefore, whilst we would have expected Ms O to have discussed her options with her GP before seeking private treatment, we can understand her actions.
34. This is a failing that caused an injustice to Ms O as she felt abandoned and forced to seek private treatment as she was discharged from the Trust. We therefore considered what should have happened had Ms O been assessed as she should have been and what did happen to her because of not being, and what disparity there is between the two.
35. We asked the Trust what NHS pathway would have been available to Ms O had she been assessed appropriately in July 2017 and what the waiting list time for accessing this pathway would have been at that time. NICE guideline 116: Post-traumatic stress disorder indicates treatment should be Cognitive Behavioural Therapy (CBT) with the offer of Eye Movement Desensitization and reprocessing (EMDR) if it is felt necessary. We have reviewed the Trust’s Healthy Minds Operational Policy and the pathway indicated aligns with this guidance. The Trust said had Ms O been assessed in July 2017 and put forward for treatment for symptoms associated with PTSD, she would have been placed on the waiting list for CBT and the approximate waiting time based on figures available from this period would have been between 10 and 11 weeks to see a fully qualified CBT therapist. The Trust said she would then be assessed to see if she was presenting with trauma symptoms and if so, then the treatment delivered would either be CBT or EMDR depending on the clinician’s qualifications and the patient’s preferred choice.
36. As Ms O felt she had an immediate need for therapy, so much so she started private treatment immediately, we asked the Trust whether their waiting time could have been expedited. They said that this was very difficult to assess but that their process was that after assessment, once a treatment had been agreed with the patient, the CBT manager would allocate directly to a clinician rather than placing on a waiting list. The clinician would then book her in to their next available appointment. Due to their diaries being booked in advanced, it would be unlikely that she would have received an appointment for treatment within 2 weeks, but likely within 2 - 4 weeks. Ms O therefore did benefit from receiving therapy sooner than she would have had she been allocated treatment through the NHS; however, she did have to pay for this benefit.
37. Therefore, even if the assessment had been followed up and Ms O assessed as needing immediate treatment, she would not have received treatment immediately, as she did by pursing the private option. However, we do note that Ms O has repeated numerous times that had an NHS option been open to her she would have taken it as the cost of private treatment was expensive.
38. The final thing we have looked at when considering the impact on Ms O is how many sessions she could have received on the NHS pathway. We asked Ms O to confirm how many sessions she had undertaken privately from 27 July 2017 to the date of her complaint to us, 31 March 2019. She confirmed that this was 64 sessions at a cost of £60 per session, totalling £3840.
39. We asked the Trust how many sessions they could have offered had she been assessed correctly. They explained that the treatment they offer follows NICE Guideline NG116 which at 1.6.17 outlines the number of sessions offered initially should be 8 to 12. We also asked them if it was deemed necessary, would further therapy have been offered. Ms O has had more sessions than those quoted by the Trust so an understanding of what the Trust would have done was needed. They explained that this option would be discussed with the patient where possible and if they had not improved significantly, further sessions or other therapies can be considered within the service or referral to other service as needed. We asked the Trust to confirm if there was a maximum number of sessions they would offer, and they confirmed that the treatment for complex trauma, could be a maximum of 24 sessions.
40. We asked Ms O’s private therapist for information regarding the treatment plan she was on, to ascertain whether 8 to 12 sessions would have been enough based on her clinical presentation. They advised that she “had experienced both complex multiple childhood trauma and adult trauma. Eye Movement Desensitisation Reprocessing (EMDR) is a phased trauma focused therapy. In view of all the above, she managed to make some marked progress during this period (July 2017 – December 2018). Some of the principal aims of the treatment plan were meet, in the form of reprocessing of traumatic material within the childhood cluster.” From this, we can surmise that 8 to 12 sessions would not have been enough as it would have only begun to unravel some of her issues.
41. If Ms O had been assessed appropriately and referred for treatment for PTSD, which she went on to source privately, she would only have been offered a maximum of 24 sessions by the Trust. It is outside of the scope of this investigation to consider whether she would have gone on to seek further treatment privately after the completion of these 24 NHS sessions and so whilst we sympathise with Ms O’s position, we cannot attribute her continuing therapy beyond these 24 sessions to the failing we identified.
42. In summary, we have found a failing that has caused an injustice to Ms O and we uphold this complaint part.
Letter regarding re-referral
43. Ms O complains about the letter she received from the Trust’s Healthy Minds service on 21 December 2018. She says this was sent to her 18 months after a telephone assessment following which she was discharged, and it was therefore completely out of the blue. She feels it should have been sent earlier, following the assessment in 2017. She also tells us that she was unable to contact the staff member who sent the letter, as they sent this prior to going on leave.
44. The Trust explained in its letter 26 March 2019 that the letter was sent to Ms O in December 2018 following a review of her file after the subject access request she had made. The team leader who reviewed the file felt that the decision to discharge Ms O without completing the assessment was incorrect and a further review should be offered. The Trust explained that it had tried to contact Ms O via telephone many times and as this was unsuccessful, it wrote to her. It explained to Ms O that whilst it believed the decision to send the letter was clinically responsible, it accepted that receiving the letter unexpectedly would have caused distress and this should have been considered, and that it could have waited until after Christmas to send the letter. It apologised for the distress caused.
45. Our Principles of Good Administration states that ‘decision making should take account of all relevant considerations, ignore irrelevant ones and balance the evidence appropriately.’ In this case, it is evident the impact of receiving the letter on Ms O was not considered and we consider this to be a failing.
46. We consider the fact the Trust tried to call Ms O to discuss a referral instead of just sending the letter shows it did at least consider the most appropriate way to communicate. It has explained that it was ‘clinically responsible’ to send the letter and we do not disagree with this; it was correct to notify her it had made a mistake in discharging her. However, it had no awareness of Ms O’s mental state that time and it could have taken steps to alleviate any potential for negative impact on her. For example, it could have delayed sending the letter until after Christmas or ensure that the contact details on the letter were for someone who was available. This may have helped to mitigate some of the impact on Ms O.
47. As a result of the complaint, the Trust explained that it had taken learning from the complaint. We asked it to explain what steps it had taken and it advised that Healthy Minds now has access to systems which enables clinicians to check previous contact before a new assessment and all staff have been given training in its use. Staff have also been advised that they should seek extra support and guidance before sending sensitive letters which could have an impact on the patient. Both staff members involved in sending the letter have attended complaint handling training to widen awareness of patient impact and how to handle sensitive situations, as well as patient feedback incorporated into managers meetings which was not the case prior to Ms O’s complaint. Furthermore, borough quality leads were appointed in 2019 which were not in place at the time of the issues subject to the complaint.
48. This investigation has considered if it was appropriate to send the letter, and the impact this was likely to have had on Ms O given the ongoing treatment she is obtaining for PTSD.
49. We believe the Trust made the offer of a re-assessment unaware of the private treatment Ms O had pursued. Whilst we can appreciate that the letter was sent with the best intentions, the Trust has accepted that the impact of the letter was not considered, as it should have been. We therefore consider this to be a failing and we go on to consider the impact of this on Ms O.
Impact
50. Ms O states the receipt of the letter re-triggered her trauma and made her feel upset. As part of our investigation, we asked Ms O to explain why she had not accepted the Trust’s offer of an assessment in December 2018, instead choosing to continue with private therapy. She explained that having felt that the Trust were unkind and leaving the assessment call distressed and traumatised, she was not prepared to risk a similar occurrence at a new assessment. She added that this would “indicate very serious concerns regarding my health and judgement if I deliberately returned to a traumatising situation.” She also expressed concerns that interrupting her therapy and changing therapists based on receiving the letter, would have meant re-capping everything and trying to build another relationship, as well as most likely having to wait on a waiting list, meaning a further interruption to her treatment.
51. She added that she weighed up the option and considered the potential success of transferring to the NHS to be extremely low, and probably distressing to her and she made this assessment based on the result of the SAR request and the information that was contained within. She said her lack of faith in the Trust was compounded by the “poor-quality complaint investigation” and further added “the thought of having to begin again with a different therapist would frankly have just been too much. It's not only about progress, it's about trust, relationship and continuity.”
52. We asked the Trust if Ms O had accepted the offer of a new assessment, what the wait time for treatment would have been, as this was one of the reasons Ms O cited as a reason for not accepting the offer. The Trust advised that in December 2018, the treatment options would have been the same as those available in July 2017, cited above. They advised that the wait time in December 2018 was 15 weeks, but this would have been expedited for Ms O and she would have started treatment within 2 to 4 weeks. Therefore, there would have been some disruption to her treatment, as even if expedited she would have experienced a break in her treatment program.
53. We asked our clinical adviser if there were any likely impacts of the delay on Ms O, had she chosen to change to the NHS pathway 18 months after the initial assessment and discharge. The NHS operates an 18-week waiting target in Mental Health Services and so if Ms O had been assessed as in need of treatment of her PTSD in July 2017, she would have been in treatment long before this time let alone experiencing another wait. Our adviser explained that research on treatment outcomes used in NICE are based on Randomised Controlled Trials and these show that people in waiting conditions do not tend to improve, whereas those in treatment do. We have seen evidence that Ms O had built a therapeutic and working alliance with her private therapist and thus trust and confidence to work on her traumatic past and she was responding successfully to treatment.
54. We also asked our adviser to consider the length of time Ms O has been receiving therapy for, 18 months at that time. They suggested that in their clinical experience it would not be appropriate to change to another therapist at that time and whilst we do not have a full understanding of Ms O’s clinical need for continued therapy after the 24 sessions indicated by NICE Guidelines, they would not recommend to a patient such as Ms O to change therapist unless this was unavoidable.
55. From this, we can surmise that interrupting her treatment, changing therapist and then a wait for therapy to resume would have been detrimental to Ms O and we therefore consider her explanation of her refusal of the Trust’s offer reasonable.
56. In summary, whilst the letter dated 21 December 2018 was sent with the best intentions, the Trust did not give due consideration to the impact it would have on Ms O. We have seen indications of a failing and our current thinking is that this caused an injustice to Ms O. Therefore, we uphold this complaint part.