20. Before we decide if we should do a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen.
PTSD questionnaire and discharge in August 2018
21. Ms M says she filled in a PTSD questionnaire (PCL form) during the appointment on 10 May 2018, but the Trust did not consider this. She says the Trust discharged her without offering a diagnosis or treatment.
22. NICE guidance CG123 says, ‘a stepped-care model is used to organise the provision of services and to help people with common mental health disorders, their families, carers and healthcare professionals to choose the most effective interventions’.
23. The guidance says, ‘when offering treatment for a common mental health disorder or making a referral, follow the stepped-care approach, usually offering or referring for the least intrusive, most effective intervention first’.
24. For PTSD, the first intervention (treatment offered) under step two of the model is trauma-focused cognitive behavioural therapy (CBT) or eye movement desensitisation and reprocessing (EMDR).
25. NICE guideline CG26 says It is important when recognising and identifying PTSD to ask specific questions in a sensitive way about both the symptoms and traumatic experiences. PTSD may present with a range of symptoms, including re-experiencing, avoidance, hyperarousal, depression, emotional numbing, drug or alcohol misuse and anger.
26. The records show Ms M attended an initial meeting for a psychology review on 10 May 2018. The practitioner asked her to complete a PCL. A PCL is a checklist form that asks how often an individual has experienced feelings about a stressful experience in the last month such as repeated, unwanted memories and trouble experiencing positive feelings. There are several entries in the notes so it shows the practitioner considered the contents of Ms M’s completed PCL form. They recorded Ms M found it difficult to complete the form and questions 12 and 13 (about loss of interest in activities and feeling cut off from people) are affected by her physical health.
27. The practitioner also noted Ms M’s physical health difficulties affected her functioning and made it hard for her to gauge how much of what she is experiencing is down to her psychological difficulties. They recorded Ms M struggles to concentrate and take in information, especially with long sentences either spoken or written and she seems to struggle to make sense of questions (written and spoken) and to formulate and give a response. The notes say Ms M is not keen to have any therapy due to her physical health and ‘possible complications she perceived from this’.
28. Ms M attended a review appointment on 20 August. She stated her epilepsy was uncontrolled and she was unable to do anything in the day as she recovered from seizures. The service decided to discharge Ms M because her physical health and lack of motivation meant the clinic was not suitable for her at that time and her physical health needed to be addressed first. The psychologist saw Ms M’s risk to herself and others as low. They gave useful contacts and the plan was for ‘mind courses, anxiety management, obsessions and compulsions and coping with low mood’.
29. We can see the psychologist was aware of the PCL and considered the contents. Our adviser says the practitioner’s assessment was in line with the NICE guidance. As above, the first intervention under step two of the model in CG123 is CBT or EMDR, but Ms M did not wish to explore therapy options at the time.
30. The Trust’s reason for discharging Ms M was that her physical health needed to be addressed first as this was preventing her from engaging in any therapy. Our adviser says this was a clinically appropriate position for the clinical team to take. Because Ms M did not want to have therapy at the time, it was appropriate for the service to discharge her back to primary care (her GP) and it appropriately directed her to other services which may be able to offer support. We cannot see any signs of fault in how the Trust managed this.
Discharge in April 2020
31. Ms M says the Trust discharged her from CMHT in April 2020 without any treatment or support.
32. The Trust says an occupational therapist (OT) assessed Ms M on 26 March 2020 and offered a large range of support which Ms M declined. It says the OT met Ms M again and discussed treatment options, but she declined a referral to Coventry Rape and Sexual Abuse Centre (CRASAC) as she said she had seen them in the past and had not found them useful.
33. The Trust says the OT discussed Ms M’s case during an MDT meeting, and they agreed it could not do more. The MDT decided to direct Ms M to Mental Health Matters (a charity providing mental health support for individuals and communities) and they confirmed this in a letter dated 19 April 2020. This letter also advised Ms M she could get support from her GP. Ms M declined an outpatient appointment for a medication review.
34. NICE guideline CG123 says, ‘If the presentation and history of a common mental health disorder suggests that it may be mild and self-limiting (that is, symptoms are improving) and the disorder is of recent onset, consider providing psychoeducation and active monitoring before offering or referring for further assessment or treatment. These approaches may improve less severe presentations and avoid the need for further interventions’.
35. The records say Ms M was offered a large range of support options during the assessment and a later phone call. Ms M stated that she did not want to pursue this as she was not able to travel. The OT noted they suggested phone contact but Ms M declined this and said she had too many seizures and could not have phone contact all the time and was waiting for an operation so did not want to start anything.
36. The OT also noted they advised Ms M more support could be given after the COVID-19 pandemic restrictions were lifted. The OT said they suggested Ms M pursue a referral with her GP once she had her physical health appointments and operation. Ms M declined a medication review because she felt she was already on too many different medications and experienced too many side effects.
37. The notes say Ms M said she will not engage with groups or travel for appointments due to her physical health. She said she needed a CPN sometimes for someone to talk to. The OT noted they explained the role of a CPN and suggested services like Mental Health Matters. Ms M said the Mental Health Matters service was not helpful and she does not use her phone for anything other than calls.
38. Our adviser says community mental health teams deal with the care and treatment of patients with a serious and long-standing mental health illness and Ms M’s symptoms were appropriate for primary care. The Trust found there was no role for secondary care in Ms M’s case and offered Ms M alternatives. We are sorry Ms M did not feel these were suitable options for her and we appreciate this would have been frustrating. From the evidence we have seen, we do not think the Trust did anything wrong.
Declined referrals
39. Ms M says the Trust refused to accept referrals from her and her GP between May and November 2020.
40. The Trust says during this time, Ms M self-referred twice and her GP referred her to the service five times. It says the service offered an outpatient appointment on 9 February 2021, which was later cancelled as the team felt there was no role for secondary care.
41. It says on 12 January 2021, due to the number of referrals, CMHWB agreed to discuss the case with a psychologist and recommended that a social worker be allocated to do a care assessment. After another GP referral on 19 January 2021, it says Ms M was offered an assessment on 21 January.
42. Our adviser says there is no evidence within the notes to suggest the Trust failed to appropriately consider Ms M’s referrals. As set in the section above, we are not critical of the Trust’s position that Ms M was not appropriate for the service, given her inability to get involved in any of the therapy it offered.
43. Our ‘Principles of Good Administration’ say, ‘when mistakes happen, organisations should acknowledge them, apologise, explain what went wrong and put things right quickly and effectively’.
44. The Trust has accepted if it had not cancelled the appointment on 9 February, this may have saved repeat referrals and reduced Ms M’s level of stress. It apologised for this. We appreciate this would have been a frustrating experience for Ms M. We are pleased to see the Trust has apologised for the way this affected her. We think this is enough to put right what happened and we are not asking it to do more.
9 February 2021 appointment
45. Ms M says the Trust bombarded her with information during an appointment on 9 February 2021 and gave incorrect information about what the appointment was for and who would be there. Ms M understood she would be diagnosed with PTSD during this appointment and it did not happen.
46. The Trust says it does not seem staff had promised Ms M a diagnosis of PTSD at this appointment because it was not a medical review appointment. It says unfortunately the member of staff who was scheduled to attend (a peer support worker with the home treatment team) was sick on the day of the appointment and could not attend.
47. The notes show Ms M had a phone appointment with a CPN on 5 February 2021. The CPN noted Ms M was keen to move house and to get a letter saying she has PTSD. The CPN noted Ms M was upset that the consultant would not be offering a medical review.
48. On 9 February, a social worker from the crisis intervention team went to visit Ms M. The social worker noted Ms M talked about wanting a PTSD diagnosis because she thinks this will help support her housing application and increase her Personal Independence Payment (PIP).
49. Our adviser says the social worker gave Ms M appropriate information during the appointment. We are sorry to hear Ms M felt bombarded with information. The Trust accepted that staff were not always aware of Ms M’s communication needs (mainly with processing information). It says it has put an alert on her notes for staff to write down information in future.
50. We cannot see that the Trust told Ms M this appointment would be for PTSD diagnosis, although we appreciate this is what Ms M wanted. The Trust has explained why the staff member could not attend, apologised if Ms M felt bombarded and put actions in place to stop this happening again.
51. We think these actions are in line with our Principles of Remedy and we do not think it needs to do more to put this right.
CPN and communication
52. Ms M says the service told her she was not eligible for a CPN when she called on 10 February 2021. She also says when she was transferring her care, a member of staff shouted at her during a phone call on 6 May 2021. Ms M says she cannot cope with being spoken to like that. She says they also referred to her as a ‘case’ but she is a person.
53. The Trust said there is no evidence to suggest a staff member told Ms M she was not eligible for a CPN during this call and the notes do not seem to match what Ms M is saying. It said the staff member recalls their contact with Ms M was difficult as she was distressed with the delays. The staff member does not remember raising their voice but they were sorry if this is how Ms M felt they had.
54. The notes show Ms M called and spoke to a support worker on 10 February. The support worker noted Ms M was crying as she could not remember the plan that had been agreed with the social worker.
55. The staff member who spoke to Ms M on 6 May 2021 noted she had told her what she needed to do to re-refer her, but she insisted she would not re-refer.
56. Our adviser explains a CPN is assigned to patients with severe and ongoing mental illness and there is nothing in the clinical records that suggests that Ms M would have needed this level of input.
57. We recognise that sometimes people hear things differently in a conversation and come away with a different understanding. How one person remembers a conversation, does not mean another person’s account of the same conversation is wrong.
58. While we do not dispute Ms M’s memory of what happened, unfortunately, without being there at the time we cannot say what, and how things were said. This means we cannot make a decision on this part of the complaint.
Transfer of records
59. Ms M says there were delays with the Trust transferring her records to her new GP practice when she moved and delays with transferring her care to the new service.
60. The Trust said staff contacted Ms M’s new GP practice and confirmed they had access to all the information it needed. It realised there was some delays in the transfer of Ms M’s records. It said this is partly because there was more than one person dealing with the transfer and there was some confusion between the CWPT team and the new service about its referral process. It apologised to Ms M for this delay.
61. Our ‘Principles of Good Administration’ say organisations should be customer focused and:
‘aim to ensure that customers are clear about their entitlements; about what they can and cannot expect from the public body; and about their own responsibilities’.
‘behave helpfully, dealing with people promptly, within reasonable timescales and within any published time limits. They should tell people if things take longer than the public body has stated, or than people can reasonably expect them to take’.
62. The notes show the service attempted to contact Ms M on 30 April 2021. Ms M returned the call and advised she had moved to a different area.
63. The same day, Ms M called the service and said she was concerned her new GP did not have her mental health information. The call handler noted they had called Ms M’s new practice who said the doctor would have her mental health information. The call handler then called Ms M back to tell her this.
64. On 6 May, there is another entry in Ms M’s notes saying the Trust contacted the new crisis team to get information about transferring her care. The crisis team advised that Ms M’s GP needs to make the referral or Ms M would need to call them to re-refer herself. The call handler contacted Ms M to tell her this, but she was not happy with this solution.
65. The records from the next day show the transfer of care was complete and the case was closed.
66. Our adviser says the Trust managed Ms M’s transfer of care appropriately.
67. We can see Ms M told the Trust she had moved on 20 April. When Ms M called with concerns about her new doctor having access to her records, staff took appropriate action to contact her new GP practice, who advised they had everything they needed. There is nothing in the notes to suggest the Practice asked for any more records.
68. The Trust made appropriate enquiries about the transfer of care on 6 May and it was marked as complete by the next day. There is evidence staff made it clear to Ms M what she needed to do to transfer her care and dealt with her queries quickly. We think the Trust dealt with the transfer of care and records in line our Principles and there is no sign of a failing.