4. Mrs C complains that her son’s (Y) declining health was not adequately supported, particularly between October and November 2022 by the Trust.
5. As a result of the above, Y’s mental and physical health declined very quicky and he sadly took his own life. His parents feel traumatised by the events that occurred.
6. Mrs C is seeking an apology, acknowledgment of failings and service improvements.
7. Y was suffering from very poor mental health and had been under the care of the Trust since 2016. He had diagnoses of anorexia (an eating disorder characterised by restriction of food intake leading to low body weight due to lack or loss of appetite), autism (a neurodevelopmental condition of variable severity characterised by difficulties with social interaction and communication and by restrictive or repetitive patterns of thought and behaviour), generalised anxiety disorder (a mental health condition where you often feel very anxious about lots of different things) and obsessive compulsive disorder (involves a pattern of unwanted thoughts and fears known as obsessions which can lead to repetitive behaviours).
8. On 29 October 2022 at around 7.30pm, Mrs C called the mental health services’ crisis line for support as Y was highly distressed and had told her he had suicidal thoughts with intent. He told her detail of how he planned to do this. Mrs C says she was left on hold for an unreasonably long amount of time given the emergency situation.
9. Mrs C says processes used by the Trust were not quick enough and did not meet the needs of Y’s rapid decline in the last month of his life. Paperwork was completed and he was ‘ready for admission’ but the Trust did not appreciate just how severe Y’s mental health was despite numerous emails and phone conversations. They did not admit him as an inpatient quick enough and in the meantime he sadly committed suicide.
11. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are indications the events complained about had a negative effect which the organisation has not put right. Having done so we have found the Trust has already done enough to put right the impact of these events.
12. Mrs C told us that her key concerns in relation to Y not being adequately supported are that she was unable to access support via the crisis line several times in 2022 (the last week of his life in particular) and he should have been admitted as an inpatient. We acknowledge the distress the inability to access the crisis line will have caused Mrs C at such critical points in time.
13. We have considered the Trust’s responses to Mrs C in detail. In the Trust’s response of 20 June 2023, it acknowledges delays in answering the crisis line and that there is more it can do and provides a detailed apology to Mrs C.
14. The Trust also explained it had already carried out a Trust-wide steering group has been created and a project focused on improving access to the crisis line, including increasing staffing to the crisis line and offering separate intensive home treatment lines and professional lines. The Trust explained immediate work was also done to reduce documentation and reviewing processes, alternate roles were put in place for screening of calls, and alternative crisis support has been implemented.
15. As a result of these service improvements, the Trust’s mental health support and crisis response times have improved.
16. In terms of future service improvements, the Trust states it is working with the North Yorkshire and York (NYYS) commissioners to put an alternate service in place that will increase the crisis line capacity and achieve a much higher response rate. Additionally, it states further funds have been raised to obtain specialist crisis support staff to support calls like Mrs C’s. The Trust says it has recognised a gap and has started recruitment for these posts.
17. In the Trust’s response of 23 February 2024, it acknowledges that it was highly likely that Y’s next review meeting would have resulted in another inpatient admission as Y’s risk was escalating and that it was not safe to support him in the community anymore. We can see the psychologist had already completed the referral for inpatient services in case an emergency admission was required but sadly this did not occur as Y took his life before this.
18. The Trust says ‘if we had not ensured that the policy had been followed as rigidly, we could have considered our ability to ‘step up’ the care or processes much sooner’, thereby acknowledging things did go wrong with Y’s care. The Trust apologises for not being able to keep Y safe in this letter and offers Mrs C a meeting.
19. Our Complaints Standards state an effective complaint handling system ‘Gives fair and accountable responses that:
• set out what happened and whether mistakes were made • fairly reflect the experiences of everyone involved • clearly set out how the organisation is accountable • give colleagues the confidence and freedom to offer fair remedies to put things right • take action to make sure any learning is identified and used to improve services’.
20. We consider the Trust’s has provided a detailed and sincere apology several times, an acknowledgement that things went wrong and an explanation as to why. It has also detailed service improvements it has made as a result of the events that occurred in relation to Y’s care and future service improvements that it will carry out. We consider these actions are appropriate to address the failings we have seen.
21. We therefore consider the Trust has done enough to put right the mistakes it made in line with the guidance above and that the outcomes Mrs C is seeking have already been achieved. It is for these reasons that we do not take further action in relation to this complaint.
22. We appreciate the significant and lasting impact these events will have had on Mrs C and her family. We recognise that our report cannot change these sad events. We hope however that our report provides some reassurance that the Trust has taken her concerns about Y’s care and the impact of this on her family seriously and has acted appropriately to improve its service.
1. We have carefully considered Mrs C’s complaint about Tees Esk and Wear Valleys NHS Foundation Trust (the Trust). Mrs C’s complaint relates to the mental health support provided to her late son. We do not underestimate the lasting effect these events have had on Mrs C and their family. We are very sorry for their loss.
2. We have carefully considered the complaint and can see the Trust has already acknowledged the failings in the support and has apologised for the impact of this on Mrs C’s family. We can also see the Trust has taken action to improve its service as the result of the failings it identified.
3. We consider the Trust’s actions are appropriate to address the impact of the failings, and therefore we do not consider further action is needed. We have set out our decision reasoning below.