A psychiatric nurse treated Mx E dismissively during the appointment on 1 August 2023 and approached them outside the Trust after their appointment to ask them if they were okay.
14. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether an investigation would be practical and whether it could lead to a satisfactory conclusion. Due to a lack of evidence about this issue, we have decided it is not practical for us to investigate it and it is unlikely that an investigation would lead to a satisfactory conclusion.
15. In their complaint to us, Mx E stated that their mental health has been affected by this experience. Mx E told us a psychiatric nurse treated them dismissively during an assessment appointment on 1 August 2023, smiled at them when they disclosed experiencing suicidal ideation, discriminated against them on the basis of their autism and approached them afterwards. Mx E said that they found this behaviour deeply inappropriate.
16. Mx E explained that following their appointment they were “ushered out a back door” into the Trust’s car park. Mx E said this traumatised them as they did not feel safe enough to leave the building.
17. Mx E then explained that the nurse approached them after the appointment in the Trust’s car park to ask them if they were okay as they looked distressed. Mx E said that the nurse asked if they were “still here?” and advised them to call a number for some further mental health support. Mx E then said that the nurse “waved his hand” in a disrespectful manner. Mx E found this behaviour deeply inappropriate.
18. In the letter dated 6 October 2023 the Trust acknowledged Mx E’s distress and apologised for the psychiatric nurse’s dismissive behaviour, stating he was “sorry to learn that you feel he was dismissive towards you and that you felt discriminated against, for it was not his intention to cause hurt and offence to you.”
19. The Trust’s response says the nurse was not aware he had smiled at Mx E when they shared their suicidal feelings with him. The psychiatric nurse acknowledged this is a highly inappropriate response to the disclosure and offered his apologies for the hurt caused by this unintentional response.
20. The Trust recognised Mx E’s claims about dismissive behaviour during their assessment appointment and offered them an apology. The Trust explained that it was sorry to hear that Mx E felt that the nurse’s behaviour after the appointment was inappropriate. It explained that it felt that it accommodated Mx E’s required adjustments, however were sorry if Mx E did not feel that the service met their expectations.
21. We recognise that Mx E felt the nurse was dismissive and inappropriate during their appointment on 1 August 2023. The Trust has apologised for this.
22. Looking at the evidence provided we cannot say that the nurse’s behaviour was inappropriate. Although the Trust have apologised if Mx E interpreted the nurse’s behaviour in that way, they do not admit to any inappropriate or dismissive behaviour taking place. As we were not there at the time and there is no independent witness, we do not think any investigation would reach a satisfactory conclusion about whether the nurse behaved in a way that was inappropriate.
23. It would not be possible for us to reach a finding on this issue, and it would be disproportionate for us to investigate it. For this reason we have decided to take no further action.
The Trust did not assess them appropriately, taking into consideration that they have autism, and denied them access to secondary mental health services when they were suffering from a mental health crisis
24. Mx E told us that a psychiatric nurse was dismissive during the assessment appointment. They believe the Trust discriminated against them as a disabled (autistic) person with diagnosed mental health conditions and denied them access to secondary mental health services because of this.
25. Mx E feels that the Trust should have taken into consideration the views of their GP and their psychologist from their previous CBT treatment that their mental health conditions need continuing treatment and that they should be offered this at the Trust.
26. The Trust’s response from 6 October 2023 concludes the nurse’s assessment to be in correct and in line with the Trust’s operational policy. The Trust said the reason it denied Mx E access to secondary mental health services was not because they are autistic. It explained Mx E did not meet the eligibility criteria for secondary mental health services, as they just completed a round of CBT on 1 June 2023.
27. The Trust’s response said secondary psychological services usually request a period of one year has lapsed before accepting any further referrals for psychological therapy. This is to give time for patients to assimilate (absorb) the therapy provided and have the opportunity to begin to practice any techniques learnt within the therapeutic space.
28. The psychiatric nurse’s report on 1 August 2023 documents Mx E’s recent therapy and their autism were both reasons they were not eligible for secondary psychological services. The report said that: “I advised that it would be unlikely that our psychologist would offer therapy as you have only just finished a course and need to apply what you have learnt. I also suggested as your main issue appeared to be related to autism, we are not commissioned to work with clients with this disorder”
29. This was further evidenced in email correspondence with the Trust from 11 December 2024. The Trust provided us with evidence about the timeframe to recommence therapy, which is outlined in the Trust’s policy saying “The Trust’s psychological therapies service is unaware of any national guidelines around the timeframe to recommence therapy. Our local policy is that we generally recommend a year’s break following a therapy to allow time to consolidate what has been achieved.”
30. Our clinical advisor supported the Trust’s rationale about Mx E’s ineligibility for secondary mental health services due to their recent CBT. They reference a research study by Behavioural and Cognitive Psychotherapy which explains the benefit of patients taking a break between treatments and returning for additional treatments after one to five years. This suggests that a break can be a natural part of the therapeutic process, allowing patients to address their needs as they arise over time.
31. Our clinical advisor also noted the issue of limited resources and the cost of providing psychological services, and the often lengthy waiting time to access these services. NHS trusts must ensure access to services for patients is fair, equitable, proportionate and offers optimal value (for the patient, the NHS and the taxpayer). This is another reason why it is appropriate for the Trust to have a policy that patients must wait a year after therapy before receiving further therapy.
32. Our clinical adviser explained that the evidence suggests the psychiatric nurse assessed Mx E appropriately and the decision not to offer therapy at that time was in line with the Trust’s operational policy. The documentation shows the nurse considered the GP’s concerns about Mx E’s expression of suicidal thoughts and increased anxiety, psychologist’s recommendations, and their autism.
33. Our clinical advisor says that the assessment and subsequent care plan are coherent and in line with the assessment guidance and the management guidance to address Mx E’s problems in a holistic sense.
34. The management guidance says to follow the stepped care model to choose the most effective intervention/care to people with generalised anxiety disorder (GAD). The stepped care model involves: • step one – identification and assessment, education about treatment options, and active monitoring in primary care (by the GP) • step two – diagnosed GAD that has not improved after education and active monitoring in primary care – offer low intensity psychological interventions, self-help, and psychoeducational groups • step three - GAD with an inadequate response to step two interventions or marked functional impairment – offer a choice of a high-intensity psychological intervention (cognitive behavioural therapy [CBT]/applied relaxation) or a drug treatment • step four – complex treatment refractory GAD and very marked functional impairment such as self-neglect or high risk of self-harm – consider highly specialist treatment such as complex drug and/or psychological treatment regimes, input from multi agency teams, crisis services, day hospitals or inpatient care.
35. Our clinical advisor noted that Mx E’s presentation (as evidenced by the psychiatric nurse’s assessment) does not indicate that step four would have been appropriate for their needs at that time.
36. The clinical advisor noted that the psychiatric nurse has also considered Mx E’s psychologist’s recommendations during the assessment. One of the psychologist’s recommendations was that Mx E’s risk of self-harm should be regularly monitored and managed.
37. The assessment guidance says that if the person who has self-harmed is being supported and given care in primary care, their GP should ensure that the person has: regular appointments with their GP for review of self-harm, a medicines review, information about available social care, voluntary and non-NHS sector support and self-help resources care for any coexisting mental health problems, including referral to mental health services as appropriate.
38. The psychiatric nurse had responded to the referral as per the assessment guidance, and following their assessment concluded that ‘I did not feel that [Mx E] currently warrants support from secondary MH services so we will be closing their referral to our service with the following plan.’ This meant that Mx Wier’s risk (and mental health) could be adequately managed by primary care at that time.
39. Our clinical advisor concluded that overall, the psychiatric nurse’s assessment is in line with the clinical standard.
40. Although the psychiatric nurse assessed Mx E correctly, we note the psychiatric nurse incorrectly documented the Trust was not commissioned to provide services to people with autism.
41. This statement indicates that people with a diagnosis of autism are excluded from secondary mental health services such as the community mental health team (CMHT), which is not the case.
42. The Trust’s autism policy sets out different care pathways depending for autistic patients, depending on whether their primary need is related to autism or mental health. It says that if a patient’s primary need is related to their mental health, and they also have autism, they can be seen by the CMHT with support from specialist services. If a patient’s primary need relates to autism, the Trust should refer them to specialist services. This policy makes it clear the Trust can provide services to autistic people, if their primary need is related to their mental health.
43. Despite the nurse being unclear in their explanation about the services it can offer to autistic people, reassuringly we have seen no indication the Trust’s decision not to offer Mx E further treatment was flawed or unduly influenced by Mx E being autistic.
44. In summary, we recognise it must have been distressing for Mx E to feel they were denied treatment on the basis of them having autism. Having looked into this and obtained clinical advice, the reason they were declined for treatment was because they had recently finished a course of CBT. The Trust has an appropriate operational policy that patients must wait 12 months before starting further therapy.
45. We recognise it was distressing for Mx E to be told they could not have therapy at that time. We hope this waiting time has given Mx E time to reflect on the initial CBT and act on and benefit from the treatment.
46. As we have seen no indications the Trust did anything wrong, we have decided to take no further action.
The Trust did not signpost Mx E to appropriate primary mental health services
47. Mx E complains the psychiatric nurse did not signpost them to the appropriate primary mental health services.
48. The records of the appointment on 1 August 2023 show that the nurse signposted Mx E to two other programmes that specifically support autistic people with mental health conditions for further support.
49. The Trust provided us with a copy of it’s operational policy which it acts under when deciding if its service is suitable for specific patients. This says if patients do not fit the treatment criteria for secondary services, they must be signposted to appropriate services.
50. We have looked at the medical records from this appointment and they show the nurse signposted Mx E in line with the policy.
51. Our clinical advisor has confirmed that a psychiatric nurse signposted Mx E appropriately as evidenced in their assessment and care plan report letter, which was sent to Mx E and their GP.
52. In conclusion, we recognise that Mx E had some difficult experiences whilst under the care of the Trust. However, we have not seen any indications these difficult experiences were due to any failings on the Trust’s part. Therefore we have decided to take no further action.