19. The law says a person needs to make their complaint to us within a year of becoming aware of the problem. We cannot investigate complaints brought to us after one year, unless we consider there is a good reason to do so. We have discussed this with Miss A to understand the reasons why she could not do so. We have also considered the time the organisation has taken to respond to Miss A.
Failure to offer appropriate group therapy between 2012 and March 2017
20. Miss A explained to our service that her date of knowledge for this element of the complaint was after she requested her clinical records following her discharge from the service on 24 November 2024. She says it was only at this point that she became aware of the extent of her mistreatment from the Trust and had cause to complain. We are sorry to hear of how distressing it was for Miss A to receive and read through her clinical records.
21. Within the clinical records we can see the Trust provided Miss A with different forms of therapy between the time she was initially referred by her GP on 12 December 2012 and 9 March 2017, when she was first offered group therapy. We have carefully considered Miss A’s stated date of knowledge further. Taking the evidence into consideration, we feel there is strong evidence to suggest Miss A first had cause for concern in respect of the failure to offer group therapy in August 2015 and September 2015.
22. The clinical records show on 3 August 2015 Miss A was seen by the community health team at the Trust and explained that she contacted the TC directly to seek a direct referral, as she felt the previous treatment options provided by the Trust had not worked and were not helpful. She was seen by the Trust again on 9 September 2015 and again reported that the previous therapies did not work, and she wanted to be referred to group therapy, which the Trust did at this time. Taking this into consideration, we consider Miss A first had cause to complain at the lack of group therapy at this point.
23. We discussed this date of knowledge with Miss A further on 18 October 2024. During this conversation she explained to our service that she has large periods of time in her life which was unaccounted for, as she had problems with addiction and lost custody of her son, which means she cannot clearly recall certain periods of time. We recognise the difficult circumstances for Miss A during this period and do not underestimate the devastating effect losing custody of her son had on her. We are truly sorry to hear how much this impacted on her life.
24. The evidence available to us does suggest Miss A had an awareness of the type of therapy she required and expressed dissatisfaction with the service and the lack of group therapy treatment provided to her during her appointments with the Trust in August and September 2015.
25. Taking this into consideration, we do not believe it is unreasonable to say Miss A had cause to make a complaint in September 2015, after she was initially referred for group therapy.
26. While it is clear to see the difficulties she experienced during this period, we do not consider there is any justifiable reason for putting the time limit to one side in this instance, given her awareness of the type of therapy she needed and her dissatisfaction with the service she had received up to this point.
27. The records show she was engaging with the service during this period, and we are satisfied this is evidence she had the capacity to make a complaint at this time and we feel Miss A could have completed the complaints process by referring the complaint to our service much sooner than she did. We know Miss A did complain to the Trust on 30 November 2017 about her concerns with the group therapy sessions, and we consider it is reasonable to say she could have complained to the Trust about the previous lack of group therapy sessions at this point. Taking this into consideration, we consider this element of Miss A’s complaint is out of time.
Failure to create safe environment between March 2017 and November 2017 28. Miss A says the Trust failed to create a safe environment in the group therapy sessions she attended between March 2017 and November 2017. She says they failed to provide appropriate safeguarding to her or correctly investigate her concerns that she was being bullied by other service users within the group therapy setting.
29. We can see Miss A complained to the Trust on 30 November 2017 about her concerns about the group therapy sessions between March and November 2017. The Trust investigated this complaint and sent a final response to her on 10 January 2018, not upholding her complaint. In the letter the Trust clearly signposted Miss A to our service if she remained unhappy with this decision.
30. During our phone call on 18 October 2024, we discussed with Miss A the reasons for the delay in her referring this element of the complaint to our service after she received the final response in January 2018. Miss A explains that as she has attention deficit hyperactivity disorder (ADHD) and autism, it takes her a long time to do anything and process information. She explained as she has problems with her mental health, she felt like her testimony would not be believed. She explains she had problems with addiction at this period in her life, and she also had her son to look after at this time. She says at this time she then lost custody of her son between this time, and this caused her immeasurable distress and upset. We are truly sorry to hear of Miss A’s concerns in respect of being heard given her mental health concerns.
31. We recognise the devastating impact the loss of her son had on her around this time, and do not intend to take away the impact this had on her. We remain satisfied Miss A could have complained to us much sooner than she did about this issue.
32. As explained above, we can see Miss A complained to the Trust in November 2017 and received a response in January 2018. The Trust’s response letter from this time also outlines that if she was unhappy with the response, she can refer the complaint to our service.
33. We can see during and after this period, the clinical records show Miss A was engaging with the service and we are satisfied this is sufficient evidence to show she had the capacity to make a complaint at this time and complete the complaints process by referring the complaint to our service.
34. It is clear to see the difficulties Miss A has experienced during this period, we do not consider there is any justifiable reason for putting the time limit to one side in this instance, given her awareness of the complaints process. We consider this element of her complaint is out of time.
Failure to offer appropriate therapy between November 2017 and September 2021 35. Miss A initially explained to our service that her date of knowledge for this element of the complaint after she requested her clinical records following her discharge from the service on 24 November 2024. She says it was only at this point that she became aware of the extent of her mistreatment from the Trust and had cause to complain.
36. We discussed this with Miss A further on 20 February 2025. At this time Miss A confirmed her date of knowledge was 14 August 2020. She says she had a telephone appointment with the Trust on 7 December 2019 about her ongoing therapy needs and was told that a referral to group therapy had been made.
37. She explained she received nothing further from the Trust about the referral but did not chase this as she was aware there was a long wait to start group therapy at this time. She says she next spoke to the Trust on 14 August 2020 when it became clear the referral had not been made. She reiterated she did not remember this period clearly and had lost custody of her son, she felt this was sufficient to explain why she did not refer the complaint to us at this time.
38. We recognise the devastating impact the loss of her son had on her around this time, we remain satisfied Miss A could have complained to us much sooner than she did about this issue.
39. Miss A has explained to us she was aware there was a delay during her telephone call with the Trust on 14 August 2020, and she then received correspondence from the Trust on 2 September 2020 to explain she had been referred to the group therapy sessions, again we are satisfied this is evidence she had knowledge of the delayed referral at this time.
40. Taking the evidence into account, we consider Miss A’s date of knowledge was 14 August 2020, when it became aware to her she had not been referred for further treatment.
41. Miss A explains she could not complain at this time, however as explained above, we can see Miss A complained to the Trust in November 2017 and received a response in January 2018. The Trust’s response letter from this time also outlines that if she was unhappy with the response, she can refer the complaint to our service.
42. We can see during and after this period, the clinical records show Miss A was engaging with the service and we are satisfied this is sufficient evidence to show she had the capacity to make a complaint at this time and complete the complaints process by referring the complaint to our service.
43. It is clear to see the difficulties Miss A has experienced during this period, we do not consider there is any justifiable reason for putting the time limit to one side in this instance, given her awareness of the complaints process. We consider this element of her complaint is out of time.
Reasonable adjustments 44. Miss A says the Trust failed to make reasonable adjustments for her in the group therapy sessions between February 2023 until her discharge on 8 November 2023 given her existing condition. As explained above, Miss A explained to our service that she has ADHD and autism and requires information breaking down into manageable pieces of information. We understand how important these adjustments are for Miss A to enable her to manage and process information effectively.
45. The Trust’s group therapy handbook outlines any service users that have any disability or health concerns that they think may inhibit their full involvement in the therapeutic community, should advise the staff facilitating the preparation group, so that early consideration can be given to how the Trust can enable them to access the full programme.
46. We have reviewed the evidence to establish if there is any indication the Trust failed to make reasonable adjustments for Miss A throughout during the therapy sessions.
47. The clinical records show prior to starting her therapy in February 2023, the Trust invited Miss A to the preparation sessions to discuss the therapy. Miss A had an individual preparation meeting with the Trust on 10 January 2023, she met the Trust again on 25 January and 31 January 2023. The clinical records from these meetings make no reference to Miss A requiring any reasonable adjustments at this time.
48. The records show the Trust provided her with its group therapy handbook for when she started therapy on 17 February 2023 in the individual sessions. This handbook makes it clear to the reader the necessity for the service user to make the unit aware of any specific adjustments needed to enable them to access the programme.
49. The Trust completed an assessment on Miss A of her needs during an appointment on 14 March, the purpose of this was for Miss A to share information with the Trust and for the clinician to gather information on Miss A to enable her to maximise the benefits of the therapy sessions. Again within the clinical record of this assessment there is no evidence Miss A made the Trust aware of the need for it to make any reasonable adjustments for her during the group therapy sessions.
50. On 16 June Miss A met with the Trust to complete a four-month review of the group therapy sessions and to discuss her progress. We can during this review the Trust updated her care plan, and there was a specific section for physical health needs and reasonable adjustments, in this section it is reported Miss A was in good physical health and this was noted not to be impacting on her ability to get the most out of the programme. Again within this record there is no evidence Miss A made the Trust aware of the need for any reasonable adjustments.
51. On 8 August the Trust had a meeting with Miss A to discuss her ongoing needs within the sessions. We can see at this point the records show the Trust discussed any reasonable adjustments with her and it was noted at this point she had difficulty retaining information. We can see at this point the Trust identified the need to break down information given to her into smaller, more manageable pieces of information. At this point we can see the Trust outlined the TC would look at different ways it could deliver information to Miss A in a way she could better process. We consider the Trust has sufficiently listened to her request for information to be broken down at this time.
52. After this point we can see on 15 September during a therapy session the clinician provided Miss A with feedback on her progress so far. The Trust then summarised the feedback in a letter to Miss A. The record shows Miss A thanked the clinician for this and for the support. This is in line with the Trust’s handbook in which it says the Trust will make reasonable adjustments to enable a service user can access the full programme.
53. After this period until November 2023, Miss A attended regular sessions and was eventually discharged from the service as it is reported she broke the terms of the contractual agreements.
54. We understand Miss A’s concerns in respect of the Trust not making reasonable adjustments for her during her time in the group therapy sessions. We acknowledge how important it is for her to have large pieces of information broken down to enable her to process and understand this properly. We are sorry to hear how difficult this has been for her.
55. Within the evidence provided, we can see no evidence to show Miss A made the Trust aware of her need for reasonable adjustments until August 2023, when the Trust took steps to address this, when we can after this period when the Trust wanted to explain her progress, made a decision about whether she can continue with the therapy, and eventually discharge her it discussed the decision and wrote to her to summarise what was discussed. We consider this is in line with the reasonable adjustment Miss A requested.
56. We sought clinical advice to establish if there was any indication the Trust did not make reasonable adjustments for Miss A in the group therapy sessions. Our adviser explains there was no evidence to suggest Miss A told the Trust that she needed any reasonable adjustments, therefore the decision not to make any reasonable adjustments does appear reasonable. They explain the Trust does appear to have followed their duties in respect of reasonable adjustments based on the evidence available and they could not make adjustments for factors they were not aware of.
57. We know Miss A disagrees with this and says she told the Trust throughout this period in the assessments that she had, that she needed this adjustment making. We do not doubt Miss A’s recollection of what was discussed during these appointments. When investigating this point we paid particular attention to what Miss A told us and looked to see if there was any evidence in the clinical records which we could use to support her account.
58. We have been unable to identify any records or any other supporting information which would allow us to challenge or criticise the information provided by the Trust. We appreciate how disappointing this will be for Miss A. It is important that any findings we make and any failings we identify are supported in the evidence available to us and we have to acknowledge where there is a lack of evidence to support a complaint. For this reason, although we do not dispute what Miss A has said, we have seen no indications of a failing here.
Discharge 59. Miss A says the Trust inappropriately discharged her from the TC on 8 November 2023 without offering any further support for her mental health. We are sorry to hear how deeply Miss A has been impacted by the decision to discharge her.
60. The RCP guidance outlines there are therapeutic boundaries in place for therapeutic communities, these boundaries outline that community members should work together to review, set and maintain rules and boundaries.
61. The Trust’s policy outlines there are numerous indicators for discharging a patient. This includes non-engagement with the services. The decision to discharged must be summarised within the clinical records and a written summary provided to the service user and their GP.
62. The Trust’s group therapy handbook clearly outlines that where members of the TC display interfering behaviours such as disclosing confidential information, then this may result in losing their place in the program. It says regular and punctual attendance of sessions is paramount to psychotherapy and the expectation is that users let the service know as soon as possible when circumstances prevent them from attending a session. It says confidentiality is crucially important for everyone to feel safe in the group and develop trust in the process. Breaching of confidentiality is taken very seriously and may result in members losing their place. Verbal and/or physical aggression will not be tolerated either as, again, people cannot make use of their therapy if they feel threatened, intimidated or otherwise unsafe. It outlines that if a user is involved in a serious incident, they will be suspended for a set period of time, at which point they will be invited back to represent to the community.
63. We can see in the initial treatment offer letter sent to Miss A on 4 March 2021, the Trust outlined the expectations and boundaries of the therapeutic model, advising of the necessity for Miss A to attend the sessions regularly, and to explain that breaching of the agreement may result in her losing her place in the therapy sessions. We are satisfied the Trust clearly outlined the expectations required of Miss A at the start of her therapy sessions, and that she would be aware that any breaches may result in her being removed from the service. This is in line with the RCP guidance on having therapeutic boundaries in place.
64. The clinical records show on 21 July 2022 the Trust first identified concerns with Miss A’s regular attendance of the group sessions. The record shows the clinician explained they were reluctant to discharge her from the service, but reiterated this would happen if she continued with her ‘patchy attendance pattern’, which goes against the contract she signed before starting treatment within the TC. The clinician documented this pattern was disruptive to both Miss A and the group, and documented a risk assessment if she was discharged from the service. The Trust wrote to Miss A on 27 July to reiterate the importance of attending regular sessions and to remind her that if she continued to miss sessions, she would lose her place in the outreach group.
65. Miss A was temporarily suspended from the TC on 1 June 2023 due to breaching the expectations of the behavioural contract. The Trust identified concerns in August 2023 that she had breached the confidentiality contract. She was suspended from the service between 22 and 23 August due to the breaches and she signed a further behavioural contract on 23 August and was let back in the group sessions. She was then suspended from the service on 31 August.
66. On 6 September Miss A sent an email to the Trust to advise she wished to leave the group sessions as she had been involved in conflict with other members of the group. Following further discussions with the clinicians at the Trust she agreed to restart the group sessions on 14 September.
67. On 3 November the Trust documented serious concerns about Miss A’s behaviour in the group sessions, it is reported she became disruptive and angry in the sessions and then interrupted another session going on at the time. She was suspended from the service again.
68. Following this the Trust reviewed Miss A’s behaviour during to date, the Trust made the decision that, given her overall behaviour and frequent breaches of the contracts she signed, she would be discharged from the service. We can see during an appointment on 8 November the Trust discussed this decision with Miss A, explained the reasons why it was discharging her from the service and then wrote to her on 24 November to confirm this decision. This is in line with the Trust’s policy on discharge.
69. In our discussions about this issue, Miss A explained to us that during her time within the TC sessions, she felt the Trust did not treat her fairly at times when she was in conflict with other members of the group sessions. We are sorry to hear how much of an impact this conflict had on Miss A. It is clear from speaking to her how much she has been impacted by this and how important this issue is for her.
70. She has provided testimony from other service users which she says proves this and would support the discharge was incorrect. We have carefully considered this to establish if there is any evidence to support her concerns. We acknowledge the difficulties Miss A had with the other service users within the group therapy sessions. This must have been very hard for her at a time when she was already vulnerable within the group therapy sessions. From reviewing the emails from the other users, we have seen nothing which would indicate the decision to discharge was incorrect.
71. Following a review of all the available evidence, we consider the decision to discharge Miss A was based on her breaking the behavioural and attendance contracts throughout her time at the TC. We would expect all service users to comply with the agreement contracts they sign at the start of therapy, to ensure the minimum level of disruption for themselves and the other service users.
72. To assist us in reaching this decision, we have sought clinical advice to establish if there are any indications to show the Trust inappropriately discharged Miss A from the service. We can see in the initial contact with Miss A and throughout her time at the TC, the Trust has clearly outlined the expectations it has of all service users in respect of their behaviour and attendance of the sessions, this was clearly outlined in the members handbook.
73. Our adviser explains the Trust provided Miss A with a clear rationale as to why she was being discharged from the service and they have said the Trust has clearly made efforts during her time at the TC to try to resolve the conflict between Miss A and the service.
74. Overall we can see Miss A has breached the behavioural and attendance contracts during this period on several occasions and discharged her, this is in line with the Trust’s policy on discharge as she was not engaging properly with the service, and our clinical advice supports this view. We have seen no indications of a failing here.
75. We can see within the discharge letter the Trust signposts Miss A to contact her GP if her mental health deteriorates in any way after she had been discharged from the service. It explains if she feels in crisis she can access help directly and reiterated the importance of accessing this help quickly if needed. Our adviser explains this is reasonable in the circumstances. We have seen no indication the Trust left her without support after the discharge and our clinical advice supports this view.
76. Overall we are satisfied there is no indication of a failing in respect of the decision to discharge Miss A from the service, and this was in line with the Trust’s guidance. Our clinical advice supports this view.