ADHD assessment and conclusion
19. Before we decide if we should conduct 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. We have done this and have not found any indications that something has gone wrong.
20. Miss D complains BeeU failed to properly diagnosis her daughter with ADHD, did not accurately assess her daughter and based its decision on inaccurate statements.
21. She says BeeU based its diagnosis having only met her daughter for an assessment and then a 20-minute meeting.
22. She explains BeeU based its decision on information previously provided during calls to BeeU, noted down by people who were call handlers and not trained professionals. She says BeeU took this information out of context.
23. She says BeeU asked inappropriate questions regarding G’s father. She confirms she felt like BeeU were not listening to her during the assessment and dismissed her comments.
24. Miss D explains as a result of the Trust’s failings, her daughter does not have a diagnosis, which would help her understand things more and get support. She says it has caused damage to her daughter’s mental health.
25. She says G has since been diagnosed with a sensory processing disorder, dyslexia and dyspraxia and has been referred to the paediatricians.
26. In its response, the Trust explained it completed a face to face assessment with G on 9 February 2023. It said any concerns were considered to be in keeping with her age and development at the time. The Trust stated between June and August 2023 G worked with a mental health practitioner. It said the outcome of this concluded that G was not thought to be experiencing any significant anxiety, mental health or problems with ADHD.
27. The Trust further explained its ADHD team looked at the assessment scores and provided a QB test (Quantified Behavioural Test). The QB test and the scores for G were not consistent with ADHD.
28. The Trust advised it arranged a meeting on 15 November with Miss D to discuss the outcomes. It said during this meeting G spent time with the mental health practitioner she had previously worked with in the summer. It said this was completed in a separate room to enable everyone to speak openly without her present.
29. The Trust said the information within the outcome letter dated 21 December had been collated from G’s records, ongoing assessments, from several interactions with G and Miss D, and on information from the GP. It says it was not solely based on the appointment from 15 November.
30. The National Institute for Health Care Excellence (NICE) provides national guidance and advice to improve health and social care.
31. Our adviser has referred us to the NICE guidance of Attention deficit hyperactivity disorder: diagnosis and management.
32. This states at section 1.3 under the section for diagnosis. ‘ADHD should only be diagnosed by a specialist psychiatrist, paediatrician or other appropriately qualified healthcare professional with training and expertise in diagnosing ADHD, on the basis of: • a full clinical and psychosocial assessment of the person; this should include discussion about behaviour and symptoms in the different domains and settings of the person's everyday life and • a full developmental and psychiatric history and • observer reports and assessment of the person's mental state’.
33. The records show on 3 January 2023 G’s GP sent a referral to BeeU, due to concerns of anxiety, behavioural issues, OCD and poor sleep. The GP sent a further letter to BeeU on 13 January requesting it assess G, due to Miss D’s concerns that she may be suffering with ADHD.
34. BeeU arranged an initial assessment for G on 9 February. The records detail this was due to concerns relating to the difficulties G was experiencing, the impact this is having on the family network and mums’ beliefs that things are worsening.
35. On 9 February BeeU completed an initial assessment with G where a mental health practitioner saw her. The notes from this assessment detail they took a family history, spoke and observed G and spoke with Miss D on her own and noted her concerns about G.
36. The clinician’s formulation following the assessment stated G did not have features of ADHD while observed in the assessment. It stated she was able to sit and draw for 30 minutes and answer questions about school.
37. The notes detail following the appointment BeeU sent out a Conners assessment to Miss D and the school. (a Connors assessment is a set of questionnaires used to evaluate symptoms associated with ADHD). BeeU detail it made Miss D aware, G will not be seen if the Connors assessment does not indicate ADHD.
38. The records show both Miss D and the school completed and returned the questionnaires to BeeU in March 2023. The school also completed a children’s communication checklist, and a strengths and difficulties questionnaire.
39. On 25 April, the records detail BeeU completed its ADHD screening outcome. The notes state after reviewing the ADHD pack, G has been accepted to the pathway for a formal assessment. The notes state BeeU were to arrange a first assessment and QB test.
40. On 9 June, G completed the QB test (this is a computer-based tool that helps assess ADHD). The results of the test showed that G performance was normal.
41. The records detail between 27 June and 29 August, G had five appointments with a mental health practitioner for help with anxiety.
42. The Trust has explained following the completion of this work with G, its conclusion was, it thought she was not experiencing any significant anxiety, mental health or problems with ADHD. The Trust stated the clinical impression that G does not have ADHD should have meant the service did not provide any additional assessment for this. The Trust has apologised this continued unnecessarily.
43. The records show in September and October Miss D contacts BeeU several times for support due to her concerns with G and also for an update on an appointment for an ADHD assessment. The records detail BeeU had contacted its ADHD team.
44. On 30 October, the records show BeeU reviewed G’s case following Miss D’s contact and concerns raised. The records state it is unclear if an ADHD diagnosis is appropriate for G and a discussion was had with the psychiatrist and mental health clinician.
45. The records show on 7 November, BeeU spoke with Miss D’s and G’s GP regarding Miss D’s concerns and obtained further information.
46. The records detail on 9 November, BeeU decided to have a joint review to see both Miss D and G. BeeU arranged this for 15 November.
47. On 15 November the psychiatrist and nurse specialist saw Miss D and G for an appointment. The records from this appointment detail the assessments and contacts with G, and the schools contact and observations. It also details the concerns Miss D had raised about G and the information it has provided to BeeU, including her own mental health concerns.
48. During the appointment the nurse specialist also saw G on her own. The notes reflect her observation and contact with G at this time.
49. The records detail the clinical impression following the appointment was that G does sometimes present with fidgeting and restlessness, which seems possibly associated with anxiety. They record there is no evidence of impairment from school, the QB test or during the extensive time with its practitioners. It recorded G would not meet the threshold for an ADHD diagnosis.
50. On 21 December, BeeU sent its report to Miss D of its conclusion from the assessment. This stated G did not meet the diagnostic criteria for ADHD.
51. We have considered the evidence from our adviser. They have explained the actual determination of ADHD is a clinical judgement based on the information provided to BeeU. Our adviser confirmed BeeU has done a reasonable assessment, and the conclusion is reasonably sound based on the information it has gathered within its assessments. BeeU has used more than one set of observations, supporting questionnaire and a QB test. Our adviser further explained it is a very defensible conclusion that G does not meet the diagnostic criteria for ADHD.
52. Our adviser confirmed BeeU has taken the action expected when assessing G, with BeeU confirming its assessment is not just based on one piece of evidence. Our adviser stated the process BeeU has used to make the assessment is correct. Therefore, BeeU’s conclusion is reasonable.
53. Our adviser also stated the information BeeU obtained is reasonable and what would be expected. They explained you would expect BeeU to take a history from the parent, information from another source e.g. a school, and do an observation. BeeU has done all these things.
54. Our adviser stated a Trust should take into account all the information available, as the clinician should be neutral to the outcome. They confirmed there is no significant evidence that BeeU took into account one piece of evidence more than another. It does appear BeeU made a balanced view based on the information available.
55. We appreciate Miss D’s concerns regarding BeeU’s assessment of G. We understand Miss D was trying to get support and help for G. We are sorry to hear of how she found the experience with BeeU, and that she was unhappy with its conclusion following the assessment. We are particularly sorry to hear of the struggles G has experienced, and the impact Miss D has described of the effect it has had on G’s mental health.
56. Based on the evidence we have seen, BeeU has reached its conclusion based on the observations, information and test completed, by a psychiatrist with the support of other mental health practitioners. This is in line with the NICE guidance.
57. The records show BeeU had completed two assessments, the Connors questionnaire, QB test and other observations from its appointments with G. Within these assessments there is evidence of observations completed on G including her mental state, psychosocial assessment, discussion about behaviours and symptoms within the home and at school. A full history is taken, including a developments history. BeeU has also obtained information from G’s school and GP. This is in line and what would be expected accordance with the NICE guidance.
58. We understand and appreciate Miss D’s concerns that the school did not support her concerns at the time. BeeU would only be able to base its decision on the information available to it at the time. From the records, it indicates BeeU obtained several pieces of evidence and did not just rely on the information from the school.
59. We acknowledge Miss D’s concerns regarding BeeU relying on evidence of information she had provided to its call handlers. We can see within the assessment completed on 15 November, the psychiatrist had listed her contacts with the service. Taking into account the evidence from our adviser, BeeU should take into consideration all the available evidence.
60. The records indicate BeeU has taken into account the family history, observations of G it has made during the assessments, and the QB assessment. It has considered all these in equal measure. There is no evidence to indicate it has taken one piece of evidence over another.
61. NICE updated its guidance in 2024, which is after G had her assessment. Therefore, this part of the guidance would not have been applicable at the time. The update states as an option an organisation can use a QB Test to help diagnose ADHD in people aged 6 to 17 years old. As such, at the time BeeU were assessing G, BeeU would not have needed to do the QB test. From the evidence we can see BeeU carried out a QB test. We consider this shows BeeU were taking extra steps that it did not need to as part of its assessment.
62. NICE guidance recommends taking a full history, assessment and having specialist clinicians. BeeU have taken this action. The evidence indicates BeeU has taken all the available information and evidence into account to complete its assessment. Based on this we consider BeeU has acted in line with the NICE guidance when it completed its assessment and diagnosis of G for ADHD. As such we do not find a failing with BeeU regarding this issue.
Judgements as a mother
63. Miss D says BeeU made judgements about her as a mother. She says the doctor during the assessment stated her concerns was her ‘anxiety talking’, that she was putting this on her daughter. She says BeeU accused her of wanting to label her daughter. She considers they were indicating she had Munchhausen’s by proxy.
64. She explains BeeU mentioned and passed judgement about her having post-natal depression and tried to link this to her assumption that her daughter has ADHD.
65. Miss D explains BeeU stated if she pursues her concerns about G having ADHD, she could be causing more emotional damage to her.
66. The Trust has explained during the appointment on 15 November some of Miss D’s views around a diagnosis were explored. It says this is a usual part of the service’s work, especially when there are differing views between a parent and its understanding of the child’s needs. The Trust confirmed this is to try to understand what needs the parent is concerned about so it can help with that.
67. The Trust stated it is also common as part of its assessments to understand the early years of the child and the health, wellbeing and support which the parent/carers currently have in place. It says parental mental health is a key area and one which it routinely asks about to try to establish where there might be needs and to provide any help if identified. It says this includes understanding factors such as relationships between key family members.
68. In relation to the reference about post-natal depression, the Trust say during the assessment process clinicians will often ask about and make reference to any experiences of the child and family, which it may have gathered across different appointments. It says in Miss D’s case, this included reference to postnatal mental health.
69. The NICE guidance says at section 1.3.4, ‘as part of the diagnostic process, include an assessment of the person's needs, coexisting conditions, social, familial and educational or occupational circumstances, and physical health. For children and young people, their parents' or carers' mental health should also be assessed’.
70. Within the records it shows throughout Miss D’s contact with BeeU she has provided a lot of information regarding her own mental health and struggles. During the meeting on 9 February 2023, with the mental health practitioner we can see they obtain a family background and history. They also speak with Miss D on her own who detailed the struggles she has faced with G.
71. The records also detail during the appointment on 15 November BeeU asked about Miss D’s mental state and whether this impacts G.
72. Within BeeU’s report dated 21 December 2023, this refers to Miss D’s mental health. The report stated maternal mental health or anxiety may be playing a role in G’s behaviour at home.
73. Our adviser has explained BeeU were correct take into account mums post-natal depression and her anxiety’s. Also, that they were correct to consider a full history.
74. We appreciate Miss D’s concerns that she considers that BeeU have made judgements about her as a mother. We can understand from the questions asked of her and the report completed on G why she considers this. We acknowledge BeeU taking Miss D’s history and it referring to this may have been upsetting to her. We are sorry to hear of the upset and distress this may have caused. We are also sorry to hear about the impact on Miss D after she received the report and the consequences that this led to.
75. The findings of BeeU within its report are the clinical view of the psychiatrist. There is no evidence there is any judgements made about Miss D as a mother.
76. We recognise there is a lot of reference to Miss D’s mental health concerns within BeeU’s assessment and report. Within the report BeeU also acknowledge the loving relationship G and Miss D have. It also details Miss D is doing her best to not let her feelings affect G.
77. In line with the NICE guidance BeeU should consider the parents mental health. Therefore, it was correct for BeeU to take the full history and consider Miss D’s mental health, within its assessment for G. As such we do not consider there was a failing by BeeU in asking questions about Miss D’s mental health or referring to this within its decision. Accordingly, we have not found a failing with this issue.
Recommendations and support
78. Miss D complains BeeU failed to provide any recommendations or support for her daughter following its assessment. She says they did not mention anything about an occupational therapist.
79. She explains during the assessment BeeU mentioned about medication to help G to sleep. She confirms there was no mention of this in the report.
80. The Trust had concluded that G did not meet the diagnostic criteria for ADHD.
81. In relation to the medication, it states the nurse specialist has stated they do acknowledge there was a quick discussion about medication and specifically about melatonin. However, they state this was not part of a treatment plan for G but more generally discussed and this was later discounted as a treatment option.
82. The Trust confirmed it would usually provide sleep hygiene advice for sleep difficulties and do not routinely prescribe Melatonin.
83. The NICE guidance says inform people (and families or carers) receiving a diagnosis of ADHD about sources of information, including,
• local and national support groups and voluntary organisations • websites • support for education and employment.
84. The guidance further states people who do not meet the threshold of a diagnosis of ADHD may benefit from similar information.
85. As referred to above G had an initial assessment on 9 February. The records show following this BeeU sent Miss D a letter regarding the next steps. Within this letter it also included resource information for Beam Shropshire (the Children’s Society). This is a BeeU service pathway, where parents can discuss current difficulties with mental health practitioners, who can offer help and support. They also provide drop-in appointments.
86. Following BeeU’s assessment on 15 November, it sent its report dated 21 December. Within this it stated G does not meet the diagnostic criteria for ADHD. The report also concluded that there is no evidence at this point that G is suffering from a mental health or neurodevelopmental condition.
87. The recommendation in the report details ‘that unless professionals feel there has been an objective change in presentation, it would not be in G’s best interest to refer for further assessment’. There are no recommendations of support for G.
88. Our adviser has explained as BeeU concluded G did not have ADHD or ASD, it would not be expected for the Trust to make any other recommendations or support.
89. Our adviser has further explained that BeeU has overstated its findings, by stating she does not suffer from any neurodevelopmental condition. Our adviser confirmed this is incorrect, as BeeU did not assess for everything in that category, as it just assessed for ASD and ADHD. They stated it did not look for all the possible neurodevelopment disorders. Our adviser confirmed later G gets a diagnosis of dyspraxia. This would be a neurodevelopmental disorder.
90. We acknowledge Miss D was seeking help and support for her daughter. We appreciate her frustration that following the assessment BeeU did not provide any further support. We are sorry to hear of the impact Miss D has described on G’s mental health due to her not getting support.
91. We can see throughout G’s contact with BeeU, it has offered support through its contacts and also the five appointments completed between June and August with a mental health practitioner for help with anxiety.
92. The evidence we have seen demonstrates BeeU completed its ADHD assessment and did not conclude G met the threshold. Due to this taking into account evidence from our adviser it would not be expected BeeU provided any further support or recommendations.
93. The records show BeeU did provide details of local support groups within its letter dated 10 February. This is good practice in line with the NICE guidance, of providing this information even though G did not meet the threshold for the ADHD diagnosis.
94. We recognise there is a potential shortcoming with BeeU overstating its finding within its report. We understand from Miss D, G has since been diagnosed with dyspraxia.
95. We have considered what our adviser has said regarding the impact of this. They explained it is not a major issue and would not lead to any impact, as G is later diagnosed with other neurodevelopment disorders, eg dyspraxia. Our adviser stated BeeU may have put it in this way to ensure they are clear with the findings. For this reason, while we acknowledge this as a shortfall, we would not so far as to say this was a failing, when reviewed in the context of the actions of BeeU as a whole.
96. As such we would not require any further action of the Trust regarding this.
Conduct during the assessment
97. Miss D explains during the meeting on 15 November 2023, BeeU did not prepare for the meeting and did not read the notes. She says during the meeting the psychiatrist was unprofessional, did not listen and kept interrupting her.
98. The Trust has explained in order to provide space for clarity regarding G’s needs and to identify any support requirements, an appointment was arranged with a consultant psychiatrist and nurse specialist.
99. The Trust apologised to Miss D that she found the appointment abrupt. It says this was due to its clinicians wanting to be very clear that ADHD is not something it is concerned about.
100. The records show the Trust engaged with its psychiatry lead on 30 October 2023, following Miss D’s contact regarding the concerns she had for G.
101. The records detail the psychiatrists notes from the appointment on 15 November. This includes the contacts and information received from Miss D regarding the concerns she had about G. It detailed the assessment and contacts with G. This stated any conclusions/observations from the contacts. Along with the outcomes of the tests/assessments completed. The notes included a summary of G, which detailed what the school have said. Also, what Miss D had told the psychiatrist. The psychiatrist also recorded their clinical impression of G.
102. The records further detail the notes and observations by the nurse specialist from the meeting on 15 November.
103. We have considered evidence from our adviser. They have explained there is no evidence there was a problem with the assessment. It was appropriate BeeU got the psychiatrist and other clinician to see G and her mother. Also to see them separately. Our adviser stated this was good practice.
104. Our adviser explained there is no evidence in the clinical file that indicates anyone acted unprofessionally.
105. We have considered carefully about whether we can reach a robust decision on this point of complaint. After reviewing the accounts of both Miss D and BeeU, we can see the accounts of what was discussed and happened differ.
106. We can see from the records both the psychiatrist and the nurse made detailed notes from the meeting. These also included the previous contacts and assessments completed. This indicates they had prepared before the meeting and had considered the case notes previously.
107. We cannot determine what was said during the meeting or the conduct of the psychiatrist, as we were not a party to the meeting. Our adviser has not indicated there was anything unprofessional about the meeting.
108. The evidence we have in this case is G’s records, the Trust response and Miss D’s account.
109. There is no other independent evidence to consider so we have considered whether we can reach a view based on the evidence we have, which is two differing accounts and G’s medical notes.
110. Having done this we are not persuaded we can reach a view either way, even trying to balance what is more likely to have happened. This is because we only have the two accounts, and in this case G’s medical records are an extension of the Trust’s account.
111. We do not doubt Miss D’s recollection of the meeting. We are sorry to hear of how she felt during the meeting and that she did not feel listened too and talked over.
112. We are impartial and have to weigh evidence from all sides to reach a view. In this case we cannot make a robust conclusion regarding what is more likely to have happened or what had been discussed, even on balance. Further investigation would not reach a satisfactory conclusion.
113. That said, we can see the Trust has given a good response in line with the Ombudsman’s Principles. These say ‘Public bodies should always deal with people fairly and with respect. They should be prepared to listen to their customers and avoid being defensive when things go wrong.’
114. The Trust response recognises Miss D’s distress and has apologised that she found the meeting abrupt. The Trust has also provided an explanation as to why this was the case.
115. While we have not identified a failing with this issue. We are pleased to see the Trust has taken action to apologise to Miss D and explain why it had taken certain action. This is in line with the ombudsman principles. As such we would not ask the Trust to do anything further regarding this issue.
116. We realise this is unlikely to be the outcome Miss D was looking for when she had approached us. We were sorry to hear of the circumstances which led to her complaint, and we do not underestimate how difficult things have been for her and G.
117. We hope our decision clearly explains the reasons why we will not be considering the complaint further. We would like to thank Miss D for bringing her concerns to our attention.