The Trust’s decision to discharge Mr A from its mental health service in October 2023
13. Mr A says the Trust forced him to agree to discharge himself from its mental health service at an appointment he had with the Trust on 16 October 2023. Mr A says he had an appointment with a psychotherapist and a team leader. He says that the two members of staff tried to persuade him to discharge from the mental health service for almost two hours during the appointment.
14. Mr A says he was told that until he moves from where he lives, he will not be receiving any help from the mental health service at the Trust. He says he was advised to contact the mental health charities, Samaritans, Mind and the Talking Shop, as he was being discharged from the Trust’s mental health service. Mr A says the Trust should not have discharged him from its service in October 2023.
15. In its response to Mr A’s complaint, the Trust stated Mr A’s appointment was with a cognitive behavioural therapist and a registered mental health nurse. The Trust outlined the care and treatment it offers is not based on social circumstance (where Mr A lives). The engagement with therapy is based on the therapist’s clinical judgment of the person’s suitability to engage with the type of therapy.
16. The Trust said the cognitive behavioural therapist discussed a report sent from a clinician at South London and Maudsley. The report stated it was not the right time for Mr A to be completing his therapy because Mr A was still at risk. This was because the person who had assaulted Mr A was still regularly visiting the building Mr A was living in. This was relevant because the type of therapy Mr A was engaging in had entailed him going outside of his home to engage in meaningful activities. This had been recommended by his previous therapist. This activity was to try and help Mr A break out of unwanted rumination cycles, or to help him develop a stronger sense of self.
17. The Trust said it would be difficult for Mr A to be engaging in therapeutic interventions if he is still living in the same area and fearful of going out of his home, should he meet the person who assaulted him.
18. The Trust said Mr A disclosed he had been thinking about moving as the person who assaulted him still lived near to him. The Trust said that at no time did the cognitive behavioural therapist indicate it was a prerequisite that he must move property for treatment to be offered. However, as the specialist report has indicated and the cognitive behavioural therapist agreed it was essential for Mr A to feel safe enough to leave his property on a regular basis, to engage in activities to help reclaim work and reducing avoidance of traumatic reminders.
19. The Trust said these are the reasons why it was not be appropriate to offer Mr A treatment at that time.
20. To determine if it was appropriate for the Trust to discharge Mr A from its mental health service in October 2023, we have reviewed his clinical records and we have received clinical advice from a cognitive behavioural therapist adviser.
21. The Trust’s clinical records show it discharged him from its service on 17 October 2023. The clinical records state Mr A had no treatment needs at that stage, and it was appropriate for the Trust to discharge him from its service. A further entry dated 19 October 2023 outlined the Trust did not consider it was the right time for Mr A to be working on his difficulties with its service because he was still at risk, as the individual who assaulted him was still visiting the building where he lived.
22. Our clinical adviser stated the Trust had concluded after clinical assessment that its service was not appropriate for Mr A at that time. The Trust signposted Mr A to the community and voluntary sector that could meet his needs.
23. A letter dated 23 June 2023 from the Community Mental Health Service Manager at the Trust sent to the Department for Work and Pensions for the purposes of his Personal Independent Payment application, clarified the function of the Recovery Team and the length of the Trust’s involvement in Mr A’s care. The letter stated:
‘Mr A has been open to the Recovery Focused Team within North Lincolnshire Care Group since March 2020. The Team work with people with severe and enduring mental health problems, providing individualised person-centred care and treatment which may include medication management, psychological therapy, occupational therapy interventions and Individual Placement Support. The Team is multi-disciplinary with Consultant Psychiatrist, Consultant Nurses, Mental Health Nurses, Principle Clinical Psychologist, Cognitive Behavioural Therapist, Occupational Therapist, Employment Support Specialist and Health Care Support staff’.
24. To determine if this discharge was appropriate, we have looked at a letter from the clinical team sent to Mr A dated 30 October 2023. The clinical team clarified the circumstances around the discharge. The letter outlined the following:
‘The purpose of the appointment was following the report from the Depersonalisation Disorder Service at the Maudsley Hospital, to establish what your current needs are and moving forward. As you are aware the report indicates that therapy is not appropriate at the current time due to circumstances and ongoing issues from the racially motivated attack on you by a neighbour. The therapist indicates that there needs to be greater stability in your environment and situation before further therapy can be considered. It would be, as you agreed, very difficult to engage in any meaningful or beneficial way due to the nature of the interventions would be exposure and reclaiming your life. Any therapeutic interventions would involve being out of your home environment, something you find currently very frightening and avoid whenever possible.’
25. The clinical team outline that Mr A’s needs did not fall into the scope of the recovery team and it signposted him to relevant services. It concluded ‘Because you have no current treatment needs that our service could support you with, it is appropriate to close you to the Team’.
26. We have reviewed the clinical report by the Depersonalisation Disorder Service at South London and Maudsley Hospital NHS Foundation Trust, dated 23 June 2023. The report highlighted that Mr A tested positive for a dissociation type clinical problem. Our clinical adviser stated dissociative problems exist on a spectrum from daydreaming to extreme problems of stress and identity disorders, where the person could experience fugue states, non-epileptic seizures, changes to personality or disconnection from the present. These can be distressing for the individual and those around them, although they are not harmful.
27. Mr A’s clinical records show that this was not a commissioned offer in Mr A’s local services and so he needed to access a national service. The national service assessment identified the history of psychological therapies that have been provided over the years to Mr A.
28. The report also highlights that Mr A is managed and maintained on a specific medication regimen, to assist with his dissociative symptoms.
29. The report states ‘Mr A has a long-standing history of depersonalisation/derealisation symptoms and body dysmorphic symptoms which have left him depressed due to the impact of these on his life. He has also been experiencing PTSD since an assault he was subjected to in 2016 ….. Unfortunately, we do not feel that this is the right time for Mr A to be working on his difficulties with our service because he still seems to be at risk, given that the individual who assaulted him still regularly visits the building he lives in. This would make it rather difficult to practice going out more as part of therapy, which it would be necessary for him to do in order to engage in valued meaningful activities as recommended by his previous therapist from our service … We have therefore decided that we will not be offering him treatment at the current time. We feel it makes more sense to wait until his appeal regarding the court case regarding the above individual has been concluded, because addressing the situation with the perpetrator through the criminal justice system seems the best way to increase Mr A’s sense of safety and ability to engage in treatment’.
30. Our clinical adviser stated that to commence psychological therapy for trauma related difficulties, it is important that the trauma is in the past and the person is not unsafe in the present. PTSD is the misinterpretation of threat in the present, however if the threat is real, then this is not a misinterpretation and the focus would be on the environment, rather than trauma focussed therapy, until the threat has passed.
31. Section 1.4.2 of the NICE guidance for PTSD regarding maintaining safe environments states: ‘Be aware of the risk of continued exposure to trauma-inducing environments. Avoid exposing people to triggers that could worsen their symptoms or stop them from engaging with treatment’.
32. Section 1.7.3 of the NICE guidance states: ‘For people with additional needs, including those with complex PTSD ...take into account the safety and stability of the person's personal circumstances (for example their housing situation) and how this might affect engagement with and success of treatment’.
33. Mr A’s therapy involved him leaving his flat to participate in activities outside, and so this was deemed not safe due to the present risks involved with this activity. Ultimately this therapy was not appropriate due to Mr A’s circumstances at that time.
34. Based on the clinical advice we have received, and the guidance we have referred to, we consider the treatment decision not to continue with therapy for Mr A was in keeping with NICE guidance for working with psychological trauma. Our clinical adviser stated the decision from the in-depth assessment by the dissociation service, which is a national specialist service, influenced the treatment decision by the local Trust. There was good clinical reasoning, which led to the decision not to pursue therapy and close Mr A’s case to the service.
35. We have found there was evidence of an overall clinical decision informed by clinical assessment conclusions and a second opinion. Our clinical adviser stated there were no identified needs outside of psychological therapy and medication management for Mr A that would indicate further involvement from the recovery team.
36. Based on the clinical advice we have received, Mr A’s records and the NICE guidance on PTSD, we have found the treatment decision at the time was based on clinical reasoning and judgement, and so the decision was clinically appropriate and informed by evidence. We have not identified an indication of a failing with the Trust’s decision to discharge him from its service in October 2023.
The level of mental health care the Trust provided to Mr A following him being discharged from the Trust in October 2023
37. Mr A says the Trust did not provide him with appropriate mental health care after he was discharged from the Trust in October 2023. To determine if the Trust provided appropriate care to Mr A after he was discharged in October 2023, we have reviewed his clinical records from the Trust and South London and Maudsley NHS Foundation Trust, and we have also received clinical advice from our clinical adviser.
38. The Trust received a letter dated 15 December 2023 from the clinical psychologist at South London and Maudsley NHS Foundation Trust’s Depersonalisation Disorder service, the letter stated: ‘This patient contacted our service recently to explain that his circumstances have changed since we assessed him last May. At that time we did not offer him treatment as this would have required him to practice going outside which he was feeling too unsafe to do because of ongoing threatening and intimidating behaviour from an individual who was regularly visiting the block of flats where he lives. I understand from Mr A that since that time this individual has stopped coming round, so he no longer feels too unsafe to go out. Sadly, in addition to this, Mr A’s father has died since the assessment. This has been motivating Mr A to go out regularly in order to provide the rest of his family with emotional and practical support in relation to the loss of his father. He therefore believes that he is now able to engage with treatment with us and requested that we contact you to ask if you could kindly re-refer him to us for a re-assessment. In order for us to see him we would require him to be under the care of his CMHT again for management of risk and ongoing support’.
39. The Trust wrote to South London and Maudsley; to state it was no longer providing care to Mr A and he should ask his GP to do an individual funding request to the local integrated care board and refer him to its service via that route.
40. On 26 March 2024, South London and Maudsley wrote back to the Trust to say that Mr A needs to be under the care of community mental health team for management of risk and ongoing support. The letter also stated that the Trust needed to refer Mr A to South London and Maudsley directly from their organisation.
41. Mr A’s clinical record dated 16 April 2024 states there was an internal multidisciplinary team meeting. The Trust agreed to reopen Mr A’s case.
42. Mr A’s clinical records dated 17 April 2024 show a clinical psychologist would be the lead clinician for Mr A. The psychologist confirmed Mr A was under the care of the community mental health team, and he would support the referral to South London and Maudsley specialist clinic for depersonalisation and derealisation. The note also stated Mr A said he now felt more optimistic about treatment and hoped he could access the therapy that would improve his quality of life.
43. On 23 April 2024, Mr A had a support call with the psychologist, and they agreed a 30-minute telephone call every two weeks where Mr A had a space to talk. The notes also state the purpose of the calls were to check in with Mr A and ensure that risks were managed. Mr A said he felt he benefited from the call. On 26 April 2024 the records show the psychologist had contacted South London and Maudsley to chase up Mr A’s referral.
44. The notes dated 21 May and 11 June 2024 show Mr A had support calls with the psychologist on these days.
45. On 24 June 2024, South London and Maudsley wrote to the Trust and confirmed Mr A had now been successfully referred back to its service.
46. The record dated 25 June 2024 stated, ‘Mr A went on to say that he finds our calls very supportive and that I seem like 'a nice chap' and easy for him to talk to…’
47. Mr A was assessed by South London and Maudsley on 10 July 2024, and we can see from the records that the psychologist at the Trust wrote to South London and Maudsley on 2 June 2024 to chase up treatment recommendations following Mr A’s assessment.
48. South London and Maudsley wrote to the Trust Letter sent to the Trust with assessment report. The main recommendations were to provide trauma focussed cognitive behaviour therapy, as Mr A stated PTSD symptoms were the main focus for therapy. South London and Maudsley stated that it would require approval from the ICB on the appropriateness of funding prior to adding Mr A to the waiting list.
49. We can see from the clinical records that Mr A continued to have support calls with the Trust every two weeks throughout 2024.
50. Mr A’s clinical records show that the Trust reopened Mr A’s case to refer him to South London and Maudsley, and to provide ongoing monitoring.
51. Section 9 of the GMC guidance on delegation and referrals (2013) outlines when referring a patient to a colleague or service in any situation the doctor: • should explain to the patient that you plan to transfer part or all of their care, and explain why • must pass on to the healthcare professional involved; relevant information about the patient’s condition and history, and the purpose of transferring care and/or the investigation, care or treatment the patient needs • must make sure the patient is informed about who is responsible for their overall care and if the transfer is temporary or permanent. You should make sure the patient knows whom to contact if they have questions or concerns about their care • should check that the patient understands what information they will pass on and why. If the patient objects to a disclosure of information about them that the doctor considers essential to the safe provision of care, they should explain they cannot refer them or arrange for their treatment without also disclosing that information.
52. We have referred to the 2013 version of the GMC guidance, and not the 2024 version, as the 2024 version did not come into effect until 30 January 2024. As Mr A was discharged by the Trust in October 2023, and South London and Maudsley wrote to the Trust in December 2023 regarding Mr A being referred, we consider it appropriate to refer to the 2013 guidance.
53. We can see the Trust spoke to Mr A on 23 April 2024. The Trust informed Mr A that he was now under the care of the community mental health team a clinical psychologist had been allocated to support him to restart the referral to the South London and Maudsley specialist clinic for depersonalisation and derealisation. The Trust explained the clinical psychologist would contact him within the next seven days, and if he did not hear from the psychologist the Trust directed Mr A to contact the mental health service.
54. This shows that the Trust had acted in line with the GMC guidance here. It explained to Mr A that it would be facilitating his referral to South London and Maudsley, it explained who was responsible for his care, and who he could contact if he had any questions.
55. Section 1.1.2 of the NICE guidance on the Service User Experience in Adult Mental Health • aim to foster their autonomy, promote active participation in treatment decisions and support self-management • maintain continuity of individual therapeutic relationships wherever possible • offer access to a trained advocate
56. The Trust provided psychological support sessions whilst Mr A was waiting for his assessment and subsequent waiting time for treatment. Our clinical adviser stated this was good practice, as Mr A had a named professional, and support was provided by a clinical psychologist. Our adviser stated the Trust was responsive and did provide general mental health support and psychological support.
57. In the clinical notes, there are specific references to discussions about body dysmorphic disorder, as well as the rationale for receiving care from South London and Maudsley. The Trust explained to Mr A on 14 November 2024 that he is being supported by the Recovery Team whilst he awaits his depersonalisation therapy at South London and Maudsley.
58. Our adviser explained the Trust did not provide any direct therapy to Mr A for his post-traumatic stress disorder and dissociative features, during the time period from when Mr A was discharged from the Trust. This was because Mr A was on a waiting list with South London and Maudsley for specialist therapy throughout this time. We can see that the Trust did provide Mr A with general psychological support throughout this period. The Trust also provided contact numbers for Mr A should he experience a mental health crisis. This shows the Trust acted in line with the NICE guidance on the Service User Experience in Adult Mental Health.
59. Our clinical adviser stated the support provided to Mr A since October 2023 was reasonable, reactive and person centred. Mr A was waiting for his active therapy with South London and Maudsley, which is why he was receiving a support call every two weeks.
Conclusion
60. Based on the clinical advice we have received, and after carefully and robustly reviewing Mr A’s records, we have not identified any indications of failings with the Trust’s decision to discharge him from its mental health service in October 2023. We have also not identified any failings with the care and treatment the Trust provided to Mr A after he was discharged from the Trust in October 2023.
61. We understand Mr A has been through a very difficult time with his mental health, and we understand he has been through some traumatic incidents. We are truly sorry to hear this.
62. We sincerely hope Mr A is assured by the robust investigation we have undertaken, and that we have not identified any indications of failings with the care and treatment he received in relation to the issues he has raised.