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Somerset NHS Foundation Trust

P-003713 · Report · Decision date: 6 July 2025 · View Somerset NHS Foundation Trust scorecard
Complaint (AI summary)
Mr I complained the Trust wrongly rejected his adult ADHD assessment referral and had poor record keeping, causing him stress, anxiety, mental health decline, and financial burden from a private assessment.
Outcome (AI summary)
Upheld. The Trust's failings led to a missed opportunity for Mr I to be two years into the ADHD assessment waitlist, contributing to his anxiety and distress.

Full decision details

The Complaint

4. Mr I complains about the Trust's decision to reject a referral for an adult ADHD assessment in March 2023.

5. He tells us this decision has caused him stress and anxiety and explains he has experienced a deterioration in his mental health as he does not know whether he has ADHD. Mr I said this led him to pursue a private assessment that has added a significant financial burden to him.

6. He also complains about poor record keeping meaning the Trust was not able to explain why it did not accept his referral. This has led him to experience frustration.

7. In bringing this complaint to us, Mr I would like the Trust to acknowledge it made the wrong decision. He would also like the Trust to pay him £1500 to cover the costs of a private assessment.​

Background

8. What follows is a summary of events. We have not included all details as both parties are aware of this.

9. Mr I has a history of body dysmorphic disorder (also known as BDD, a mental health condition where a person spends a lot of time worrying about flaws in their appearance), obsessive compulsive disorder (also known as OCD, a mental health condition where a person has obsessive thoughts and compulsive behaviours) and anxiety.

10. On 1 November 2022 Mr I’s GP referred him for an ADHD assessment.

11. On 30 March 2023 the Trust’s adult ADHD specialist nurse wrote to Mr I’s GP advising the service had rejected his referral. The nurse explained Mr I did not meet the criteria for an ADHD assessment as the team felt his symptoms were better explained by anxiety.

Findings

15. Mr I complains about the Trust’s decision to reject his referral for an adult ADHD assessment in March 2023.

16. The Trust wrote to Mr I’s GP advising it had rejected his request for ADHD assessment as he did not meet its criteria for assessment. It said its clinicians considered it was more likely that Mr I’s symptoms were associated with obsessional thought patterns and anxiety rather than ADHD. It explained Mr I could seek an assessment from another organisation under the right to choose process. It explained he should speak to his GP if he wanted to do so.

17. Mr I considers his existing anxiety and other mental health issues should not be a reason not to carry out an ADHD assessment. He says his mental health conditions have been the same for many years. He explains they are chronic and complex with little change of a full recovery at this stage.

18. The relevant guidance for this aspect of the complaint is the Trust’s SAAS document. This says the Trust will not accept referrals for patients who already have an ADHD diagnosis or who have other psychiatric conditions (such as anxiety, severe OCD etc). It does also contain exceptions to the exclusion criteria.

19. The SAAS document explains the service can accept referrals for patients with psychiatric conditions if their mental health conditions have been stable for a considerable length of time. It says this is either at least three months or if the patient’s keyworker has assessed them and deemed them stable.

20. Mr I’s GP referred him to the Trust for an ADHD assessment on 1 November 2022. His key worker attended a mental health panel meeting with the Trust on 25 January 2023. They told the panel Mr I’s mental health was stable and detailed a psychiatry consultation on 5 January where a psychiatrist reported there had been no change in his condition. At the end of the meeting the panel recommended the referral to the ADHD service should remain in place.

21. It is not clear from Mr I’s clinical records what happened between January and March to change the service’s view on accepting the referral. The Trust’s complaint response said clinicians made the decision not to add Mr I to the waiting list during a multidisciplinary triage (MDT) meeting. The response did not detail when this meeting took place.

22. The Trust has not been able to provide us with the records from its MDT meeting. It has also told us it holds no record of how its clinicians decided Mr I did not meet the criteria for an ADHD assessment. The Trust advised us it would not be usual practice for clinicians to list everything they read to come to a decision. Whilst we recognise the Trust’s view on accepting Mr I’s referral changed between January and March 2023, it has not provided us with any evidence from this period to support or explain this.

23. GMC’s Good medical practice says doctors must ensure documents they make to formally record their work must be clear, accurate and legible. They should make records at the same time as the events they are recording or as soon as possible afterwards.

24. Our adviser said for any MDT meeting, in which clinicians discuss a patient’s care and treatment, there should always be notes or a documented written record of what clinicians discussed. They explained this could either be in the form of a clinical note on the patient’s electronic medical record, an email or a letter. They said the Trust’s actions in not making any notes from the MDT meeting or having any form of written record of what was discussed in the meeting is not representative of good and safe clinical practice.

25. This lack of documentation has affected our ability to comment on clinicians’ decision making. We do not know when the MDT meeting took place or what was discussed. Nor do we know how clinicians decided Mr I did not meet the criteria for an ADHD assessment.

26. We consider the Trust’s decision not to document the above was not in line with GMC’s Good medical practice. This amounts to a failing.

27. The Trust’s view was that it could not offer Mr I an ADHD assessment as he did not meet the criteria within its SAAS. Having reviewed this document, we note it says that the service can assess people with comorbid psychiatric conditions if their keyworker has assessed them and deemed them stable.

28. Our adviser agreed Mr I’s records show he met this criteria as both his keyworker and a psychiatrist deemed his mental health was stable during the period of complaint. It therefore appears the Trust could have accepted the referral. The evidence suggests that the Trust did not act in line with its own policy when declining Mr I’s referral and therefore this is a failing.

Impact

29. We will now consider what impact the failings we have identified had on Mr I. Mr I initially told us he pursued a private assessment which added a significant financial burden to him. We now understand he has not paid for a private assessment meaning he has not faced the financial impact he initially described. For this reason, we have not explored any claimed financial impact.

30. We have found failings in the Trust’s decision to reject Mr I’s referral for ADHD assessment. The evidence suggests he met its own criteria for assessment, and it should have accepted the referral.

31. Mr I says the Trust’s decision to reject his referral has caused him stress and anxiety. He says he has experienced a deterioration in his mental health as he does not know whether he has ADHD.

32. From work we have done on similar complaints we understand waiting times for ADHD assessment are significant across the NHS. The Trust’s wait list is currently upwards of three years and was similar during the period of complaint. This means that had the Trust accepted Mr I’s referral in March 2023, he would still be awaiting assessment and would not know if he had ADHD yet. We therefore cannot say the Trust not accepting the referral has caused the distress caused by not knowing about his diagnosis.

33. We recognise how distressing Mr I has found the deterioration in his mental health and do not dismiss the impact of this.

34. Had the failings not occurred, Mr I would be around two years into the wait list for ADHD assessment. We consider the Trust missed an opportunity to alleviate some of his stress and anxiety by accepting the referral.

35. The Trust has agreed to put Mr I in the position on the waiting list he should have been at, had it not declined the referral incorrectly.

36. It noted Mr I had previously expressed an intention to pursue the right to choose process of accessing an assessment. It said if he did choose to do this, it would have to remove him from the waitlist as it could not hold a patient on two wait lists.

37. Our Principles for Remedy make it clear that if service failure occurs organisations should put the person affected back into the position they would have been in, had the service failure not have happened. We consider that by putting Mr I back into the waitlist, the Trust will remedy the impact of the failing in line with our Principles.

Our Decision

1. We have carefully considered Mr I’s complaint about Somerset NHS Foundation Trust (the Trust). We are sorry to hear of the distress and frustration he has experienced because of the concerns he raises.

2. We have found failings in this complaint. We can see these led to a missed opportunity for Mr I to be around two years into the wait for attention deficit hyperactivity disorder (ADHD is a condition involving inattentiveness, hyperactivity and being impulsive) assessment. We consider the Trust’s actions contributed to Mr I’s anxiety and distress.

3. We have upheld this complaint. We recommend the Trust puts Mr I onto the wait list for an ADHD assessment at the point where he would have been now, had it accepted his referral in 2023. The Trust has agreed to do this. We also recommend the Trust apologises and takes action to prevent these failings happening again.

Recommendations

38. In considering our recommendations, we have referred to our NHS complaint standards. These state that where poor service or maladministration has led to injustice or hardship, the organisation responsible should take steps to put things right.

39. The NHS complaints standards say, wherever possible, staff should explain why things went wrong and identify suitable ways to put things right for people. Staff should give meaningful and sincere apologies and explanations that openly reflect the impact on the people concerned.

40. In line with this, we recommend that within one month of our final report the Trust writes to Mr I to acknowledge the failings identified and to apologise for the impact these had on him.

41. We also recommend that within one month of our final report the Trust puts Mr I back onto the wait list at the appropriate point and writes to him to confirm it has done so. The Trust has agreed to do this. It should also send a copy of these letters to us.

42. The NHS complaints Standards says should ensure staff should recognise the need to be accountable for their actions and to identify what learning can be taken from a complaint. They are clear about how the learning will be used to improve services and support staff.

43. In line with this, we recommend that within three months of our final report the Trust evaluates what led to the failings in Mr I’s care and what it needs to do to stop this happening again. It should produce an action plan setting out what it has done or intends to do, who is responsible for the action, when it will be completed by and how it will monitor the changes to ensure an improvement is maintained.

44. The Trust should send a copy of the action plan to Mr I, us, the Care Quality Commission and NHS Improvement.

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