Lack of one-to-one support and offer of family therapy
13. Mrs B says she disagrees with the decision not to offer her daughter any further one-to-one support and to instead offer her family therapy. She does not think this provides the support her daughter needs and she and her husband are very worried about the impact this will have on her.
14. NICE guidance says that young people who are affected to a moderate or severe degree by OCD, and where self-help techniques have not worked, ‘should be offered CBT’ (cognitive behavioural therapy).
15. Our adviser has explained this is a talking therapy that is used to treat OCD by asking the person to carry out activities that cause them anxiety, but not to take the actions they usually use to manage this. Repeating this exercise can help change the way a person reacts to anxiety.
16. A letter written by her psychologist on 12 May 2022 explains their assessment after working with her for ten months. It sets out their recommendations for the support CAMHS should offer next. The psychologist noted she said CBT exercises did not help her and felt ‘too much’. The psychologist recommended she should first be offered family therapy to help make sure she has a ‘stable and consistent environment where she feels safe to tolerate the distress that CBT can bring’.
17. Our adviser said the psychologist’s letter is thorough and their decisions about the care that would be appropriate for C are evidence based. The psychologist thought that encouraging her to have time with her parents, and to continue with her daily activities was the right approach to take. Our adviser said this was a clinically appropriate plan based on evidence.
18. NICE guidance says that clinicians should consider the ‘individual needs and preferences of people with OCD’ when offering treatment. It says that because OCD often impacts the family around a person, healthcare professionals should encourage people and their family or carers to work together, wherever this is appropriate and possible.
19. Our adviser says CBT can be very distressing for a person because they are asked to go through an uncomfortable process. We consider it was right for the psychologist to think about whether CBT was appropriate while also considering the patients’ thoughts about this.
20. We think CAMHS acted in line with NICE guidance as it took C’s preferences into account and involved her family in the plan. We have not seen that anything went wrong in the care CAMHS offered. It considered if CBT would be suitable to offer but decided that before C goes through this challenging treatment, she would benefit from working with her family in therapy. We have not seen signs of a failing in this approach to her treatment.
21. We are sorry to hear of how concerned Mrs B is about the change in the support CAMHS offered to C in May 2022. We understand this had a big impact on C and it has been a very difficult time for the family. We hope we have been able to explain how we have reached our decision for this part of the complaint.
Access to medication
22. Mrs B told us her daughter had considered taking medication to help manage her symptoms in 2021 and discussed this with a doctor, but she then changed her mind. She told her mother in 2022 she would consider taking medication again. Mrs B is unhappy that when she asked CAMHS if it could prescribe the medication the doctor had discussed with them in 2021, it just put her on a waiting list again.
23. NICE guidance says clinicians can consider prescribing young people with a diagnosis of OCD selective serotonin reuptake inhibitors (SSRI is a type of anti-depressant drug). This should only happen after an ‘assessment and diagnosis by a child and adolescent psychiatrist who should also be involved in decisions about dose changes and discontinuation’. The young person should be closely monitored throughout.
24. The records show Mrs B asked CAMHS if they could prescribe her daughter medication on 30 June 2022. The CAMHS team manager responded to Mrs B on 11 July to say that the team had discussed this and agreed that she should be added to a waiting list for an urgent medication review.
25. Our adviser said that before the CAMHS team could prescribe her medication, she would need to have a detailed assessment. This would need to be carefully explored, especially because she had some uncertainty about this option.
26. We consider CAMHS acted in-line with NICE guidance by considering her suitability for medication at a team meeting, and then arranging for her to have a medical assessment. Our adviser says while this had happened in 2021, the medical team would need to carefully review her again to make sure they made the right decision for her.
27. We consider the approach taken by CAMHS to arrange for C to be assessed before making any prescribing decisions was appropriate. For this reason, we have not seen that anything went wrong in this part of the complaint.
28. We appreciate Mrs B’s frustration that she felt medication could help her daughter during a very difficult time. We are sorry to learn that she is still waiting for this assessment.
Monitoring physical health
29. Mrs B complains her daughter started to increasingly self-harm around the time her psychologist left, but CAMHS did not offer any monitoring or support. She also says her daughter is underweight but she feels CAMHS has not really been interested in helping her with this. She questions why CAMHS did not do any welfare checks.
30. In its complaint response CAMHS agreed it could have done more to monitor her physical health. It said it should have offered her a face-to-face review to allow for some physical checks and apologised it did not do this.
31. CAMHS ‘Process for managing young people on the waiting list in CHYPS (Children and Young People’s Care Delivery Service)’ sets out how its team should support young people and their families as they wait for treatment. It says when the team is made aware of a child or young person deteriorating or being in crisis, they should act to assess and contain the risk. To do this, staff can: • provide support over the phone • advise the person or their family to call 111 or attend A&E • speak with other agencies • offer an urgent high-risk assessment • speak with a lead practitioner - if allocated • re-refer into CAMHS.
32. A risk assessment on 12 May 2022 says CAMHS was not aware that C had engaged in any recent self-harm behaviour, and she had not made known any urges to harm herself.
33. The first record of self-harm is from 23 June 2022 when Mrs B told a psychologist in the CAMHS team that her daughter was cutting her arm with scissors. The psychologist documented she tried to ask more details about this, but her parents were focused on discussing their unhappiness with the plan in place.
34. The case was discussed in a meeting that same day and it was decided that the plan in place for her was appropriate. The psychologist explained this when speaking with her parents.
35. On 28 June, Mr B emailed CAMHS to say his daughter was cutting her arms and legs and she was finding it hard to eat. A psychologist working in A&E emailed CAMHS on 29 June to say she had attended hospital due to her low mood and self-harm behaviour. They asked for CAMHS to provide a ‘7 day follow up’.
36. In response to this, the CAMHS team offered her an appointment on 8 July. The team manager also spoke to Mr and Mrs B on the phone about the plan in place for their daughter. They were told that if there was a change in her risk before then, they could call CAMHS, the NHS 111 medical helpline or 999 as appropriate.
37. A psychologist saw Mrs B’s daughter on 8 July and noted she was not expressing any urges to self-harm, and she had no plans to act on her suicidal thoughts. The psychologist did not consider she was high risk at that time, and she was prevented from self-harm by being under supervision from her parents and having objects removed from her. The psychologist identified she was highly vulnerable and recommended CAMHS prioritise her care.
38. After this appointment, CAMHS added her to the urgent waiting list for a medication review. In October, she was also allocated a care-co-ordinator.
39. Our adviser says that CAMHS appropriately responded to concerns about self-harm by reviewing her case in its team meeting and assessing her after she attended A&E. The records show the team was monitoring her risk and they spoke to relevant services when concerns came up. However, our adviser says CAMHS could have been more flexible and responsive in arranging to see her for a physical health check, and it did not do this.
40. In terms of her weight, her parents said she struggled to eat due to her compulsive behaviours. The risk assessment from 12 May 2022 describes her as being at a very low weight due to poor food intake and she had struggled with this for a long time. She was under the care of a dietician.
41. Our adviser says CAMHS could have done more to monitor her weight. The records show CAMHS were aware that she had stopped attending physical health checks with her GP and had not had a dietician review for over a year. She was also not taking the prescribed supplements and was refusing blood tests.
42. Our adviser says CAMHS could have worked more closely with the GP and dietician to review her physical health. The team could have arranged to review her at the clinic, or at home. This would have made sure it was doing all it could to limit her risk. CAMHS has agreed it could have arranged a face-to-face review to monitor her.
43. We think CAMHS should have done more to monitor her physical health. This shows a failing in care.
44. We have considered the impact caused by this. Mrs B says the lack of care played a part in her daughter’s deteriorating health. Our adviser says the psychologist leaving CAMHS seems to have caused her deterioration from May 2022, and so we cannot say a lack of monitoring caused her deterioration, or what difference this would have made. However, we consider this was a missed opportunity for CAMHS to provide further support to her and her family.
45. CAMHS has apologised it did not do more to monitor her physical health. We considered that, in-line with our ‘Principles for Remedy’, CAMHS should learn from this concern and explain to Mrs B what it will do differently in future to improve its services.
46. CAMHS considered what we said and told us it could see that its team had not followed up on the outcomes of the reviews with her dietician. It has since shared with its staff the importance of doing this. It has also given feedback to its team that when a physical health concern is identified in a care plan, a responsible person should be monitoring this. It also told its team that concerns and risks relating to physical health should be clearly documented and highlighted so they can take appropriate action.
47. We are satisfied these actions show CAMHS has learned from this case and has made improvements to its processes. CAMHS agreed to write to Mrs B to tell her what it has done.
48. We spoke to Mrs B about this and she told us she was not happy to accept this action as an outcome for her complaint. We do not consider there is anything further we would ask CAMHS to do to address this concern and for this reason, we will not take any further action.
49. We understand how important Mrs B’s complaint is to her and we thank her for bringing this to us to consider.