16. 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.
Social, emotional and mental health needs
17. Dr J says the Trust did not measure R’s social, emotional and mental health needs. She says this led to the Trust not offering the correct support to help with the issues R was experiencing.
18. NICE guidelines say when clinicians are assessing social anxiety disorder and other mental health issues they should use a formal tool to aid the diagnosis. The guidelines say clinicians should use both the parent and child version of the tool where applicable and specifically mentions the revised child anxiety and depression scale (RCADS). RCADS is a questionnaire used to assess the symptoms of anxiety and depression in 8-18 year olds.
19. Our adviser said it is usual practice for CAMHS services to use RCADS in its initial assessment of a young person’s social, emotional and mental health needs. This allows the service to get a baseline measurement of the child’s needs and measure improvement following intervention. They said the results of RCADS guide the intervention the young person may receive.
20. We reviewed the records. These show the parent and child version of the RCADS were sent to sent to Dr J to complete and return before the appointment. We did not see the RCADS had been used in the assessment process. This is not in line with NICE guidelines or with what our adviser told us
21. The Trust said its records show it did receive the completed RCADS back from Dr J. It said these were forwarded to the clinician before the assessment. It said there were no records of the RCADS being entered in the records and no notes to suggest these were reviewed or considered prior to or following the assessment.
22. We consider this to be an indication of a failing. The Trust did not use the RCADS to inform its assessment of R in line with NICE guidelines. This means it would not have been able to adequately assess R’s needs and plan appropriate interventions based on the results of the RCADS.
23. Our Principles for Remedy explain when things go wrong, we expect organisations to apologise and acknowledge responsibility. They also say organisations should take remedial action to prevent the same thing from happening again and this can be any combination of the following:
• revise procedures to prevent the same thing from happening again • train or supervise their staff.
24. We note the Trust opened up its services to R following a review of Dr J’s complaint. However, as the Trust acknowledged, there is no evidence to suggest the RCADS were used so we consider the Trust still has work to do to remedy the issue.
25. We contacted the Trust about this. It confirmed it will write to Dr J to provide a full written apology which explains and acknowledges its failing to use the RCADS in its assessment of R. We consider this in line with our Principles for Remedy.
26. The Trust has agreed to update Dr J on the actions it is taking to make sure this does not happen again. The Trust is currently reviewing its recording and documentation procedures to limit the potential of RCADS not being entered into the system. We consider this to be in line with our Principles for Remedy to ensure poor service is not repeated.
27. The Trust has also already spoken to staff, during a meeting, about the importance of clinical record keeping as a result of its response to this complaint. This was to improve how staff record the documentation it uses in its work. This is a form of training and so is in line with our Principles for Remedy.
28. The Trust will also explain to Dr J that it can accept another referral for R to its services, which will be screened by its access team. The Trust said any assessment it offers will use the RCADS and any new up to date information about R’s needs. This is in line with Dr J’s requested outcome of a review of the decision. We consider this to be in line with our Principles for Remedy.
29. We were sorry to hear of Dr J’s concern the Trust did not measure R’s social, emotional and mental health needs. We hope our work with the Trust assures her a suitable resolution has been reached in line with our Principles. We will therefore take no further action, as the Trust is acting to put things right here.
Evidence used in the assessment process
30. Dr J says the Trust did not use the full scope of evidence when deciding whether R was suitable for admission to its Learning Disabilities (LD) service. She says this led to the Trust considering R not disabled enough for intervention with its specialist LD team. NICE guidelines explain LD is defined by three core criteria. These are having a lower intellectual ability, significant impairment of social or adaptive functioning, and an onset in childhood.
31. The Trust said R’s referral was screened by its CAMHS access team. This team screen the referrals made to CAMHS and make any necessary onward referrals. It said the referral highlighted additional needs in relation to LD. This led to the access team seeking advice from its LD team.
32. The Trust said its LD team screened the referral to see if R met the criteria for receiving support. It said the LD team is commissioned to work with children who have moderate and severe LD. It said it uses the WHO criteria of LD to assess eligibility to its service when there is no existing clinical diagnosis of LD.
33. The Trust said its LD team reviewed the information in R’s patient record and there was no evidence he had an existing formal diagnosis of LD. It said it reviewed R’s British ability scales (BAS) scores which had been undertaken by an external psychologist five months earlier. BAS scores measure a child’s cognitive (learning and understanding) ability. The scores are separated into verbal, non-verbal and spatial ability.
34. The Trust said R was accepted for assessment by the CAMHS locality team. This is a branch of CAMHS that provides community based mental health support for children up to the age of 18. It said the CAMHS LD service joined the assessment to assist with any adaptions or reasonable adjustments R required.
35. Our adviser said it was appropriate for the CAMHS LD clinician to attend the assessment due to the complexity of information the Trust had received about R’s needs and the fact he attends a specialist school.
36. Our Principles of Good Administration say organisations should act in accordance with recognised quality standards and established good practice.
37. Our adviser said there is no guidance to tell Trusts which framework to use when assessing a child’s eligibility for the LD service, but that it should be evidenced based. They said BAS scores are an accepted tool to determine levels of cognitive ability and the WHO guidelines is the authoritative framework for categorising LD so was appropriate to use.
38. Our adviser said the use of BAS scores is important to help Trusts decide on the child’s level of understanding. This helps Trusts to guide the work undertaken and adapt interventions to meet the child’s needs.
39. Our adviser said many Trusts have very strict criteria for admission to LD teams. They said CAMHS LD teams usually only admit children who have a diagnosis of moderate, severe or profound LD. They said in situations such as this, when there is no evidence of a formal LD diagnosis, Trusts will use other information they have about the child’s cognitive ability to decide if they are eligible for support.
40. We reviewed the Trust’s LD assessment pathway policy. This says the LD team complete assessments for children and young people with a moderate to severe LD who are experiencing difficulties managing their emotions, feelings and mental well-being. This is in line with what our adviser told us about the remit of CAMHS LD services.
41. We also reviewed R’s records. We have seen there was no evidence R had received a formal LD diagnosis prior to his CAMHS assessment.
42. We have not seen any indication the Trust should have used a wider range of evidence to determine R’s eligibility for its LD service. In the absence of a formal diagnosis of LD, the Trust used R’s BAS scores to determine his level of cognitive functioning. This is in line with the advice we received. We have also seen the Trust’s decision to use the BAS scores to determine R’s position on the WHO criteria of learning disabilities was in line with the advice we received.
43. The Trust’s actions here appear to be in line with our Principles of Good Administration. It used an accepted tool to help inform its decision about R’s suitability for its service. As we have not seen any indication the Trust did anything wrong here, we will be taking no further action.
44. We appreciate why Dr J would feel the Trust did not use the full scope of evidence in light of the fact she feels R’s mental health needs are not being supported. We hope our explanation assures Dr J of the remit of the LD team and that we have not seen any indication of a failing in the care he received here.
Labelled R as having a mild learning disability
45. Dr J says the Trust labelled R as having a mild learning disability without using a diagnostic tool or formal diagnosis. She says this label will be very damaging for R and will lead to other professionals believing he can do more than he can.
46. The Trust said following a second review of the information available, its clinical opinion is R’s level of LD remains at mild. It said this is not a diagnostic clinical opinion but a statistical statement. It said there is no intent to diagnose any level of disability, but to better understand which mental health service would best meet R’s needs.
47. WHO guidelines define four levels of learning disability. Each level is determined by the percentile (the individual’s performance relative to their peer group) the person’s intellectual functioning falls into. The four levels and the percentile of intellectual functioning are defined as follows:
• mild (0.1 – 2.3) • moderate (0.003-0.1) • severe (lower than 0.003) • profound (lower than 0.003).
48. This means for someone with a mild LD, testing will show they performed as well as or better than 0.1 to 2.3 percent of their same age peers in the general population.
49. We reviewed the records. These show the Trust used R’s BAS scores to decide on his level of LD in the absence of a formal diagnosis. R’s BAS scores ranged between 0.2 and 0.5 percentile. According to the WHO criteria, this places R in the mild category of LD in line with WHO guidelines.
50. The Trust said R’s BAS scores fell within the WHO’s 0.1 to 2.3 percentile range. It said this percentile placed R into the WHO’s category of mild learning disabilities and so he did not meet the criteria for support through the LD pathway.
51. Our adviser said the term mild is not a diagnosis but an assessment of R’s cognitive functioning. They said BAS scores are an accepted tool to determine levels of cognitive functioning and the WHO criteria is the authoritative framework for coding LD so was appropriate to use.
52. In summary, taking into account the evidence we have seen and the advice we have received, we have not seen any indication the Trust did anything wrong when labelling R as mild using the WHO criteria. We have seen R’s BAS scores did mean the Trust’s assessment of his cognitive functioning as mild was in line with WHO guidelines.
53. We have seen it was necessary for the Trust to use evidence based tools in its assessment of R so it could assess his eligibility for its LD service and to inform its approach in any interventions offered by the CAMHS locality team. We have seen no indications this was a formal LD diagnosis.
54. As we have not seen any indication the Trust did anything wrong, we will be taking no further action.
55. It is understandable Dr J is concerned the Trust’s recording of R’s level of LD as being in the mild category will lead to professionals believing he can do and understand more than he can. We have not seen this was a formal LD diagnosis but was necessary for the Trust’s understanding of R’s needs. We hope our explanation helps to show the Trust acted within relevant guidelines. We thank Dr J for bringing her complaint to us.