Reassessment and second opinion
19. Mrs I complains that between February and March 2023 the Trust refused to reassess her son for ADHD.
20. In its responses to the complaint, the Trust explained it did not consider reassessment was necessary as it had assessed Mr L already and found he did not meet the criteria for diagnosis. It advised it had reviewed the information from Mr L’s school and considered this was consistent with information it had seen during the initial assessment.
21. Our adviser said there are no specific standards or guidelines on reassessing a child for ADHD. For this reason, we have referred to NICE guidance, ‘Attention deficit hyperactivity disorder: diagnosis and management’.
22. This states only a specialist psychiatrist, paediatrician, or other appropriately qualified healthcare professional with training and expertise in the diagnosis of ADHD should make a diagnosis. This should be 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.
23. Mr L was between five and six years old when the Trust assessed him for ADHD. As of February 2023, he was nine years old. Our adviser reviewed documentation from the Trust’s assessment of Mr L alongside the new information from his school and mother. They noted Mr L’s ASD and ODD make him a complex case.
24. Clinical records from the original assessment period clearly note that Mr L had strong ADHD features causing impairment. A paediatrician specifically wrote Mr L was ‘likely to have ADHD’ and that this ‘is having a bigger impact’.
25. We have therefore seen a disconnect between what the Trust wrote in its responses and the contents of Mr L’s clinical notes.
26. In its complaints responses it said no reassessment was necessary as it had carried out two school observations and Mr L did not meet the criteria for ADHD.
27. Notes from the second school observation state the observer was unable to ascertain whether Mr L had ADHD symptoms. This suggests that during the assessment process clinicians were unsure whether Mr L had ADHD.
28. Our adviser said that whilst the report may be accurate in saying Mr L did not meet the criteria for ADHD diagnosis in December 2020, it does not mean he did not have ADHD symptoms. They explained symptoms and the impairment these cause in children can change over time.
29. The Trust based its decision not to offer reassessment on an assessment it carried out when Mr L was around five to six years old. Mrs I asked for a reassessment in 2023 when her son was around ten years old. A significant amount of time had passed, and our adviser said there is a possibility things could have changed. They explained whilst Mr L may not have had ADHD during the initial assessment, he may have gone on to develop this afterwards.
30. NICE guidance explains clinicians should consider children and young people’s views when determining the clinical significance of impairment resulting from the symptoms of ADHD.
31. Our adviser said whilst it is likely Mr L was too young to provide his views on how his symptoms affected him during the first assessment, in 2023 he was old enough to provide some input. We have seen no evidence the Trust obtained or considered this.
32. It is clear from Mrs I’s complaint to the Trust that she considered her son had ADHD and this is why she asked for a second opinion. We note the Trust’s view that it gave a second opinion as two separate senior clinicians reviewed the contents of the original assessment.
33. The Trust’s response said the ADHD team had undertaken a review of records of the assessment and held discussions with specialist colleagues to review the information. It explained a clinical director and a consultant psychiatrist had reviewed all information available and considered no reassessment was necessary.
34. The Trust has explained there is no record of its review of this assessment or the discussion between colleagues. It said this was because Mr L was no longer open to the ADHD service and discussions were not representative of a clinical contact.
35. 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.
36. Our adviser said the conversations the Trust has described are clearly of a clinical nature as they involved critical decision making about Mr L’s future care. The Trust used the contents of these conversations to make clinical decisions.
37. This lack of documentation has affected our ability to comment on clinicians’ decision making. We do not know how detailed these conversations were or what those involved said.
38. We consider the Trust’s decision not to document the above was not in line with GMC’s Good medical practice. We consider this amounts to a failing.
39. Our adviser said there is no formal definition of a second opinion within guidance. They advised generally a second opinion is provided by a different professional who sees the patient. They agreed there are occasions where a review of notes constitutes a second opinion. However, we are not persuaded this applies here as the evidence suggests things may have changed since Mr L’s first assessment.
40. It is clear from clinical records that some clinicians involved in the original assessment considered Mr L had features of ADHD. At the time of the assessment their view was that these features were not severe enough to reach a diagnosis. We understand that ADHD impairment can change with age. Mr L’s mother, his school and GP told the Trust his level of impairment had increased since the initial assessment.
41. The Trust’s view was an ADHD reassessment was not necessary. Our adviser said the complexity of Mr L’s case, the existing strong features of ADHD with impairment and the amount of time that had passed are all clinical indications that reassessment was necessary.
42. GMC’s Good medical practice states doctors should refer a patient to another practitioner when this serves the patient’s needs. On balance, given the factors outlined above we consider the evidence suggests Mr L did need reassessing in 2023 and the Trust should have added him to the wait list for this.
43. The Trust did not place Mr L on its wait list for reassessment, nor did it offer to refer Mr L to another service for a second opinion. We consider this was not in line with GMC’s Good medical practice. We have found a failing in this aspect of the complaint. We go onto consider the impact of this in a later section of the report.
Referral to SLAM
44. Mrs I also complains that the Trust refused to refer her son to SLAM.
45. Mrs I suggests that she wanted SLAM to provide her son with support for his ASD and OSD. Whereas her complaint to the Trust on 16 February clearly asks it to refer her son to SLAM for a second opinion for ADHD. She advised her son’s GP had attempted to refer him to SLAM who explained it could only accept referrals from the Trust’s ADHD service.
46. The Trust explained it was unable to refer Mr L to SLAM as it did not consider this would provide any additional benefit to Mr L.
47. As this was an administrative decision, we have referred to our Principles of Good Administration. These say organisations should aim to ensure people are clear about what they can and cannot expect. If they cannot do something, organisations should explain why using clear language that people can understand. They should be truthful when accounting for their decisions and give reasons for these.
48. SLAM has confirmed it is only able to accept referrals from the Trust’s ADHD service. Mr L was not under this service during the period of complaint. Mr L would only come under this service if the Trust had reassessed him and reached a diagnosis.
49. As we explain in an earlier section of this report, we consider the Trust should have placed Mr L onto its wait list for reassessment in February 2023. We do not know exactly how long the Trust’s wait list for ADHD assessment was in 2023. It tells us its wait list is significant and reflects the national picture.
50. We understand that wait lists for assessment are extensive across the NHS. In October 2023 ADHD UK published a report on NHS ADHD assessment waiting lists. This stated that in some areas the wait was around five years. Similarly in July 2024, the BBC did an investigation into ADHD backlogs at NHS clinics. This revealed an average of an eight-year backlog.
51. We cannot say with any certainty when Mr L’s reassessment would have taken place had the Trust placed him on its wait list. The information available suggests Mr L would still be awaiting reassessment now. This means we cannot say he would be under its ADHD service had failings not occurred.
52. The evidence we have seen suggests that referral to SLAM was not open to Mr L in 2023.
53. Our Principles of Good Administration clearly set out that if an organisation is unable to do something, it should clearly explain this and give reasons why.
54. Having reviewed the Trust’s responses to Mrs I we are satisfied it properly explained why it could not refer her son to SLAM. We consider it acted in line with our Principles of Good Administration when handling Mrs I’s request. For this reason, we do not find a failing in this aspect of the complaint.
Impact
55. We have found a failing in how the Trust responded to the request for reassessment. Mrs I says this meant her son continued to struggle with concentration, emotional regulation and self-harm. She says these difficulties affected his learning and friendships. She believes her son would have an NHS diagnosis and treatment if failings had not occurred.
56. The evidence shows the Trust should have accepted Mr L for reassessment in 2023. This would have placed him on a waiting list. Given current NHS waiting times we consider it likely he would still be waiting for reassessment now.
57. For this reason, we cannot say Mr L would have an NHS diagnosis or be receiving treatment had the failings not occurred. We therefore cannot link the failings we have identified with any physical impact to Mr L. The evidence suggests his situation would have remained the same.
58. Mrs I chose to pay for a private assessment in October 202. She told us she would not have done this if the Trust agreed to reassess her son. The evidence suggests Mr L would still be awaiting reassessment had the Trust placed him on its waiting list when it should have done. For this reason, we cannot say Mrs I would not have felt the need to pay for private care had the failings not occurred.
59. She also told us the lack of support for her son has affected her own wellbeing. We recognise how difficult the last two years have been and that Mrs I has worked hard to get her son the help he needs. The evidence suggests her son’s situation would have been the same had the failings not occurred. We therefore cannot link the specific health impacts she describes to the Trust’s actions.
60. We have identified a missed opportunity for Mr L to have been on the waiting list for reassessment for around two years. We consider this contributed to Mrs I’s existing distress and an anxiety. It is clear only a confirmed diagnosis and treatment would have alleviated her concerns.