22. 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. We have done this and have not found any indications that something has gone wrong.
Lack of treatment from the mental health service
23. Mrs H complains she has not had any treatment from the mental health service at the Trust despite numerous referrals and requests to do so. She states she has not received any support in working through the difficulties she faces.
24. The Trust says is does not accept that it had ‘done nothing’. It said she has had various contacts and interventions from a social worker, consultant psychiatrist, health care support worker and deputy team manager since July 2021.
25. We have seen from the records following an initial risk assessment by a social worker Mrs H was assessed in November 2021 by a consultant psychiatrist. The consultation included taking a detailed history including her recent mental and physical health concerns. It also noted she was taking fluoxetine (antidepressant) and amitriptyline (antidepressant, taken for pain), her weight, and her diagnosis of geographic tongue (an inflammatory but harmless condition affecting the surface of the tongue).
26. It noted Mrs H’s views, including that she thought she was being given too many tablets and the root cause of her concerns were not being addressed. A medical care plan was written. It set out a diagnosis of recurrent depressive disorder, considered risk and how she had experienced thoughts of suicide, and included a crisis plan to contact the duty team or out of hours crisis team. It set out she would continue on her medication, the core team would consider someone for Mrs H to talk to, and a review would be arranged in six months time.
27. GMC Good Medical Practice, states, ‘In providing clinical care you must: adequately assess a patient’s condition(s), taking account of their history, including symptoms, relevant psychological, spiritual, social, economic, and cultural factors, and the patient’s views, needs, and values’. This assessment was completed in line with this and a care plan set out.
28. We have seen the social worker at the Trust wrote to Mrs H’s GP in February 2022 following a recent appointment. It set out Mrs H had a support worker in place and was working with them and the social worker to help with anxiety management.
29. A medical care plan was written in May, following a telephone review of Mrs H carried out by the consultant psychiatrist. The care plan details her recent history and the support she was receiving at that time. The care plan states a diagnosis of recurrent depressive disorder and prescribed a medication dosage increase from 20mg of Fluoxetine to 40mg, at Mrs H’s request. A further review was scheduled for six to eight months’ time. This assesment was appropriate and included all the relevant information it should.
30. A telephone review took place on 3 October with the consultant psychiatrist and a care plan was written. This detailed her recent concerns and her significant difficulties with anxiety. It clearly set out options for the management of her condition, including anxiety management in the community and medication options, with the option of commencing an antipsychotic medication which may help settle her thinking enough for her to engage in other treatment. Mrs H was diagnosed with specific (isolated) phobias and a mixed personality disorder. The possibility of inpatient treatment was also discussed. This assessment was appropriate.
31. A further face to face review took place with the psychiatrist on 11 October.
32. A medical care plan was written on 13 March 2023 by a specialty doctor in psychiatry following a face-to-face appointment. This set out her history in detail, which were captured in previous medical care plans. It set out her clinical management plan and the medication she was taking.
33. Mrs H was assessed on 9 May 2023, and a care plan was written. The assessment and care plan contained detailed of her diagnoses and her trauma. It sets out her specific triggers and her views on the proposed treatment plan- the care plan states she ‘is in agreement with this and says this has been suggested by her GP.’ This is in line with the GMC guidelines detailed above.
34. Mrs H was invited to an appointment on 3 July 2023 to review her social care package.
35. In a letter dated 13 March 2023, the Trust stated Mrs H does not want to do any trauma-related work with the team. This is also set out in the care plan dated 9 May 2023. Mrs H has explained she does want to do trauma related work, and disputes the information in this letter.
36. We have seen Mrs H received regular contact from the Trust. Our adviser explained Mrs H’s case is diagnostically quite complex. Our adviser said Mrs H had reasonable assessments which resulted in a diagnosis of anxiety and depression in 2021. Mrs H then developed a geographical tongue and had issues with eating and drinking, resulting in a diagnosis of specific phobias of food and drink.
37. Our adviser said her assessment was prolonged because her condition was complex, and her diagnosis did change over time. The records demonstrate Mrs H was not suitable for psychological therapy.
38. Generalised anxiety disorder and panic disorder in adults: management, sets out the management of anxiety disorder in a four-step table. We have seen from the records Mrs H’s treatment reached step three of four. Our adviser said was appropriate management.
39. Step three states if there is anxiety disorder with an inadequate response to step 2 interventions or marked functional impairment, a choice of a high-intensity psychological intervention (cognitive behavioural therapy [CBT]/applied relaxation) or a drug treatment should be offered. A letter dated 14 March 2023 explains that she should be referred to psychology and her management should be mainly psychological intervention CBT. This is in line with this guidance.
40. Our adviser explained Mrs H needed psychotherapy to tackle the root of her problems, and she had to be in a state to accept this. The Trust concluded she was not ready for this. During the telephone review in October 2022, the psychiatrist discussed medication options, including an antipsychotic which may help settle her thinking sufficiently for her to ‘engage with other treatment options.’ The face-to-face review on 11 October 2022 also states Mrs H was initially willing but later unwilling to attend for inpatient treatment if available.
41. We can see from the records that Mrs H needed and received regular support until she was ready for more intensive psychological treatment. She was also in contact with social services for support. Our clinical adviser said this was reasonable in the circumstances.
42. We understand Mrs H wanted further support and how she felt she was not receiving any treatment to manage her challenging symptoms. We have seen she was regularly reviewed and assessed by the Trust. Consideration was given to mediation, in patient treatment and therapy but a clinical decision was reached that she was not ready for this additional support. We recognise how challenging it can be to find the right treatment for an individual and how this can be frustrating for the patient. We see the Trust appropriately assessed and provided appropriate treatment options we therefore will not consider this further.
Discharged from the Trust due to raising a complaint
43. Mrs H complains she was discharged from the Trust because she made a complaint about her care. She states a staff member confirmed this was the case on 8 August 2023.
44. The said this is not the case. It said during a conversation on 8 August 2023 between the deputy team manager and social worker and Mrs H, it had explained there is a need to develop an effective therapeutic relationship with the team, which might be difficult given her ongoing dissatisfaction with Trust services. The Trust confirmed Mrs H was not discharged from the Trust due to raising a complaint.
45. The Trust sets out the decision to discharge Mrs H was based solely on clinical considerations. Given she was not ready for psychological therapy the wider multi-disciplinary team (MDT) needed to discuss whether there was an ongoing role for Trust services. The MDT met on 25 September 2023 and concluded Mrs H should be discharged from the enhanced team. When Mrs H first spoke with the mental health social worker, she agreed a break from the mental health services would be beneficial, and she was accessing cognitive behavioural therapy privately. She told the Trust she refused to take any medication.
46. We have seen a customer services administrator told Mrs H a key principle of the NHS Complaints (England) Regulations 2009 is that raising concerns will not affect any care and treatment a person may receive from the Trust, and no record of their complaint will be held on their healthcare records. This was reiterated to her in the formal acknowledgment of her complaint, dated 24 November 2023.
47. NHS complaint standards (2022) state, ‘Organisations actively reassure people who use their services that their care will not be compromised if they make a complaint and what they can do if they feel it has been’. We can see the letter of 15 January 2024 offers reassurance that her care was not compromised because she made a complaint. This is in line with the complaint standards.
48. We have not identified any evidence to suggest Mrs H was discharged from the Trust because she made a complaint. We understand Mrs H is concerned about this, and we recognise being told an effective therapeutic relationship may be difficult with her ongoing concerns has made her feel she was discharged for raising concerns.
49. Based on the records we have seen, the decision to discharge Mrs H was a clinical decision. There are no specific guidelines which set out under what circumstances someone can be discharged from outpatient mental health treatment. The Trust’s decision she was not able to undergo the specific psychological therapy at that time is reasonable. Given there was nothing further the Trust could offer Mrs H at that time the decision to discharge was appropriate.
Letter dated 14 March 2023
50. Mrs H complains in the letter from the specialty doctor in psychiatry to the GP, the doctor said Mrs H was clear her symptoms were not trauma informed, and she did not want to do trauma related work whilst with the team. Mrs H states she does want to do trauma work, and this information is incorrect.
51. We have seen from the records the psychiatry speciality doctor set out, ‘Mrs H was clear that her symptoms were not trauma informed and that she does not want to do trauma related work whilst with the team.’
52. This is then amended by a consultant psychiatrist who noted, ‘Though Mrs H has experienced trauma related to childhood sexual abuse she does not wish to engage in any psychology related to this. In the future she would be open to engaging in psychology around her trauma, but she feels she needs to overcome her fear of food first.’ This is set out in the medical care plan to the GP dated 9 May 2023.
53. These are consistent with the notes written, and the medical records so support the statement in the letter. It appears Mrs H and the psychiatry specialty doctor had differing views on the statements made about trauma.
54. Our adviser explained the psychologist’s assessment supports that she was not ready for psychotherapy, which is trauma informed work. If Mrs H was ready for this treatment, she would have been offered it.
55. Our adviser explained the definitive treatment is trauma informed psychotherapy, which is extremely challenging to go through. Mrs H was considered not to be ready for this, and she had adequate professional assessments which concluded she was not ready for this form of psychotherapy.
56. We understand it is frustrating to feel that inaccurate information has been recorded and the belief this may be preventing access to treatment. We recognise it may not have been clearly explained to Mrs H why the trauma informed therapy was not offered. We consider the Trust’s decision not to offer this treatment to Mrs H is reasonable and supported by robust assessments. We have therefore not identified any indications of failings in the content of the letter.
Complaint handling
57. Mrs H first raised concerns with the Trust in October 2022. She complains the Trust did not reply to her complaint until prompted to do so by her advocate.
58. The Trust sent a letter to Mrs H on 11 January 2023 explaining there was a backlog of complaints, and the Trust will allocate her complaint to a complaint handler as soon as possible. This letter apologises for this.
59. The Trust wrote to Mrs H on 23 June 2023 and set out the questions it would consider in its investigation and asked for her comments. The Trust responded to her complaint on 3 November 2023.
60. A new complaint was raised with the Trust, and this was acknowledged on 24 November 2023. This was responded to in full on 15 January 2024. This response referred Mrs H to us if she had outstanding concerns.
61. The NHS complaint standards states ‘Staff respond to complaints at the earliest opportunity and consistently meet expected timescales for acknowledging a complaint. They give clear timeframes for how long it will take to look into the issues, taking into account the complexity of the matter’.
62. We understand it is frustrating to have to wait a long time for a response to a complaint, and it is difficult to feel you are being ignored. We understand there was a long wait for the Trust to respond to Mrs H and this would have been difficult for her. The Trust did apologise for the delays and sent letters explaining the reasons for the delays. Once the complaint was allocated to a complaint handler, the Trust provided its full response in five months. The second complaint was responded to in two months. We consider this is reasonable.
63. We do not consider the delay in responding to the first complaint falls so far below the generally accepted standard that we consider this a failing. We know it is frustrating to have to wait for a complaint response, but we also recognise that sometimes these delays cannot be avoided. The Trust has apologised and explained the reasons for the delays. We therefore do not propose to take any further action on this.
Hiding behind a mask
64. Mrs H complains a staff member accused her of hiding behind a mask due to her wearing a wig during an appointment on 13 July 2023.
65. The Trust set out the psychologist asked if there was a reason for Mrs H wearing a wig and she replied, ‘It’s my mask.’ Mrs H discussed how she cannot leave her house without some form of mask. To further understand this statement from a therapeutic perspective, the psychologist explored what she meant by a ‘mask’, and her reasons for wanting to hide.
66. Mrs H has said to us that she disputes this. She explained to us that she was messing around with her hair during the appointment, and the psychologist accused her of hiding behind a mask. Mrs H says she explained she only wears a wig to present herself.
67. As we were not present during this conversation, we cannot objectively conclude what took place and what was said. We understand Mrs H’s concerns as she feels that she has been misunderstood or not listened to. It is not possible for us to reach an objective conclusion about a conversation which we were not present for. It appears there has been a misunderstanding, and we recognise Mrs H found this shocking and difficult. Given there is no objective evidence in relation to this, we cannot take any further action on this point.
68. We understand this has been an extremely difficult process for Mrs H, and she feels very upset about the care and treatment she has received. We do not wish to take away from her experience, and we hope this decision provides reassurance the Trust provided the care it could. We thank Mrs H for bringing this complaint to our attention.