Voicemail
12. Mr I complains on 5 March 2025 the Trust failed to return his voicemail and did not provide a sufficient explanation as to why it wasn’t recorded. Mr I contacted the Trust on 5 March and was transferred to the community mental health team (CMHT). He remained on hold until the line went to voicemail. He explains his call was not returned which left him feeling lost and exacerbated his distress. He requested confirmation of what systemic reviews or process changes will be made to prevent such occurrences in the future.
13. The Trust said it reviewed the records on the day his call had been transferred through to CMHT. The Trust checked the voicemails to see if a message had been left and was unable to find one. The Trust accepted Mr I had left a voicemail. It conducted an investigation and it appeared to be a one off incident. The Trust issued an apology. The Trust could not suggest any procedural changes and systemic reviews.
14. We have reviewed the records. We can see a call was made to the Trust at 1.23pm on 5 March. This call was transferred to the CMHT. The records do not show a voicemail was left. As noted above, the Trust have agreed a voicemail was left. A second call was made at 6.44pm to the Trust. Mr I was then able to discuss his mental health with the out of hours team.
15. In this situation we will never be able to say exactly what happened and if the voicemail was lost or did not record. The Trust have accepted the voicemail was left and issued an apology to Mr I. We will consider if this was appropriate.
16. NHS Complaint Standards set out how all organisations that provide NHS services should approach complaint handling. Before deciding whether there is any further action we should take, we have carefully considered if the Trust’s response to the complaint is in line with the standards.
17. The complaint standards say: • ‘The organisation has actively listened to the complaint and demonstrated a clear understanding of what the main issues are for the complainant and the outcomes they seek’ • The response has given a clear, balanced account of what happened based on established facts. Each account compares what happened with what should have happened.
• Wherever possible, the organisation has explained what went wrong and identified suitable ways to put things right for people.
• Organisations give meaningful and sincere apologies and explanations that openly reflect the impact on the service user concerned.’
18. We consider the Trust acknowledged Mr I was seeking service improvements. The Trust provided a balanced account, and while it did not find evidence a voicemail had been left it accepted one had. The Trust provided an apology for the inconvenience caused. It explained as this appeared to be a one off incident, no further action was required. We consider the Trust’s response is in line with the complaint standards and there was no requirement for service improvements as this was a one off incident.
19. We have considered our severity of injustice scale. It says an apology will be an appropriate remedy for a single (one-off) incidence of maladministration or service failure, where the effect on the person complaining is of short duration, and where there are no other adverse effects or ongoing wider impact. We can see from the records Mr I was able to contact the Trust five hours after his first call. We consider an apology an appropriate remedy.
20. We acknowledge Mr I’s frustration as his voicemail was not recorded and did not receive a call back. We are sorry to hear of his experience. The Trust conducted a full investigation and provided an apology for Mr I’s experience. The actions the Trust took were appropriate and we would not expect it to anything else.
Care and Treatment
21. Mr I complains he received no care or treatment by the Trust for his ADHD diagnosis. Mr I first received his diagnosis of ADHD from a private organisation. The diagnosis was submitted to the Trust in August 2024.
22. The Trust said Mr I’ GP first requested a review of the private diagnosis on 17 September 2024. It said it could not do this until Mr I reached the top of the ADHD waiting list.
23. We have reviewed the records.
24. In August 2024 Mr I shared his diagnosis of ADHD with the Trust.
25. On 4 December 2024 the Trust wrote a letter to Mr I’s GP Practice. It explained it was aware of Mr I’s private diagnosis. It said it could not review or take over his prescribing until he came to the top of its ADHD waiting list.
26. On 10 March Mr I made his complaint to the Trust. He explained he remained on a waiting list.
27. On 26 March the Trust explained Mr I remained on a waiting list for ADHD review. It explained it could not prioritise one person over another. On the same day Mr I responded. He remained unhappy with the wait times for an ADHD review.
28. On 8 May the Trust responded. It confirmed again he remained on a waitlist. On 13 June Mr I completed his complaint form to us.
29. We have seen on 31 July 2025 the Trust confirmed to Mr I’s GP it had taken over specialist oversight of his ADHD management.
30. We have considered the period between August 2024 and 31 July 2025. This is the gap between Mr I informing the Trust he had been diagnosed with ADHD and the Trust accepting him as a patient.
31. The Trust indicated on 26 March 2025 its wait list for assessment is three years. We have not been able to see this information is publicly available. We are aware there are currently very lengthy waitlists for ADHD treatment throughout the country. The NHS page on ADHD says wait times vary and you may have to wait several months or years to access ADHD specialist services.
32. The Trust has also provided its policy, standard operating procedure for management of ADHD referrals. It says: “1.0 Receipt of Referral for new assessment 1.2 This will automatically add the referral to the ADHD screening waiting list.”
14.0 Other Transitions 14.1 Adult ADHD transition assessment – this could include; • ADHD diagnosis privately 14.3 Diagnosed privately should include copy of assessment. Follow new assessment process.”
33. In line with its policy, the Trust should have treated Mr I’s referral under the new assessment process. This meant placing Mr I on an ADHD waiting list. In line with this process, we cannot say the Trust got anything wrong here.
34. Our advisor explains there is no national standards or guidance regarding waiting times for ADHD. Long waits are common due to high demand for ADHD services.
35. We understand Mr I’s frustration at the time he had to wait before being accepted at the Trust. By 31 July 2025 the Trust had accepted Mr I as a patient. We have seen the Trust acted in line with its own policy by placing him on a waiting list. We have not seen the waitlist time was above or beyond the national average. Therefore we will take no further action.
DBT
36. Mr I complains the Trust did not inform him his dialectical behaviour therapy (DBT) referral on 19 November 2024 had gone to the wrong place or he was being transferred to another service.
37. The Trust acknowledged there had been poor communication. The Trust said a referral for DBT was made to the adult psychology service (APS) on 19 November 2024. On 27 November APS referred Mr I to psychological therapies service (IPTS) for DBT instead. In responding to Mr I’s complaint on 26 March 2025, the Trust acknowledged Mr I had not been contacted.
38. The Trust issued an apology for this and hoped to reduce the potential for this happening again by using his complaint as an example of the impact the known staffing issues have had. The Trust confirmed Mr I’s case will be discussed at the next liaison meeting.
39. We have seen in the records IPTS contacted Mr I within two weeks of its response on 11 April 2025.
40. We have considered Mr I’s complaint. We can see the Trust have upheld this aspect and acknowledges its communication fell below its own expected standard. Mr I is seeking service improvements. We will consider if the Trust’s actions are enough to remedy this complaint.
41. As noted above, we have considered the NHS complaint standards. We consider the Trust have demonstrated a clear understanding of Mr I’s complaint. It explained what had happened and acknowledged its failings. The Trust identified ways to put this complaint right. We were pleased to see within two weeks of the complaint response the ICB actioned Mr I’s referral.
42. The Trust provided a meaningful and sincere apology and explanation. These actions are in line with the complaint standards.
43. We acknowledge Mr I’s upset as he feels the abandonment and disregard by the Trust has exacerbated his mental health. The Trust upheld this aspect of this complaint and provided service improvements. We consider the actions taken by the Trust are in line with the NHS complaint standards. There is nothing further we can add to this complaint.