Conduct and attitude
15. Ms O complains about the conduct and attitude of the mental health crisis team. In her complaint of 17 January, she says the call felt ‘incredibly personal’ and she ‘felt victimised during this call’. The Trust has not responded about this issue. We consider these issues refers to the way a person behaves. We looked at all the available information and acknowledge Ms O’s version of events.
16. We recognise it has been a frustrating and distressing time for Ms O as she is eager to get support when she calls the crisis team. From review of the available information, we have not seen any impartial evidence to confirm the poor conduct and attitude of the mental health crisis team. We acknowledge attitude and conduct is subjective as individuals can perceive it differently. We are unable to reach a clear decision about this issue.
Complaints of January 2024
17. Ms O complains the Trust refused to formally respond to her complaints of January 2024. We can see Ms O made two complaints to the Trust in January 2024. The Trust’s complaint manager’s response of 8 February 2024 said it recognised Ms O continued to be dissatisfied with interactions with the crisis resolution home treatment team (CRHTT), and her new concerns relate to similar issues with members of staff.
18. It said having discussed this with senior colleagues in the service, it decided it would not commence further formal investigation through its complaint’s procedure at this time. It said it would continue to thoroughly review any new concerns. It encouraged her to keep letting it know about her experience and assured her it was working closely with the clinicians to make the contacts with the service as helpful as possible.
19. Our adviser said they considered the Trust’s decision is understandable for the position it took to not formally respond to Ms O’s complaints of January 2024. They said they could understand the position continuing with a complaint in this way could be more harmful than beneficial. Ms O had a diagnosis of emotionally unstable personality disorder (EUPD).
20. The borderline personality disorder guidance says a common trait of individuals with EUPD is rejection sensitivity:
‘Borderline personality disorder is characterised by significant instability of interpersonal relationships, self-image and mood, and impulsive behaviour. There is a pattern of sometimes rapid fluctuation from periods of confidence to despair, with fear of abandonment and rejection, and a strong tendency towards suicidal thinking and self-harm.’
21. They said therefore it is not uncommon for individuals with EUPD to feel unsupported. They said the best practice on supporting individuals with EUPD is to remain calm, consistent and provide validation. The borderline personality disorder guidance supports this approach. Our adviser said they could see this would be best done informally and face to face as opposed to a formal investigation.
22. Due to the complexity of Ms O’s mental health, the Trust’s complaints department took clinical advice and input from the crisis team service to assist in its decision to not formally investigate and respond to her complaints of January 2024. Our adviser said this was in Ms O’s best interests and to ensure it was not to her detriment.
23. We can see the Trust tried to explain this would be the best way in its response of 7 May 2024. It said, ‘Having had discussions with the CRHTT, it would be beneficial for you to engage with senior staff within the CRHTT, so that you can work together to review your care plan, which was last updated on 22 February 2024. We agreed that the elements about raising concerns need to be revised in your care plan…’
24. However, our adviser said the Trust has not clearly explained its decision and clinical rationale in its responses of 8 February 2024 and 7 May 2024 to Ms O. They considered the Trust should have clearly explained its reason for its decision to Ms O to ensure she was supported in line with the above guidance.
25. If it had done this it would have shown it was taking her concerns seriously by providing Ms O with the appropriate support in response to her complaints. From review of the available information, we agreed with this position in the Trust not clearly explaining its decision and service improvements it made in response to Ms O’s concerns. The NHS complaints standards say,
‘An effective complaint handling system…gives an open and honest answer as quickly as possible, considering the complexity of the issues.’
26. Therefore, we consider there are indications of potential failings in the Trust’s complaint handling, and it is not in line with the NHS complaints standards and the borderline personality disorder guidance. We consider the Trust’s responses of February 2024, and May 2024 does not put right the impact of her distress from not feeling supported and reassured.
27. Our Principles of Remedy (Putting things right) says, if possible, the organisation should return the complainant to the position they would have been in if the maladministration or poor service had not occurred. Ms O wanted the Trust to acknowledge, apologise and provide service improvements for this issue.
28. In our email to the Trust on 11 December 2025 we set out the indication of failing. We consider this indication of failing would have caused Ms O distress from not feeling reassured and supported following her complaints of January 2024. We are pleased the Trust agreed to acknowledge and apologise for this indication of failing in its email of 15 January 2026.
29. It also outlined several service improvements it made following her concerns to ensure it does not happen again in the future. We have confirmed this to Ms O. We consider the Trust has now appropriately addressed Ms O’s concerns. This is because the outcome is what we expect to achieve to address the impact of the indication of failing.
30. This is in line with our Principles of Remedy. We are reassured to see the Trust has offered Ms O an opportunity for mediation which we consider shall help rebuild trust, provides support, facilitate effective communication with the parties and alleviate any further concerns going forwards.
31. We understand this has been a difficult time for Ms O. We wish her all the best in her mental health.