Trauma therapy
24. At the time of making her complaint, Mrs E said her child needed individual trauma therapy by a clinical psychologist. Mrs E said her child was seen by a private psychiatrist whose view was that Mrs E’s child’s presentation could be understood within the diagnostic label of Complex Trauma (PTSD).
25. The private psychiatrist’s report said individual therapy for Mrs E’s child such as trauma-focused Cognitive Behavioural Therapy (CBT) or Eye movement desensitisation and reprocessing (EMDR) could be considered as possible interventions for their past traumatic experiences.
26. The NHS webpage on trauma explains EDMR is a psychological treatment which involves recalling the traumatic incident in detail while making eye movements, usually by following the movement of a therapist's finger. While trauma-focused CBT uses a range of psychological techniques to help the patients come to terms with the traumatic event.
27. We will now consider if the Trust should have offered individual trauma focused therapy to Mrs E’s child by a clinical psychologist. From Mrs E’s child’s medical records, we can see he has trauma, related to past experiences at school.
28. In its final response, the Trust said when considering interventions, careful thought is always given to what is the right intervention at the right time. It said trauma-focused interventions such as trauma-focused CBT or EDMR can potentially destabilise things and increase the risk for a period of time before things start to improve.
29. Our adviser has explained EDMR, and trauma-focused CBT can expose the person to past trauma and can potentially cause destabilisation and trauma reactivation in vulnerable young people. This means it is very important that the treatment is only considered at the appropriate time.
30. In line with section 16B of GMC guidelines, we would expect the trust to have provided effective treatments based on the best available evidence at the time.
31. Our adviser has signposted us to evidence which supports the Trust’s explanation, which included the peer reviewed journal article ‘Adverse effects of eye movement de-sensitisation and reprocessing therapy: systemic review’ This states ‘harms of EDMR are under reported and that more systemic monitoring is needed’.
32. From Mrs E’s child’s medical records, we can see information about the family being at ‘breaking point’. Considering this, our adviser said this would not have been the right time to consider a trauma-focussed intervention, as this could potentially destabilise things further and increase risk causing further strain on Mrs E’s child and the rest of the family.
33. They said from a clinical perspective, priority was therefore on preventing family breakdown and it was felt this required a multi-agency approach including CAMHS, Aspire Life Skills, and other agencies involved with Mrs E’s child and the rest of the family.
34. We appreciate Mrs E’s child was seen by a private psychiatrist who said the Trust could have considered Mrs E’s child have trauma focused intervention and acknowledge why the psychiatrist’s assertion may have caused them to further question the treatment the Trust was giving at that time.
35. However, our adviser explained there is no legal obligation for the Trust to accept a diagnosis or recommendations made by a private psychiatrist. Under GMC guidance, whilst an NHS clinician should consider external medical options, they are not required to adopt them.
36. As noted above we can see at this stage, the Trust had already considered trauma focused intervention in early 2023.
37. We would not expect the Trust to accept private recommendations, when its own clinicians had already (and according to the evidence we have seen appropriately), concluded trauma focused intervention was not suitable at this stage.
38. Having considered all the available evidence from the period we have looked at, we consider it was a reasonable decision by the Trust not to offer trauma focused intervention during the time period complained about.
39. While we did not find that the Trust should have offered trauma therapy at this time, we understand from our correspondence with the Trust, following the period complained about, Mrs E’s child was later in a position to be able to be offered trauma focused therapy from the Trust.
Lead professional, care plan, risk assessments
40. Mrs E says her child went without a lead professional, and risk assessments and review of care plan from March 2023.
41. The Trusts response acknowledged Mrs E’s child was overdue for a review of his care plan and risk assessments as they had not been seen by a clinician since 9 March 2023.
42. We have reviewed the records from this time with our adviser.
43. Following this medical review Mrs E’s child did not attend their appointments scheduled for late March and early June 2023.
44. In June, Mrs E’s child’s psychiatrist spoke to their parents who said their mental health had deteriorated. They said there was an increase in meltdowns and self-injurious behaviour.
45. In mid-June, a multi-agency meeting was held. Mrs E raised concerns about medication and a lack of therapeutic support. The psychiatrist said it was difficult to review Mrs E’s child’s medication if they did not attend appointments.
46. The Trust psychiatrist agreed to liaise with the specialist autism team to see what they could offer. There was also enquired whether family therapy sessions were available out of hours due to parents work commitments and Mrs E’s child’s educational placement.
47. Mrs E’s child did not attend their next appointments with their psychiatrist in late July. Their parents said this was due to another ‘meltdown’.
48. Our adviser explained that care plans should be reviewed at the end of interventions or if any changes were required, or if the risk changes due to risk management.
49. They also signposted us to section 2.5 of the Code, which states that you must:
2 Listen to people and respond to their preferences and concerns To achieve this, you must: 2.1 work in partnership with people to make sure you deliver care effectively 2.2 recognise and respect the contribution that people can make to their own health and wellbeing 2.3 encourage and empower people to share decisions about their treatment and care 2.4 respect the level to which people receiving care want to be involved in decisions about their own health, wellbeing and care 2.5 respect, support and document a person’s right to accept or refuse care and treatment 2.6 recognise when people are anxious or in distress and respond compassionately and politely.
50. They explained it would be for this reason that if Mrs E’s child refused to engage and did not attend appointments, they would normally honour this decision in keeping with this code of conduct. The said that on the basis of the records there was little else the Trust should have done to support Mrs E’s at this point of their care journey.
51. While we make no criticism of Mrs E and fully understand in the circumstances why they were unable to attend appointments, we consider this did impact on the Trust’s ability to conduct adequate reviews and risk assessments when Mrs E’s child was unable attend appointments, rather than being indicative of a failing on the Trust’s behalf.
52. From Mrs E’s child’s records, we can see their family did not feel they were making adequate progress under their current psychiatrist and therefore requested a change in July 2023.
53. In its final response, the Trust explained Mrs E’s child’s psychiatrist was also allocated as their lead professional, so performed a dual role.
54. When the family requested a change of psychiatrist the Trust agreed to do this, however this meant this resulted in a transitional period when alternative arrangements were being made for a new psychiatrist to take over as their lead professional.
55. The GMC’s Good ‘Good Medical Practice’ says clinicians should work in partnership with patients and listen to and respond to their concerns and preferences.
56. We consider the Trust listened to Mrs E’s concerns about the relationship with their psychiatrist raised and arranged an alternative psychiatrist on that basis.
57. From Mrs E’s child’s medical records, we can see in September 2023, the Trust wrote to Mrs E’s child’s parents which confirmed an appointment had been arranged with Mrs E’s child’s new psychiatrist for December 2023.
58. However, because of the dual role the psychiatrist played (also acting as lead professional), we appreciate there was a period when Mrs E’s child was without a lead professional, whilst the Trust made arrangements for a new psychiatrist.
59. We understand psychiatry is a limited resource with high demands, and it would have taken the Trust some time to arrange a new psychiatrist who was suitable to meet Mrs E’s child’s needs, it is unfortunate they were not available for an appointment until December.
60. While there is no indication the delay in reassignment of a new psychiatrist was a result of an avoidable delay, nevertheless we can see the Trust overlooked that Mrs E’s child and their family, in not having a lead professional during this time, also did not have a key point of contact within the CAMHs team.
61. The Trust has acknowledged shortcomings around communication during the period when Mrs E’s child was without a lead professional. The Trust has also apologised for this.
62. In addition, and in line with our complaint standards which say organisations need to be open and honest where improvements can be made, we are therefore pleased to see that in its final response it said the service has a new process in place for when patients request a change in clinician.
63. It has also taken a learning point to ensure families are aware of who their CAMHS point of contact during any transition period to prevent any shortcomings around communication.
64. We hope this can reassure Mrs E the Trust has taken learning from her case.
Conclusion
65. We appreciate that this has been a very difficult time, and our decision is not intended to diminish the effect of the issues in this complaint have had and continue to have on the family.
66. We hope we have clearly explained the reasons for our decision regarding the concerns Mrs E has raised and where possible reassure her with our explanation of the care provided by the Trust.
67. We would like to thank Mrs E for giving us the opportunity to consider her complaint.