17. 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.
Issue 1 – Communication method, engagement, and closure of referrals
18. Mr D complains that the Trust: • failed to make reasonable adjustments by refusing his request for email-only contact; • inappropriately closed referrals when he did not engage by telephone; • did not sufficiently consider the underlying reasons for his engagement difficulties, including trauma-related barriers.
19. The Trust explained that while it recognised Mr D’s preference for email communication, email-only contact is not clinically safe for crisis or urgent mental health care. It stated that telephone contact was used where necessary to assess risk and plan care, and that Mr D’s preference for email communication would be followed where appropriate and safe to do so.
20. National NHS guidance on digital communications confirms that services should respect communication preferences where possible. However, it also makes clear that emails are not appropriate for urgent, high-risk, or time-critical clinical interactions, particularly where risk assessment, escalation, and immediate decision-making are required.
21. We also considered relevant professional standards, including the NMC Code, which requires professionals to: • assess deterioration promptly (section 13), • protect people at risk of harm (section 17), and • arrange emergency care without delay (section 15).
22. Our clinical adviser explained that crisis and urgent mental health services depend on real-time, interactive communication to assess mental state, evaluate immediate risk, and coordinate emergency interventions. These professional duties cannot be carried out safely or effectively through email or written correspondence alone.
23. We understand that telephone communication can be difficult for Mr D. However, we agree with the Trust that relying exclusively on email would not be clinically safe in the context of urgent mental health care. We also note evidence that Mr D was able to engage by telephone at times when necessary, and that the Trust stated it would use email communication where appropriate.
24. Mr D also says the Trust inappropriately closed referrals when he did not engage by telephone. The Trust explained that it followed its DNA policy. The policy requires staff to:
• make at least two proactive attempts to contact the patient using the most appropriate method • attempt contact at different times of day where possible • document all attempts • consider any known risks or reasonable adjustments before closing a referral • escalate concerns to a senior practitioner if risk is identified • and only close a referral when it is clinically safe to do so
25. The records show the Trust made multiple attempts to engage Mr D by telephone, considered safety and risk, and continued to offer support over an extended period. Where engagement could not be achieved, referrals were closed in line with policy and professional obligations.
26. In considering Mr D’s engagement difficulties, including trauma-related barriers, our adviser acknowledged the complexity of his mental health history and that such difficulties can arise for a range of reasons. The evidence shows the Trust continued to offer assessments and support despite repeated disengagement and complexity, and that care was not withdrawn prematurely.
27. Overall, we have not seen evidence that the Trust acted unreasonably, failed to consider Mr D’s engagement difficulties, or breached relevant professional standards. We therefore do not consider this issue to indicate a service failure and will not be taking any further action on this part of the complaint.
Issue 2 – Response following the 16 January 2024 crisis call
28. Mr D complains that the Trust failed to respond appropriately following his crisis call and did not contact him within the required timeframe.
29. The Trust’s records show multiple attempts were made to contact Mr D within the four-hour response standard. The Trust explained that contact was delayed due to service pressures but remained within the required timeframe.
30. The NHS England Mental Health Access and Waiting Time Standards require crisis services to make timely contact following urgent requests for support. The records show that the Trust made multiple attempts to contact Mr D within the four-hour response window.
31. The four-hour window is explicitly outlined as an internal expectation within the Trust’s response and also supports the expectation in the NHS England Mental Health Access and Waiting Time Standards’ guidance of a timely urgent response.
32. Our clinical adviser confirmed that the documented attempts were consistent with the expected response under national standards.
33. For these reasons, we have not seen any indications of delay or failure in the Trust’s response to the crisis call.
Issue 3 – Recording and assessment of the crisis call
34. Mr D believes the practitioner was unaware of the reason for his call and that his concerns were not accurately recorded, contributing to later harm.
35. Our clinical adviser reviewed the records using the UK Mental Health Triage Scale as a benchmark.
36. The UK Mental Health Triage Scale requires practitioners to assess key factors including presentation, immediate risk, past risk history, psychosocial stressors, substance use, and physical health concerns in order to assign an appropriate triage category.
37. In reviewing the notes against these factors, our adviser confirmed that all relevant elements were documented.
38. While Mr D disagrees with how his presentation was understood and recorded, we consider the records demonstrate that an appropriate triage assessment was undertaken in line with The UK Mental Health Triage Scale.
39. Without independent evidence that the assessment was inaccurate or unsafe, we are unable to conclude that there are any indications the Trust’s recording or assessment fell below acceptable standards.
Issue 4 – Support following discharges
40. Mr D believes the Trust should have provided additional support following multiple discharges and adopted a more trauma informed approach.
41. The Trust explained that the discharges followed non-engagement and were managed in line with its DNA policy. This included documenting each attempted contact, reviewing risk information prior to discharge decisions, considering any reasonable adjustments, and ensuring escalation where appropriate. Opportunities for re-referral were also available.
42. When reviewing the records with our adviser, we have identified evidence Mr D could engage by telephone when necessary. From this we concluded they do not indicate a documented clinical barrier that would have prevented telephone contact entirely. We also noted evidence within the records that the Trust followed its DNA policy when discharging Mr D.
43. Further to this, we can see the Trust has signposted Mr D to several supportive resources including his GP, Live Well Kent, Mental Health Matters, Samaritans, NHS 111 and the crisis lines in the discharge letters sent. This evidences that Mr D was made aware of who he could reach out to, should he require additional support.
44. While we recognise Mr D’s experience of repeated discharge was distressing, we have decided there are no indications that the Trust failed to act in line with policy or professional standards.
Issue 5 – Allegations regarding criminal conduct
45. Mr D reported alleged criminal conduct by police officers and believes the Trust failed to safeguard him appropriately.
46. The Trust explained that the concerns were considered within a clinical context and did not meet thresholds for safeguarding referrals.
47. In considering this issue, we had regard to relevant professional and national guidance. The Nursing and Midwifery Council (NMC) Code requires practitioners to protect people from harm, to recognise and respond appropriately to risk, and to raise safeguarding concerns where there is a reasonable belief that a person is at risk of abuse or neglect.
48. Similarly, the General Medical Council requires clinicians to act when patient safety is at risk, to use professional judgement, and to share information with appropriate agencies where safeguarding thresholds are met.
49. NHS safeguarding guidance also makes clear that safeguarding referrals should be made where there is evidence or reasonable suspicion of abuse or neglect, and that services must apply clinical judgement when concerns arise in the context of mental illness, including where reports may be influenced by a person’s mental state.
50. The records show that the Trust did consider safeguarding concerns in response to Mr D’s reports. Two safeguarding referrals were submitted by other organisations and reviewed. On both occasions, it was decided that the concerns did not meet the threshold for further safeguarding action and the Trust was aware of this.
51. The records also show that the Trust maintained an extensive safeguarding log, documenting ongoing consideration of risk and actions taken to monitor and support Mr D’s safety. We are therefore satisfied that the Trust did not disregard safeguarding responsibilities and that concerns were actively considered, recorded, and managed, even where the decision was ultimately not to escalate the referrals in relation to criminal conduct further.
52. Our adviser considered that the Trust applied appropriate clinical judgement, noting that the concerns were consistent with Mr D’s mental health presentation.
53. Overall, we consider the Trust’s approach was consistent with relevant professional standards and safeguarding guidance and was within the range of acceptable clinical practice.
Conclusion
54. We recognise that Mr D has experienced significant distress and frustration in his interactions with mental health services. However, having carefully considered all the evidence and relevant standards, we have not identified indications of maladministration or unremedied injustice.