Issue 1 – Whether the Trust missed opportunities to identify Mr U’s ASC
24. Mr U complains the Trust missed earlier opportunities to identify that ASC was an underlying reason for his mental health symptoms, not only in 2014 when he raised this with his psychiatrist and was dismissed without any further consideration or onward referral, but also prior to his discharge from mental health services in September 2020.
25. The NICE ASC guidelines say clinicians should consider assessment for possible autism (including ASC) when a person has one or more of the following:
• persistent difficulties in social interaction • persistent difficulties in social communication • stereotypic (rigid and repetitive) behaviours, resistance to change or restricted interests.
26. The NICE ASC guidelines say, in addition to the above, a person should also have one or more of the following to be considered for assessment for possible autism:
• problems in obtaining or sustaining employment or education • difficulties in initiating or sustaining social relationships • previous or current contact with mental health or learning disability services • a history of a neurodevelopmental condition (including learning disabilities and attention deficit hyperactivity disorder) or mental disorder.
27. The NICE ASC guidelines also say that for adults with possible autism who do not have a moderate or severe learning disability, [clinicians should] consider using the Autism-Spectrum Quotient – 10 (AQ-10). If a person scores 6 or above on the AQ-10, or autism is suspected based on clinical judgement (considering any past history provided by the patient) clinicians should offer a comprehensive assessment for autism.
28. The records show Mr U sent an email to his psychiatrist in November 2014. The email outlined his symptoms from childhood to the present day. Some of the symptoms included persistent difficulties in social interaction and communication as well as problems in sustaining employment and initiating and sustaining social relationships.
29. Mr U asked his psychiatrist if there was anything else apart from bipolar and financial worries contributing to his poor mental health. He subsequently emailed his psychiatrist to inform him that he thought he had ASC and had taken an online AQ-50 test scoring 36. Mr U’s psychiatrist telephoned him to tell him he had not considered ASC as a diagnosis to explain his problems. He said he still considered Mr U’s presentation was explained as an adjustment to current stressful life events coupled with mood swings related to his bipolar.
30. Our advice is that when Mr U informed his psychiatrist of possible ASC symptoms, this should have alerted him to consider a potential ASC diagnosis. In addition, Mr U’s score of 36 on the AQ-50 test was significantly above the threshold of 33 where an autism diagnosis is likely. All this information should have led Mr U’s psychiatrist to refer him for an ASC assessment. However, this did not happen for another seven years. We find the Trust did not act in line with NICE ASC guidelines. This fell so far below the relevant standards to be service failure.
31. We have not identified another opportunity when the Trust could have considered assessing Mr U for ASC prior to his discharge from community mental health services in September 2020.
Issue 2 – The Trust failed to understand Mr U’s ASC, appropriately assess his needs and provide appropriate care and support
32. Mr U complains that despite identifying his potential autism diagnosis in January 2021, the Trust failed to understand his condition, properly assess his needs or provide care and support which was appropriate for a mental health trust to provide.
33. Good Medical Practice says clinicians should refer a patient to another practitioner when this serves the patient’s needs. Our advice is this would mean the Trust liaising between generalist mental health services and specialist neurodivergence services and referring Mr U for assessment at a specialist service providing expertise in ASC and neurodivergence. The responsibility for treating Mr U’s bipolar disorder would remain with CMHT.
34. The Trust was not a provider of specialist neurodivergent services. However, we have seen evidence that the Psychologist liaised with Mr U’s GP to obtain specific funding for him to receive an expedited specialist ASC assessment. This was due to concerns about the length of waiting times for specialist assessment and their potential negative impact on Mr U’s mental health. This was the correct course of action to support Mr U and subsequently led to him receiving a formal diagnosis of ASC.
35. Mr U told us his past traumatic experiences should have led to continued support from CMHT, including ongoing input from a care coordinator (a person assigned to liaise with different health and social services on behalf the patient, so they receive the most appropriate care). We have seen no evidence that Mr U should have been offered continued support or care coordination from CMHT.
36. Mr U was offered the availability of crisis services and the opportunity to develop a safety plan by CMHT. This would be the usual and appropriate intervention from CMHT for mental health conditions such as bipolar disorder at the point of discharge to GP care. These actions were in line with Good Medical Practice although we note Mr U declined the offer of a safety plan. For these reasons, we do not uphold this part of Mr U’s complaint.
Issue 3 – Complaint Handling
37. Mr U also complains about the Trust’s handling of his complaint. He says it failed to respond to his complaint promptly and he was not satisfied with its responses as it did not satisfactorily address his concerns about the issues raised above.
38. The NHS complaint regulations say NHS bodies are expected to respond to complaints within six months of receipt.
39. Mr U first complained to the Trust on 14 March 2021 about how PALS responded to two approaches he made in October 2020 and January 2021 to discuss his concerns about his discharge from CMHT and his request to have appropriate services put in place, including having a dedicated care coordinator, following his ‘misdiagnosis’. The Trust responded just over three months later on 1 July 2021. We find this was a reasonable timescale in which to respond to Mr U’s complaint and was in line with the NHS complaints standards.
40. Mr U made a further complaint to the Trust on 27 August 2021 about the quality of support he received from CMHT from 2018 to 2020 and the adequacy of the mental health assessment which took place in 2021. The records show the Trust only acknowledged, and did not respond, to Mr U’s second complaint on 6 May 2022 – just over eight months later after he had complained to us. The Trust apologised for the delay but did not explain why it had taken so long to respond. It said Mr U would receive a final response by the end of June. A final response was issued to Mr U a further two months later on 27 June 2022.
41. In total, the Trust took 10 months to answer Mr U’s concerns. We acknowledge that the Trust apologised to Mr U of the delay. However, we find that four months over the six-month target to respond is not in line with the NHS complaints regulations.
42. We now turn to Mr U’s dissatisfaction with the Trust’s responses to his concerns about the:
43. failure to identify his ASC earlier 44. failure to understand his ASC 45. failure to assess his needs 46. failure to provide appropriate care and support.
47. The NHS complaints standards say NHS bodies are expected to give a clear, balanced account of what happened based on established facts.
48. The Trust responded to the four issues above. It said that when Mr U approached PALS in January 2021, he was under the impression that a formal diagnosis had been made, but this was not the case. The Trust said the Psychologist considered there was no further role for CMHT in his care and no indicated psychological therapy he could benefit from. The Trust said the Psychologist identified Mr U’s needs related to potential autism and not a mental health condition and supported his GP in getting an ASC assessment.
49. The Trust said Mr U had received an assessment and formulation of his needs between February and April 2021. It said this assessment is done for all patients referred to CMHT services and it informs the offer of any interventions as part of a care plan. The Trust said the assessment did not identify that Mr U had any mental health needs which required secondary mental health services.
50. The Trust outlined all the interventions that had been provided for Mr U. It said the aim of CMHT involvement is about recovery focused interventions and Mr U had received several appropriate psychological interventions prior to his discharge from mental health services.
51. We can see, above, from the Trust’s responses to Mr U that all four issues were addressed by the Trust. It appears Mr U is dissatisfied with the Trust responses because they disagree with his view that there were failings in his care. We have identified only one failing in Mr U’s care – the failure to refer him for ASC assessment in 2014. The Trust’s view on the remaining issues is in keeping with our findings about the care and treatment he received. Therefore, we do not see that the Trust has given him incorrect or inappropriate answers to three of his concerns. It has acted in keeping with the NHS Complaint Standards to this extent
52. However, we have not seen any acknowledgement from the Trust that there was a missed opportunity to potentially have diagnosed Mr U’s ASC in 2014. Given this was central to Mr U’s concerns about his care and he had been formally diagnosed at this point, this should have been addressed by the Trust, and we cannot see that it has been. This is not in line with the NHS complaints standards as the Trust did not to give a clear, balanced account of what happened based on established facts
53. In summary, the Trust provided Mr U with a relatively quick response to his first complaint, and its responses were, overall, evidence based. However, there was a significant delay in responding to Mr U’s second complaint and the Trust also failed to properly address the missed opportunity to refer Mr U for ASC assessment in 2014. On balance, we find these two failings in the complaint handling are significant enough to amount to maladministration.
Injustice
Care and treatment
54. We have found service failure because the Trust failed to properly consider Mr U potentially had ASC in 2014 and did not refer him for an ASC assessment. Had that happened it is more likely than not that his ASC would have been identified seven years earlier than it was, considering his diagnosis in January 2022. Mr U says he lived an additional seven years (2014-21) with no understanding of, or support for, his ASC due to failings in care. He says he received inappropriate treatment and medication as a result.
55. We have considered the impact of the Trust’s service failure on Mr U. Mr U told us that before his diagnosis he lacked self-confidence and had no sense of self-identity. He said he found it difficult to communicate, and form a bond, with other people. Mr U said this affected his relationships with his children who he had been estranged from and meant he found it hard to make and keep friends.
56. Mr U said he had not been able to seek and hold down employment. He said that he attended a prestigious university as a young man and trained to be a solicitor. He believed he could have improved his job prospects with earlier knowledge of his autism. He also said he had neglected his self-care to the extent he needed support and care from a personal assistant. He said these negative behaviours were caused by his autism and destroyed his marriage, relationships, career and finances. Mr U said the medication he took for bipolar disorder caused him to become obese and this led to diabetes and a lack of insulin control.
57. Mr U said his life had completely changed since his diagnosis. He said he now understood why he had felt different from other people and why he had felt the way he did. Mr U said he had attended 95 therapy sessions for his autism, which have helped restore his identity and connection with himself. He said these have helped to teach him important communication and relationship skills, and to understand what he had previously been doing wrong so he can modify his behaviour and explain his condition.
58. Mr U said this led him to improve his relationships with people. He said this initially included his daughter, who he started to rebuild a relationship with, but this had changed recently and he was not certain if he would have a relationship with any of his children in future. Mr U said he had gained self-confidence, self-knowledge and self-respect. Mr U said his diagnosis of ASC had given him the opportunity to recover.
59. Our Clinical advice is that it is very difficult to evaluate the impact of a delayed diagnosis of ASC as it appears it was co-existing with Mr U’s bipolar disorder for which he was receiving appropriate care and treatment. He was also receiving good quality appropriate community mental health support at the time and there is a significant overlap between the support provided for ASC and for bipolar disorder. Because of this, we cannot say Mr U was receiving inappropriate medication or support, or that his lack of a diagnosis for ASC was responsible for the side-effects of his bipolar medication which he described.
60. However, we have considered what Mr U told us about how his life changed following his diagnosis of ASC and how extensive therapy following this significantly changed his life for the better. We can see that a lack of a formal diagnosis of ASC would have had a significant impact on Mr U in terms of his understanding of the cause of some of the difficulties he was experiencing at the time. This has clearly been a significant help and comfort to him since his diagnosis in 2021, and something that he missed the opportunity of having in the seven years preceding his diagnosis.
61. Unfortunately, we cannot know for sure whether an earlier diagnosis of ASC would have changed all his difficulties at the time, especially as bipolar disorder was also a feature of Mr U’s condition. In addition, Mr U said his relationship with his children continues to be challenging, so we cannot conclusively establish an earlier diagnosis in 2014 would necessarily have changed that.
62. In relation to Mr U’s job prospects, we cannot know on the balance of probability if he would have been able to improve his professional and earning capacity before he retired. We can say, however that he was denied the opportunity to seek specialist support for his ASC which subsequently transformed his life for the better. This is a serious injustice to Mr U and one which has clearly caused a great deal of frustration and anxiety for him.
63. The Trust eventually remedied the missed opportunity to assess Mr U for ASC, but we have seen no evidence the Trust has remedied the injustices he suffered in the intervening seven years, which we have identified above. We are therefore proposing to uphold this part of Mr U’s complaint.
Complaint handling
64. Mr U says the Trust’s complaint handling compounded his stress and frustration. He says it has contributed to the reoccurrence of his burnout in 2021 and 2022. We find the significant delay in responding to Mr U’s second complaint and the failure to properly address the missed opportunity to refer him for ASC assessment in 2014 amounts to maladministration.
65. Had it not been for the maladministration we have found, it is likely Mr U would have received a response to his second complaint by the end of February 2022 or at least an acknowledgment of his complaint and a timescale for when he could expect a response. In the event, the Trust only provided an acknowledgement and timescale for its response eight months after Mr U complained. Moreover, it has still not acknowledged there was a missed opportunity to diagnose Mr U’s ASC in 2014.
66. We can see how these failings in the Trust’s complaint handling would have compounded the stress and frustration Mr U understandably felt after several years of not having the opportunity to have his ASC addressed and the impact this had on him. We have found no reason to doubt Mr U’s contention that the process contributed to his autistic burnout.
67. These are injustices to Mr U in consequence of the maladministration we have identified that have still not been remedied three and a half years later. We are therefore proposing to uphold this aspect of his complain.
Our Recommendations
68. We make recommendations in line with our Principles for Remedy which say public bodies should acknowledge failures, apologise, make amends, and use the opportunity to improve their services. The Principles say we aim to ensure the public body puts the complainant back in the position they would have been in had nothing gone wrong. If that is not possible, the public body should compensate them appropriately.
69. Our Principles for Remedy are reflected in the NHS Complaints Standards which say organisations should offer fair remedies to put things right and identify learning and use it to improve services.
What we found
70. Through investigating this complaint, we found:
• The Trust failed to properly consider Mr U potentially had ASC in 2014 and did not refer him for an ASC assessment.
• The Trust took far too long to respond to Mr U’s concerns, and when it did it, it did not acknowledge there was a missed opportunity to potentially have diagnosed his ASC in 2014.
What the organisation should do
71. Our Principles for Remedy say organisations should acknowledge poor service and take steps to put things right when this leads to an injustice or hardship.
72. The Trust should write to Mr U within one month of the final report to:
• acknowledge, and apologise for, not properly considering he had ASC in 2014 and the way it responded to his concerns about this. It should acknowledge, and apologise for, the impact these failings had on Mr U.
73. Our Principles for Remedy also say organisations should look for continuous improvement and learn lessons from complaints to make sure poor service is not repeated.
• The Trust should also explain in its letter to Mr U what it has done, or plans to do, to prevent a repeat of the identified failings happening again.
• send a copy of this letter to us by 11 March 2026
74. Our Principles for Remedy say organisations should compensate people appropriately if they cannot return the person affected to the position they would have been in if the poor service had not occurred.
75. To decide on a level of financial remedy, we review similar cases where the person has experienced a similar injustice, along with our severity of injustice scale.
Following this review, we recommend the Trust:
• pay Mr U £1750 within two months of this final report in recognition of the missed opportunity to access specialist services for his ASC from 2014 and the uncertainty he lived with regarding his condition for eight years.
• send us evidence it has done this by 13 April 2026.