Support and intervention
16. 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 Trust did not provide support and intervention to Mr Y.
17. Mr Y said the Service did not provide him with the mental health care he needed. He complains it did not create or maintain an individual care plan and did not allocate a consistent care coordinator.
18. Mr Y said the Service did not give him any regular or meaningful contact and it failed to follow up with him when he asked for help. He said he was told to contact the crisis line, even though he required consistent support, not just emergency responses.
19. The Trust response refers to the time period from September 2024 following the access team referring Mr Y into its service. It said it reviewed Mr Y in October, with a follow up review two days later. In November it allocated Mr Y with a care coordinator in November who visited that month, and again in December 2024. It then referred Mr Y to the Support and Recovery service to develop self-esteem, improve resilience and increase confidence.
20. The Trust added whilst Mr Y was with the Support and Recovery Team, he remained open to the Service and still had access to support from his key worker and duty team.
21. The Trust apologised for Mr Y feeling unsupported and offered him a further appointment to review his needs in May 2025.
22. NICE guidance NG225 says, ‘if people who self-harm are referred to local health and social care services under local safeguarding procedures, use a multi-disciplinary approach, including education and/or third sector services, to ensure that different areas of the person’s life are taken into account when accessing and planning for their needs’.
23. Prior to the access team referring Mr Y to the Service, we can see from Mr Y’s clinical records evidence of the team holding multi-disciplinary meetings. In February 2023, there is an urgent care report describing a multi-disciplinary team review of this case.
24. We can see evidence of the access team making regular contact with Mr Y when a referral was made to them. There is evidence of contact and follow up contacts throughout the records.
25. Our psychological specialist adviser said this indicates the Trust was providing a level of ‘continuity of care’ when Mr Y needed support. This is because Mr Y’s care was ongoing with regular contact made by the service.
26. The Team referred Mr Y to secondary services is September 2024. We cannot see from records why the Team make the decision to refer him to secondary services at this point. The Trust has not documented the rationale for making the referral at this point, as opposed to following previous contacts with the access team. We can see it was documented the team considered he needed further assessment, formulation and treatment because his needs could not be met in primary care services.
27. Our psychological specialist adviser told us there is no specific guidance which sets out when a crisis team should refer a person to secondary services. It is a process of assessing the situation on an ongoing basis.
28. We can see once Mr Y was referred into the Service, the Service reviewed him three weeks later. It followed up this up two days later. The service offered Mr Y a home visit the next month and saw him again the month after. Our psychological adviser said they considered this demonstrated appropriate continuity of care, because there was a clear plan for Mr Y with regular contact made by the Service
29. From what Mr Y has told us, it seems he thought the Trust discharged him at this point. Records indicate he remained open to the service, but it had referred him on to the support and recovery service.
30. It also referred him to other community resources – ARCH recovery (a resource base for adults struggling with their mental health) and a bereavement service.
31. We consider the service acted appropriately and in line with NICE NG225 guidance. It reviewed Mr Y just three weeks after receiving the referral. It assessed the type of support he needed and made referrals accordingly. The service kept him open during this time.
32. We can see Mr Y had a review in May 2025 and the Trust held a further multidisciplinary meeting. At the time of Mr Y’s second complaint response, he was on a waiting list for allocation to a key worker.
33. In the time period we are looking at, we can see the access team initially provided support to Mr Y, until referring him to the Service. We consider the Trust reviewed and assessed Mr Y appropriately and referred him on to relevant services. We cannot see indications of failings by the Trust.
Safety plan
34. Mr Y said despite his evidential struggles and threats of suicide, the Trust did not support him with a safety plan. He said this meant he was left in a vulnerable situation and was at risk of harming himself. We are sorry to hear how vulnerable Mr Y was feeling at this time.
35. The Trust apologised for Mr Y not feeling supported. It does not specifically address the issue of a safety plan. As stated, it said it had put Mr Y on a waiting list for a keyworker. The plan was for them to complete a pathway with him. It encouraged Mr Y to continue to access support from the Service and the crisis team (out of hours) in the interim.
36. NICE guidance NG225 sets out appropriate steps when safety planning with a person who self-harms. It refers to the importance of developing a safety plan and of ensuring this is done collaboratively with the individual who self-harms.
37. We can see in the records the Trust completed a safety plan in August 2023, with Mr Y’s involvement. We can see this was updated in 2024.
38. Our psychological specialist adviser did not identify any concerns with regards to safety planning or risk assessment.
39. We cannot see indications of failings by the Trust with regards to safety planning with Mr Y.
40. We do not underestimate the trauma Mr Y has experienced in his life, and the impact his experiences have had. We are sorry he has felt so desperate to the point of self-harm and suicidal ideations. We hope he can access the support he needs in the future.