Delays
17. Mr C complains that after experiencing a mental health breakdown in April 2023, the Trust did not accept his referral to a consultant psychiatrist. A community psychiatric nurse made the referral following a conversation with Mr C when he called the crisis line. His GP and Healthy Minds (the service used by the Trust to provide talking therapies) made a further three referrals before acceptance.
18. Talking therapies are a psychological treatment where the person discusses their thoughts, feelings and behaviours with a trained professional.
19. Mr C says the Trust accepted his referral only after intervention by his local MP.
20. Once accepted and assessed, he was diagnosed with traits of personality disorder and he was prescribed risperidone.
21. In its responses to Mr C, the Trust explained it brought forward his appointment for assessment by four months and apologised for any distress he had experienced.
22. In its second response, sent after Mr C raised additional concerns, the Trust explained the consultant who screened his referral had felt that he did not need specific medical treatment.
23. The Trust went on to explain it did not generally treat personality disorders with medication, and talking therapies are the first treatment option. As Mr C did not want to follow the therapy route, it then considered medication as this can help in some cases.
24. To reach a view we have considered the Trust’s policy. This sets out the Trust’s referral policy for talking therapies as being:
• ‘Adults aged 18 and over...
• Anxiety disorder and/or depression...
• anxiety disorders include generalised anxiety disorder (where a person becomes anxious about specific situations or issues), obsessive compulsive disorder (where a person becomes obsessive), post-traumatic stress disorders (caused by traumatic events), panic, social anxiety (intense fear of social situations) and health anxiety (intense concern about health conditions) • Complex, non-psychotic conditions (mental health conditions that do not affect concept of reality) and stable psychosis (where psychotic symptoms are consistent and do not fluctuate) …with ensuing mental health problems, including some with personality disorders • Non-urgent risk...clients at urgent risk should be referred to crisis assessment’
25. NICE CG78 guidance recommends stepped care with potential to use both psychological intervention (structured strategies to improve mental health) and antidepressants (medication used to treat mental health conditions) or mood stabilisers (psychotic medication to prevent mood swings) for personality disorders.
26. In section 1.3.1 NICE CG78 says community mental health Trusts should assess: ‘psychosocial and occupational functioning (the ability to participate in daily activities and fulfil a meaningful role), coping strategies, strengths and vulnerabilities, comorbid mental disorders and social problems’
27. NICE NG222 guidance, section 1.4.2 requires clinicians to ‘match the choice of treatment to meet the needs and preferences of the person’.
28. From the medical records provided, we can see Mr C first called the Trust for help in mid April 2023. The referral form lists symptoms such previous anxiety and stress, gambling addiction which had started again, previous suicidal thoughts but not active thoughts currently, although he had experienced these in the last week.
29. Mr C also shared information about his family and relationships, inability to maintain employment, wanting a diagnosis and medication and other information about physical health issues.
30. The psychiatric nurse Mr C spoke with recommended he be assessed for referral to a psychiatrist consultant within seven days of the call.
31. The medical records show Mr C had a telephone assessment a few days later. Notes of the call refer to previous mental health history, his family, a previous diagnosis of impulsive disorder and noted his GP had recently prescribed sertraline (an antidepressant medication). but he had not collected this yet.
32. The Trust sent a letter to Mr C after the call explaining what would happen next. This included referrals to outpatients, Ask Mark (an organisation which offers support to those suffering from abuse and violence as well as supporting victims to recover from this), a wellbeing team and a completed safety plan should he need this. The letter also provided details of organisations Mr C could self-refer to if he was in crisis.
33. At the beginning of May, the medical records show the Trust wrote to Mr C’s GP to ask that he try psychological intervention (strategies to bring positive change to a person’s mental state) or counselling (provision of guidance and support) from the wellbeing team or Healthy Minds in the first instance. It said if this was not successful, then the GP should rerefer Mr C.
34. Mr C says after he received this letter, he spoke with the community psychiatric nurse who made the initial referral. The medical records show a copy of the letter from the psychiatric nurse to the psychiatric consultant to ask them to reconsider seeing him.
35. At the end of July, Mr C’s GP referred him to the Trust again.
36. Within a few days of referral, the Trust contacted the GP to confirm it had referred Mr C for an outpatient's appointment with a consultant.
37. The consultant wrote to the GP a few days later advising Mr C needed to try psychological intervention/counselling in the first instance and said he should be re-referred if this did not lead to improvement.
38. Mr C’s GP referred him for a third time at the beginning of September as he advised of having tried counselling previously and did not want to do this again. The Trust wrote to his GP a few days later saying he needed to see Healthy Minds as there was ‘no role for secondary care mental health Trusts’.
39. Later in September, Healthy Minds wrote to the Trust to explain Mr C did not want counselling as he had undergone this previously. It said he wanted to see a psychiatrist and to be prescribed medication.
40. At around the same date, Mr C contacted his MP to ask that they intervene to get him an appointment with a psychiatric consultant. The MP wrote back to say they had contacted the integrated care board (ICB) to ask it to investigate.
41. A few days later, the MP advised Mr C the ICB had contacted the Trust and asked that it change his consultant and review his medication.
42. At the start of October, Mr C received an appointment for a telephone assessment to take place in February 2024, and a face-to-face appointment with a psychiatric consultant to take place in May.
43. Mr C has provided email trails which show he contacted the Trust in late September, October and November to ask for an appointment. He copied his MP into these, and the MP contacted Mr C in November to say they had not yet had a response from the ICB.
44. In December, the Trust brought forward Mr C’s appointment from May 2024 to January 2024 and cancelled the telephone appointment booked for February.
45. At the appointment in January, the consultant diagnosed Mr C with ‘unspecified mood (affective) disorder, gambling addiction, personality disorder traits’.
46. In a letter to his GP, the consultant explained as Mr C did not want to try talking therapies again and wanted medication, they had prescribed risperidone, asking the GP monitor this to ensure it was not affecting his physical health.
47. We asked our adviser whether the Trust ought to have accepted Mr C earlier.
48. Our adviser says whilst Mr C met the criteria for talking therapies, without sight of the Trust’s policy or standard operating procedure for referrals to community mental health Trusts, it was not possible to say whether the Trust ought to have accepted Mr C’s referral to a psychiatric consultant in the first instance.
49. We asked the Trust to provide us a copy of the required policy, and it was unable to do so, sending us only its Healthy Minds policy.
50. Our adviser says Mr C presented as having complex symptoms such as low mood and anxiety, emotional dysregulation (difficulty in regulating or reacting to intense emotion), previous abuse and use of gambling as a coping strategy.
51. They said whilst not presenting as at immediate risk of self-harm, he had referred to having suicidal thoughts. As he did not have a diagnosis, our adviser says it was clinically appropriate as well as best and safe practice for him to see psychiatric consultant.
52. We cannot see the Trust followed the requirements of NICE CG78 guidance which says community and mental health Trusts should assess a patient and consider ‘psychosocial and occupational functioning’. Mr C had said he had left five jobs because of his mental health issues and had acted on impulse. We cannot see anything in his medical records to show this was considered before the Trust decided not to accept his referrals.
53. We do not consider the Trust followed the NICE NG222 guidance whereby clinicians should consider patient’s preferences when agreeing treatment. Mr C had specifically said he wanted a diagnosis and medication to manage his mental health needs and that he did not want talking therapies, but the consultant referred him to this service anyway.
54. The third referral mentioned him having tried talking therapies previously, but the Trust declined this again and directed him to Healthy Minds for talking therapies. This does not support the Trust having read his notes properly at this time or acting in line with guidance.
55. We have found there are failings in the Trust not accepting Mr C’s referral in the first instance. We consider it did not follow NICE guidance in considering his psychological and occupational functioning properly or his preference for medication rather than talking therapies.
56. While we recognise Mr C met the criteria for referral to talking therapies, this was not his preference.
57. In respect of Mr C’s concern that it needed the intervention of his MP to been seen in a timely manner, we know he contacted his MP mid-September after Healthy Mind’s referred him back to the Trust as he did not want Talking Therapies. The MP responded the day after receipt of Mr C’s email to say they had referred the matter to the ICB.
58. At the beginning of October, he received an appointment for a telephone consultation in February 2024 and a face-to-face appointment in May.
59. The email trails and medical records show Mr C contacted the Trust in October and November to ask to be seen sooner. He copied his MP into these, and the MP contacted Mr C in November to say they had not yet had a response from ICB.
60. From this is it not possible to say with any certainty that Mr C’s appointments were expedited due to the intervention of his MP. Whilst the MP had escalated their concerns to the ICB, Mr C had maintained contact with the Trust directly to ask for an earlier appointment.
61. There is no evidence the MP came back to Mr C to advise of the outcome of their contact with ICB either before or after the Trust brought his appointment forwards.
62. The letter in which Mr C is advised of the appointment being brought forward is a response to his second complaint raised in August. The letter also includes an apology for his experience with the Trust.
63. Our decision is that we have seen no evidence the MP’s intervention led to Mr C's appointment being expedited.
64. We can understand Mr C’s frustration at this time and why he considers his treatment was delayed because of the delays in accepting his referral.
Impact
65. Mr C says because of the delay in accepting his referral, he went through undue suffering and distress as he did not receive a diagnosis or treatment soon enough.
66. We consider the referral not being accepted at the earliest point will have caused him frustration and led to him feeling his mental health issues were not being taken seriously.
67. To reach a view on impact, we have considered the timeline of events from Mr C’s first referral being declined in April 2023.
68. From this we can see he was referred in April, then July and twice in September. After the second referral in September, he received a letter offering him a telephone appointment in February 2024 with a consultant psychiatrist appointment in May.
69. The appointments were due to take place five and eight months after acceptance of the referral.
70. In December 2023, these appointments were cancelled with an appointment for January 2024 being offered instead. This reduced the wait time to four months following acceptance of Mr C’s fourth referral and five months after he complained to the Trust about the delays.
71. On the basis that in April 2023, the wait time will likely have been similar, Mr C would likely have had a telephone appointment in September, and an appointment with a consultant psychiatrist in December.
72. We consider, as the Trust expedited his appointment and the telephone appointment was by-passed, the delay in Mr C seeing a consultant psychiatrist was one month rather than the eight months wait had the appointment not been brought forwards.
73. Looking at the referrals made, the referral of April made by the community mental health nurse and that made by Mr C’s GP in July include the same symptoms at the same severity levels. This shows the symptoms not to have worsened across this period making it realistic to think the months delay in being seen will not have resulted in his condition worsening significantly.
74. In view of this, have decided the impact of not being accepted by the Trust on referral in April 2023 has been minimal, with diagnosis and medication being delayed by one month and this month did not result in his symptoms worsening by a significant degree.
75. We recognise his appointment was brought forward because of his complaint and acknowledge patients should not need to complain to be seen in a timely manner. This meant the actual delay he experienced was not as lengthy as may have been the case had he not complained.
76. Mr C has asked for a financial remedy of between £600 and £1200 in recognition of the delays caused by the Trust. This is in line with level three of our SoI. Our consideration of the impact of the delay in his referral being accepted has not found the impact be of this level.
77. This is because despite the delay in the referral being accepted, any delay in a consultant seeing Mr C was substantially reduced by his appointment being brought forwards. As such, we have found that the delay was one month, in line with level one of our SoI and not the several months delay required to meet the criteria of level three.
78. Other indicators for level three of our scale include functional impairment lasting for a period of up to three months. We acknowledge Mr C was experiencing functional impairment due to his illness during this period from the time of the first referral in April. We do not consider the impact one month delay was so severe to meet the description in our SOI.
79. Throughout the period from contacting the Trust in April 2023, Mr C was able to attend GP appointments, contact the Trust and specific individuals at the Trust as well as contacting his MP. This does not show functional impairment to the degree of not being able to function on a day-to-day basis and our view is that this does not meet the criteria of level three of our scale.
80. We have found the impact to have been in line with level one of the SoI, where the delay in the referral being accepted resulted in a delay of only a short period (one month) and the impact of this did not prevent Mr C from going about his day to day life for the majority of the time. In such instances, we would view an apology to be enough to put things right.
81. We have found the actual impact on Mr C’s diagnosis and prescription of medication was around one month longer than had his referral been accepted in the first instance and placed in the waiting list for consultant appointments.
82. Mr C has asked that the Trust apologise for the delays caused by not accepting his referral in the first instance.
83. We have found the Trust has already apologised for Mr C’s experience in the same letter as informed him his appointment had been brought forwards. It also says the Trust has learned from this.
84. We consider this shows the Trust has recognised its failings in not accepting the referral in the first instance and it has said it will make changes to prevent reoccurrence. We are also aware that the policy of referral to Healthy Minds for talking therapy is no longer in use.
85. This is in line with our Principles of Good Complaint Handling, where in section 5, ‘Putting Things Right’ it says: ‘In many cases...an apology will be a sufficient and appropriate response’. The principles also say in section 6, that the organisation should make changes to prevent reoccurrence when appropriate. The Trust has done both of these actions.
86. Our decisions is the Trust acted to put things right for Mr C in bringing forward his appointment and there was minimal impact caused by the eventual delay in the first referral not being accepted. We do not require it take any further action in respect of this matter.
87. We recognise Mr C feels the Trust did not take his mental health issues seriously and acknowledge his view that this delayed him being diagnosed and prescribed medication to help him. We thank him for sharing his personal experience with us.