Conflicting mental health care plans
Care plans for high-risk mental health patients containing contradictory instructions, incompatible with legal duties.
292 items
10 sources
2 inquiries
Source spread
Where this theme appears
Conflicting mental health care plans has been flagged across 10 independent accountability sources:
2 inquiry recs
97 PFD reports
1 committee rec
1 CQC action
1 PPO rec
1 PHSO rec
5 IMB recs
1 Article 2 learning point
45 PHSO decisions
138 LGO/SPSO decisions
When the same issue appears across inquiries, coroner reports, and regulators independently, it indicates a recurring issue across the public record.
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Inquiry Recommendations (2)
SP51 — GMMH local structured risk assessment responsibility
Recommendation: At the local level, Greater Manchester Mental Health NHS Foundation Trust should liaise with all of the relevant community healthcare organisations (including Child and Adolescent Mental Health Services and Criminal Justice Liaison Services) to ensure that there is clarity about …
Response Pending
BRIS-19 — Require effective communication among healthcare professionals to avoid conflicting patient advice
Recommendation: Healthcare professionals responsible for the care of any particular patient must communicate effectively with each other. The aim must be to avoid giving the patient conflicting advice and information.
Unknown
PFD Reports (97) — showing 50 strongest matches
David Chatburn
Concerns: The GP failed to refer the patient to psychiatric services, inappropriately managed medication, and had poor record-keeping. Systemic issues included bureaucratic barriers to mental health referrals and non-medical triage.
Response (Department of Health): The Department of Health acknowledges the concerns raised regarding the patient's care and referral process, and notes that patients with a mental health condition have the same legal rights as …
Overdue
Norma Sheppard
Concerns: The report describes confusion regarding the terms of the deceased's discharge from hospital to the care home, specifically regarding the provision of sub-cutaneous fluids, which presented difficulties in finding a suitable placement.
Overdue
Stephen Goodhall
Concerns: A lack of clear policy for determining ITU candidacy and contradictory messages from nursing and medical staff pose risks to patient care.
Overdue
Samiyo Farah
Concerns: Critical concerns include the absence of national observation guidelines for children in mental health units, poor communication protocols for inter-sector patient transfers, and inconsistent psychiatric referrals from A&E.
Response (Department of Health): The Department of Health acknowledges the concerns raised and highlights existing NICE guidance on self-harm and a government suicide prevention strategy. They note that Trusts develop their own transfer protocols …
Overdue
Darren Arnoup
Concerns: Concerns exist regarding the coordination and handover of care for a patient with known mental health issues and suicidal ideation following discharge and communication to the GP.
Response: The medical centre will develop clear lines of communication with NCH&C staff, alert GPs to referrals related to mental health or substance misuse, and ensure GPs fully document any areas …
Overdue
Samarjit Singh
Concerns: The lack of a Specialist Community Perinatal Mental Health Service and a Mother and Baby in-patient unit in the region resulted in sub-optimal treatment and declined referrals for mothers with severe postnatal depression.
Response (Wirral Clinical Commissioning Group): NHS Wirral CCG established a working group to review the perinatal mental health pathway. They are revising the Liaison Psychiatry service specification to include dedicated consultant psychiatrist time and requiring …
Response (Department of Health): The Department of Health acknowledges the coroner's concerns regarding perinatal mental health services in the Wirral and Liverpool. They state that commissioning of local services is the responsibility of Clinical …
Overdue
Katherine Bonaventura
Concerns: The system for assessing detained patients returning from leave is flawed, lacking thorough family/carer consultation and adequate mental state assessment documentation.
Overdue
Michael McCrory
Concerns: The therapeutic observation policy was not consistently followed, with staff recording 'on ward' instead of precise patient whereabouts, and there was unclear training on minimising recurrence risks.
Overdue
Simon Tree
Concerns: The unit's new airlock system has security flaws, allowing patients to 'tailgate' visitors and leave, with inadequate monitoring by reception staff.
Response (Surrey Borders Partnership): The Trust has recruited a Security Manager, employs an out-of-hours receptionist, transferred administration support to the wards and improved camera coverage in the airlock. The Trust has also introduced cards …
Responded
Tanya Page
Concerns: Critical information about a patient's self-harm attempt was not shared between hospital wards due to staff reluctance driven by fear of perceived blame, hindering patient safety and learning.
Overdue
Mark Daniels
Concerns: The crisis team failed to conduct planned patient visits, adequately record actions, communicate within the team, promptly refer to crisis houses, or consider hospital admission despite the patient's severe suicide risk.
Response (Camden and Islington NHS Trust): Camden and Islington NHS Foundation Trust have put in place a comprehensive action plan to address the concerns raised regarding failures by the Crisis team, with measures implemented across all …
Responded
Masoud Ghaderi
Concerns: Inconsistent record-keeping for service user engagement and the absence of a dedicated staff member for reviewing risk assessments prevented identification of changing patient risks. Ward rounds relied on inadequate, brief summaries, risking errors and omissions in care.
Response (Avon and Wiltshire NHS Trust): The Trust Engagement and Observation Policy will be reviewed to ensure consistent recording of engagements. The Clinical Executive has commissioned an audit of reviewing risks across inpatient units and will …
Overdue
Lee Bates
Concerns: A critical lack of communication between psychiatry and sleep apnoea specialists, along with inadequate guidance and monitoring protocols for OSA patients receiving sedative medication, creates an ongoing risk of avoidable deaths.
Response (Cambian Group): Cambian Group has met with St Thomas' and agreed a protocol to reduce the possibility of inadequate communication or care in the future.
Overdue
Charlotte Bevan and Zaani Malbrouck
Concerns: There was no mandatory multi-disciplinary team meeting or widely circulated care plan for pregnant women with known mental health conditions, risking fragmented and uncoordinated care.
Response: A consultant perinatal psychiatrist has been tasked to review individual pathway arrangements against NICE guidelines, aiming to agree and implement a Trust-wide pathway. The Trust also plans to prepare and …
Responded
David Pooley
Concerns: A named nurse was not allocated until the day before death, breaching trust policy and resulting in a failure to carry out essential risk assessments and care plans.
Response (Lancashire Care NHS Trust): • All staff have been briefed on the referral process, and learning from the joint investigation has been shared. • The Trust is exploring using the CRISP board in the …
Overdue
Julie Rose
Concerns: The "Unable to Make Contact Protocol" lacks clarity on mandatory police welfare checks for high-risk patients, and staff demonstrated inadequate understanding of its procedures.
Overdue
Dorota Kijowska
Concerns: The outcome of a critical review meeting was not formally signed off by attendees nor clearly communicated to the patient, leading to a lack of clarity.
Overdue
Tracey Lynch
Concerns: No specific concerns are provided in the truncated text.
Overdue
Lee Grimes
Concerns: Home health care failed to act on overdose disclosures and ensure follow-up with mental health services, compounded by inadequate staff training in managing overdose reports.
Responded
Leslie Morrison
Concerns: No formal mental capacity assessment or consideration of a DoLS authorisation was undertaken in the community, and details of the patient's mental health condition did not accompany him to the hospital; the coroner suggests policies to ensure up-to-date information is provided upon admission or discharge.
Response (MORRISON Leslie): The Trust will discuss the coroner's letter at the Clinical Effectiveness Committee to consider how to address the concerns raised regarding information transfer and mental capacity assessments. They are also …
Overdue
Danny Sweet
Concerns: The coroner questioned whether it was appropriate to presume the best-case scenario for patients presenting inconsistently and whether there should be a check to ensure consistency in treatment decisions; the Serious Incident Report was also incomplete.
Response (Cornwall NHS Trust): The Trust will launch a review of clinical risk assessments for people presenting with suicidal thoughts or acts, particularly focusing on the use of the STORM risk assessment tool. They …
Responded
Pamela Gressman
Concerns: There was insufficient consideration of physical effects from reported foreign body ingestion, leading to an absence of a clear treatment and observation plan for physical symptoms.
Responded
Rohan Fitzsimons
Concerns: Insufficient inpatient mental health beds, influenced by funding, led to significant delays in Mental Health Act assessments, posing a risk of individuals taking their own lives while awaiting necessary detention.
Response (Avon and Wiltshire NHS Trust): The Trust has reviewed and simplified its joint protocol for the Management of Missing Persons and Absent Without Leave, consulting with clinicians and police. A standard template to record relevant …
Overdue
Anthony Preston
Concerns: The discharge system lacked robustness, with no documentary proof of a telephone call to the Crisis Team, and no immediate follow-up notification of discharge; the coroner noted this left a high-risk patient without support.
Overdue
Oliver Ford
Concerns: The telephone triage process lacked a robust risk assessment, and any assessments were often undocumented. Insufficient PCLS weekend cover led to crucial follow-up delays for patients triaged on Fridays.
Response (Avon and Wiltshire NHS Trust): The telephone triage process now includes the access trigger tool, which assesses risk. There are now two clinicians on duty at PCLS until 8pm Monday to Friday, and the clinicians …
Responded
Margaret Richardson
Concerns: A robust, comprehensive Action Plan with timescales needs to be put in place, following the findings of the Serious Incident Investigation and the evidence heard during the inquest.
Overdue
John Jones
Concerns: A significant delay in notifying the GP of patient discharge from the Crisis Team left the patient without community support. Crisis Team training lacked clear communication protocols for such handovers.
Overdue
Sandra Brotherton
Concerns: A sole carer did not have a contingency plan in place for emergencies, a personal assistant's care plan was not clearly documented or provided, and an urgent consultant psychiatrist appointment was difficult to obtain.
Response (Pennine Care NHS Trust): The Trust has updated its audit tool to include questions about contingency plans for carers, reminded care coordinators to document these plans, and developed a 7-minute briefing on this topic …
Responded
Jonathan Zucker
Concerns: A lack of a lead clinician or systemic coordination between private and NHS mental health services resulted in fragmented patient care oversight.
Response (PSYCH): The Royal College of Psychiatrists will discuss consultant accountability, ownership during transitions, and care involving multiple teams at its Professional Practice and Ethics Committee meeting on November 2, 2017, to …
Response (Department of Health): The Department of Health acknowledges the concerns raised and highlights existing guidance on care planning and continuity of care, including GMC guidance and consensus statements. It notes that the Royal …
Responded
Janet Muller
Concerns: Deficient nursing records, risk assessments, and care plans, coupled with inadequate staffing and persistent issues allowing Mental Health Act patients to abscond, increased patient risk.
Response (Janet Muller): NHS England is implementing enhanced governance arrangements to monitor QVH's action plan, engaging with the Trust to promote networking with BSUH, and assessing the suitability of QVH for specialized services. …
Responded
Matthew Edwards
Concerns: Hospital discharge processes were severely deficient, with long delays in dispatching summaries to GPs, failure to book follow-up appointments, and significant waits for critical diagnostic scans.
Response (Matthew Edwards): The Trust has addressed the issue of timely discharge summaries by clearing a backlog with extra resources. Training has been implemented and processes have been revised, and discharge lounges have …
Responded
Olaseni Lewis
Concerns: Police training on restraint techniques and Acute Behavioural Disturbance (ABD) was inadequate and misunderstood, leading to officers misinterpreting risks, especially regarding "prolonged restraint." Additionally, there was a critical lack of clarity and training on inter-agency roles and responsibilities between police and healthcare staff.
Response (Metropolitan Police Service): The Metropolitan Police Service describes updated training for officers regarding restraint techniques, Acute Behavioural Disturbance (ABD), and mental health, including de-escalation techniques and communication skills. It also notes the implementation …
Response (South London and Maudsley NHS Trust): The South London and Maudsley NHS Trust outlined actions to address training compliance, including immediate action requests and potential service suspension if training levels fall below minimum safety standards.
Responded
Dean Rowland
Concerns: Delays in accessing GP appointments for antidepressant review and premature discharge from community mental health services, despite previous serious suicide attempts, posed significant risks.
Response (South Staffordshire and Shropshire Healthcare): The Trust states that the CMHT conducted a sufficiently detailed assessment of Mr. Rowland's needs and appropriately discharged him, providing resources for future support and contact information.
Response (Peel Medical Practice): Peel Medical Practice has instituted a duty doctor and telephone triage system to improve access for patients needing appointments or telephone consultations sooner than routine appointments.
Responded
Jonathan Meaney
Concerns: Prolonged waiting for a mental health bed and a flawed discharge assessment, where overdose intent was not adequately addressed, resulted in the patient's premature release without proper consultation or confirmed follow-up care.
Response: The Royal Free London NHS Foundation Trust notes that the concerns relate to Camden & Islington NHS Foundation Trust (CANDI)'s Mental Health Liaison service, and that CANDI is undertaking a …
Response: Camden and Islington NHS Foundation Trust outlines several actions taken and planned: Clinicians involved have been prevented from working at this level of expertise until the SIR review is complete. …
Responded
Andrew Codling
Concerns: A community health team's voicemail to a patient missed an opportunity to reinforce crisis support numbers, potentially contributing to a missed chance to prevent self-harm over a weekend.
Response (East London NHS Trust): East London NHS Trust has developed and implemented a new protocol within CMHTs regarding the use of mobile phones in communication with service users, including an explanatory letter with contact …
Responded
Rebecca Romero
Concerns: The patient was discharged into an inadequate community care package with insufficient post-discharge contact and delayed medical review. There was confusion over unit transfers and inconsistent risk assessment terminology among staff.
Overdue
John Sloan
Concerns: Mental health professionals failed to inquire about suicidal ideation and did not record concerns from the patient's daughter, representing missed opportunities to provide supportive measures.
Overdue
Keith Heatley
Concerns: There was a lack of documented multidisciplinary decision-making and policy guidance regarding leave for informal patients, coupled with inconsistent recording of MDT meetings and no clinical review before high-risk patient leave.
Response (Swansea Bay Health Board): The health board implemented a checklist to ensure multidisciplinary team members, including the Community Mental Health Team and family, can express their views on patient leave. They also appointed a …
Responded
Patricia Chambers
Concerns: Concerns were identified regarding practices at West London Mental Health Trust, indicating a risk of future deaths if appropriate action is not taken.
Overdue
Neil Black
Concerns: Inadequate coordination and unclear responsibilities between prison nursing teams, compounded by a lack of protocols for examining critical injection and DVT sites.
Response (Birmingham Community Healthcare NHS Trust): A new protocol clarifies physical observations for prisoners, and IDTS nurses now complete the National Early Warning Score (NEWS). Healthcare staff were reminded on February 13, 2019, to ensure appropriate …
Responded
Nicky Reilly
Concerns: The provided text is incomplete and does not detail specific concerns regarding future deaths, primarily describing the deceased's history and transfer.
Response (Greater Manchester Mental Health NHS Foundation Trust): Prison psychology teams can request access to patient's clinical records and have been informed how to gain access. A rewritten guidance document for staff addresses patients who are non-concordant with …
Response (HM Prison and Probation Service): HMPPS provides a Care and Management Plan for prisoners managed by the Managing Challenging Behaviour Strategy (MCBS). They are rolling out 'Working with Challenging Behaviour' training, have developed a toolkit …
Responded
Kieran Hubbard
Concerns: Mental health trusts failed to expedite securing an inpatient bed and communicate effectively about placement requirements for a suicidal patient. There was also no clear guidance for advising patients in crisis about driving restrictions.
Overdue
Irene Whittingham
Concerns: Conflicting guidance on Vitamin D and Calcium blood level monitoring for high-dose patients and confusing software interfaces allowed prescribing errors that exceeded national guidelines without GP notification.
Response (Bolton NHS Foundation Trust): The Trust developed a prescribing guideline to standardize and support the safe prescribing and administration of colecaliferol in adult patients, in response to concerns about monitoring following a high loading …
Overdue
Lee Carpenter
Concerns: An urgent GP mental health referral was downgraded without documented rationale, patient/GP discussion, or identification of the decision-making staff, indicating no system for clear documentation and accountability in clinical triage.
Overdue
Billy Jenkins
Concerns: An inadequate mental health assessment, lacking robust information gathering and documentation, failed to properly diagnose and treat the patient, with no clear evidence of lessons learned or staff training.
Response (Oxleas NHS Foundation): Oxleas NHS Foundation Trust has shared the RCA report with the team and across the Trust so that similar Teams can reflect on the lessons learnt and implemented actions from …
Overdue
Daniel Moran
Concerns: Staff lacked critical understanding of patient confidentiality breaches for safety, efficient patient flow, and clear roles in risk management and leave authorization. Decision-making for self-discharge and Mental Health Act detention also lacked sufficient senior input.
Overdue
Sam Pringle
Concerns: Psychiatrists are circumventing shared care protocols by asking GPs to prescribe Lithium, causing delays or non-provision of this critical medication to mentally ill patients, with potentially fatal consequences.
Response (Greater Manchester Medicines Management Group NHS Stockport Clinical Commission Groupw): Stockport CCG, Pennine Care NHS Foundation Trust, and the Greater Manchester Medicines Management Group (GMMMG) are jointly reviewing shared care protocols, including Lithium, to prevent delays in prescribing. Proposed actions …
Responded
Sophie Boothe
Concerns: Poor communication and insufficient exploration of information from foreign jurisdictions, specifically misunderstanding critical medical terms, led to inadequate mental health assessment and referral downgrading.
Response (Berkshire NHS Foundation Trust): Learning events have taken place reflecting on the case, attended by both Talking Therapies and CPE teams, utilising the referral as a case study for further training on how the …
Responded
Kimberley Smith
Concerns: The Trust lacks clear written policies for managing informal patients' leave requests, including risk assessments and monitoring. A vital recommendation for a comprehensive alcohol detoxification protocol also remains unimplemented.
Response (Surrey and Borders Partnership NHS Foundation Trust): The Trust has developed guidance regarding alcohol detoxification for people admitted to inpatient wards and are developing new guidelines for managing people with Alcohol Use Disorders (AuDs). They have also …
Responded
Katy Samuels
Concerns: The Section 17 Leave Policy lacked clear guidance on escorted leave and escort identity verification, enabling a detained patient to leave unobserved, return intoxicated, and subsequently self-harm.
Response (Coventry and Warwickshire Partnership NHS Trust): Coventry and Warwickshire Partnership NHS Trust has amended its Section 17 Leave Policy to ensure patients are collected from and returned to the ward by identified individuals. The Trust is …
Responded
IMB Recommendations (5)
Swinfen Hall (2020)
Swinfen Hall received many prisoners on open challenge, support, and intervention plans (CSIPs) or uninvestigated referrals (43 last year). This places additional demands on the prison’s resources and potentially disadvantages prisoners. In any case, the outcomes of CSIPs are poor (see paragraph 4.3(c)). What is the Prison Service proposing to do to improve this situation?
HMPPS
Lowdham Grange (2022)
There is a compelling need for all government departments to work together to ensure that appropriate facilities are available for those prisoners with severe mental health disorders; this will avoid the need for prisons to hold such prisoners in segregation for extended periods.
Ministry of Justice
Isle of Wight (2022)
the urgent need to strengthen mental health provision and to carefully consider decisions about the relocation of individuals with complex mental health conditions from secure locations to mainstream prisons
HMPPS
Gartree (2024)
The Board remains concerned that many prisoners wait for long periods to access specialist mental health services and/or assessments. Can the Minister please explain how longstanding problems with the assessment and transfer of prisoners who present with serious mental health and personality disorders from Gartree to suitable secure hospital will be addressed (as per Section 47 of the Mental Health …
Ministry of Justice
Altcourse (2020)
The inpatient facility has 12 beds, which are used for prisoners with physical and mental health needs. This results in an uneasy mix, as both sets of patients require different approaches and skills. This, together with the length of time taken to transfer mental health patients to secure units, creates an environment which could be detrimental to some patients’ recovery. …
Ministry of Justice
PHSO Casework Decisions (45)
P-004782 — Central and North West London NHS Foundation Trust
Mr and Mrs R complain about their son's mental health assessment and the psychiatrist declining to prescribe bupropion medication.
NHS in England
Partly Upheld
Feb 2026
P-001064 — Pennine Care NHS Foundation Trust
Ms O’s complains about a letter she received from the Trust’s Healthy Minds service which she says was sent to her 18 months after a telephone assessment following which she was discharged, and it was therefore completely out of the blue. She feels it should have been sent following the …
NHS in England
Upheld
May 2021
P-001907 — Mersey Care NHS Foundation Trust
Mrs E complains the Trust changed its mind about helping her get specialised funding to treat her son's obsessive compulsive disorder (OCD). She says the Trust discharged her son without putting a treatment plan in place.
NHS in England
Mar 2023
P-002857 — Herefordshire and Worcestershire Health and Care NHS Trust
Mr A complains about the Adult Mental Health Team at the Trust. He specifically complains he was misdiagnosed with a mixed personality disorder in February 2019 when he had bipolar affective disorder. He also says he was not provided with psychological help for anxiety and other mental health issues including …
NHS in England
Partly Upheld
Aug 2024
P-004755 — Lancashire and South Cumbria NHS Foundation Trust
Mr H complains the Trust incorrectly maintained his diagnosis of emotionally unstable personality disorder (EUPD), overlooked his complex needs and did not consider other diagnoses. Mr H also complains the Trust failed to provide him with community mental health support, a caseworker and a mood stabiliser.
NHS in England
Jan 2026
P-001114 — Southern Health NHS Foundation Trust
Mrs I complains about Southern Health NHS Foundation Trust. She complains that it changed her mental health referral from urgent to routine without telling her, and that it recommended medication which her clinical records say she cannot have. Mrs I also complains it did not provide her with individual psychotherapy …
NHS in England
Partly Upheld
Sep 2021
P-001717 — Avon and Wiltshire Mental Health Partnership NHS Trust
Mr A complains about the Trust's care and treatment of his fiancée, Ms E. He complains about the communication and its decision-making regarding her anorexia and autism.
NHS in England
Partly Upheld
Jan 2023
P-002575 — George Eliot Hospital NHS Trust
Mr M complains the Trust dismissed his mental health diagnosis that he has had for over ten years. He also complains the specialist nurse he has been under the care of for HIV treatment also said there was nothing in his records about a mental health diagnosis.
NHS in England
Apr 2024
P-002854 — South West Yorkshire Partnership NHS Foundation Trust
Miss P complains the Trust wrongly diagnosed her with a personality disorder. She says the Trust did not recognise her privately-made diagnosis and stopped prescribing medication for it.
NHS in England
Aug 2024
P-003121 — Cheshire and Wirral Partnership NHS Foundation Trust
Mr R complains the Trust decided to stop his clozapine medication after a standard monthly blood test on 18 July 2023, without putting in place an alternative treatment plan.
NHS in England
Nov 2024
P-003363 — East London NHS Foundation Trust
Mr O complains about aspects of the care provided to his brother by the Trust’s Community Mental Health Team between December 2021 and May 2022.
NHS in England
Upheld
Feb 2025
P-003508 — Black Country Healthcare NHS Foundation Trust
Miss U complains about the way Black Country Healthcare NHS Foundation Trust and The Royal Wolverhampton NHS Trust managed her father’s mental health medication.
NHS in England
Apr 2025
P-003778 — An independent provider in the York area
Mr E complains the organisation applied ADHD diagnostic criteria too strictly. He also says it was not impartial when he asked for a review and it recommended a medication that his GP was unable to prescribe.
NHS in England
Aug 2025
P-003994 — Kent and Medway Mental Health NHS Trust
Ms N complains about the support given to her and her son when he was experiencing mental health crises in the community. This includes a failure to assess his level of risk, review his medication, and support her as his carer.
NHS in England
Upheld
Sep 2025
P-004369 — Norfolk and Suffolk NHS Foundation Trust
Mrs I complains the Trust refused to reassess her son for ADHD despite his school’s request, did not refer him for a second opinion, did not properly document clinical discussions and declined to refer him to another trust for specialist autism and oppositional defiant disorder support.
NHS in England
Partly Upheld
Nov 2025
P-004668 — Kingston and Richmond NHS Foundation Trust
Mr A complains about the care and treatment he received from the Trust following three consultations from the end of 2023 to 2024. He explains he feels dismissed, ignored, and pressured into accepting a psychiatric diagnosis and treatment without adequate investigation into his symptoms.
NHS in England
Jan 2026
P-004570 — Sussex Partnership NHS Foundation Trust
Miss O complains Sussex Partnership NHS Foundation Trust (the Trust) did not provide her with support or treatment since March 2024 and incorrectly discharged her from the service in October 2024. She also complains the Trust’s communication was poor.
NHS in England
Jan 2026
P-002273 — Sussex Partnership NHS Foundation Trust
Mr G complains the Trust did not arrange urgent appointments for his daughter. He also says it arranged consultations with the wrong staff, ignored a previous diagnosis and treated him badly by writing false statements about him in his daughter's medical records.
NHS in England
Oct 2023
P-002418 — Mersey Care NHS Foundation Trust
Ms E complains about the Trust's service saying there was no consistency with which psychiatrist or psychologist she saw, her medication kept on changing, appointments were cancelled, helpful referrals were not made and there was a lack of support and grief counselling.
NHS in England
Jan 2024
P-002405 — Sussex Partnership NHS Foundation Trust
Mrs E complains the Trust did not appropriately assess her past medical history when it decided on which medication it would prescribe to manage her attention deficit hyperactivity disorder (ADHD).
NHS in England
Jan 2024
P-002552 — King's College Hospital NHS Foundation Trust
Mr R complains about the care and treatment given to his mother in March 2023. He complains the Trust inappropriately discharged her, failed to manage her condition and gave conflicting information.
NHS in England
Apr 2024
P-002532 — Sussex Partnership NHS Foundation Trust
Mr R complains the Trust failed to recognise his deteriorating mental health. He says the Trust did not prescribe him testosterone, delayed his referral for CBT treatment and his autism screening referral, it did not make his care providers or school know about his risk of suicidal ideation, it did …
NHS in England
Apr 2024
P-002748 — Surrey and Sussex Healthcare NHS Trust
Mrs L complains the Trust incorrectly stopped medication to treat her mental health condition which led to a long hospital stay and affected her mobility and mental health.
NHS in England
Jul 2024
P-002767 — Hampshire and Isle of Wight Integrated Care Board
Mrs A complains the Hampshire and Isle of Wight Integrated Care Board did not ensure her son had the mental health care he needed, as it had agreed to following a tribunal. She also complains it delayed psychiatric funding for both her sons.
NHS in England
Jul 2024
P-003053 — Mersey and West Lancashire Teaching Hospitals NHS Trust
Mrs T complains about two NHS Trusts' treatment decisions and care when Mr T was in a mental health crisis and would not eat or drink.
NHS in England
Oct 2024
P-003544 — University Hospitals of Derby and Burton NHS Foundation …
Mrs M complains about the treatment her son received during his admission in June 2023. She says the Trust did not follow its own safeguarding policy, it did not complete a referral to cardiology, it gave her conflicting information about her son’s possible heart murmur and the discharge papers included …
NHS in England
May 2025
P-003616 — A practice in the Canterbury area
Miss G complains the Practice referred her to a community mental health team without her consent and prescribed inappropriate medication for her condition.
NHS in England
Jun 2025
P-003734 — Cambridgeshire and Peterborough NHS Foundation Trust
Mrs U complains about Cambridgeshire and Peterborough NHS Foundation Trust’s mental health support and care planning for Mr U’s challenging behaviour due to dementia.
NHS in England
Jun 2025
P-003803 — University Hospitals Coventry and Warwickshire NHS Trust
Mrs T complains about several different aspects of the care and treatment clinicians at a hospital gave to her husband in April 2021. She is particularly concerned about the management of her husband's PTSD.
NHS in England
Aug 2025
P-003967 — Surrey and Borders Partnership NHS Foundation Trust
Mrs E complains the Trust misdiagnosed her son's psychotic crisis and about the lack of assessment by a consultant.
NHS in England
Sep 2025
P-004218 — A practice in the Sheffield area
Mr O believes he was poisoned and complains the Practice refused to do blood tests to confirm this and provide treatment. Mr O complains that the Trust refused to remove the delusional disorder diagnosis in his medical record.
NHS in England
Sep 2025
P-004388 — Gloucestershire Health and Care NHS Foundation Trust
Mr C complains the Trust's Child and Adolescent Mental Health Service (CAMHS) delayed prescribing him medication which was recommended in July 2024. He also complains about its decision to decline his referral to its eating disorder services in August 2024.
NHS in England
Dec 2025
P-004662 — Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Mrs B complains about the advice the Trust’s Community Eating Disorders Service (CED team) gave to a different NHS Trust regarding care provided for her daughter’s anorexia. Mrs B says the CED team wrongly advised the hospital to keep her daughter in a wheelchair for longer than was necessary and …
NHS in England
Jan 2026
P-002028 — Southern Health NHS Foundation Trust
Ms A complains about the Trust's care and treatment of her sister between 18 May and 6 August 2018. She complains the Trust discharged her sister from the mother and baby unit too soon, it did not look at her history properly, it prescribed medication that made her unwell and …
NHS in England
Jun 2023
P-002303 — South West Yorkshire Partnership NHS Foundation Trust
Miss H complains the Trust changed her olanzapine medication (an antipsychotic medicine used to treat schizophrenia) and would not let her go back on it.
NHS in England
Upheld
Nov 2023
P-002469 — Tees, Esk and Wear Valleys NHS Foundation Trust
Mrs A complains about the mental health care and treatment given to her son in the last 20 years.
NHS in England
Feb 2024
P-002465 — York and Scarborough Teaching Hospitals NHS Foundation Trust
Mrs H complains the Trust was inconsistent when putting restrictions on her contacting it for updates about her husband and it did not allow her to visit. Mrs H also disagrees that her husband had capacity to make decisions.
NHS in England
Feb 2024
P-002626 — A practice in the North Yorkshire area
Mrs N complains that two organisations provided incorrect information to a mental health tribunal.
NHS in England
May 2024
P-002721 — Kent and Medway NHS and Social Care Partnership …
Mrs U complains the Trust prescribed her inappropriate antipsychotic medication in 2017 and did not review this.
NHS in England
Jun 2024
P-003585 — Nottinghamshire Healthcare NHS Foundation Trust
Mrs R complains that in the months leading up to her father’s death in May 2022, the Trust discharged him despite him saying he was suicidal. She complains it did not allocate face to face appointments, it cancelled scheduled appointments and did not liaise with other services to ensure his …
NHS in England
Upheld
Jun 2025
P-003805 — Berkshire Healthcare NHS Foundation Trust
Mr R complains the Trust requested his mother be put under a Deprivation of Liberty Safeguards instead of a Section 3 and did not communicate effectively with him and his sister, who both have Lasting Power of Attorney.
NHS in England
Aug 2025
P-004126 — Lincolnshire Partnership NHS Foundation Trust
Mrs I complains about the care and treatment provided to her son Mr I from 2011 to 2023. Mrs I complains her son did not get the appropriate treatment for his heart condition or mental health support.
NHS in England
Oct 2025
P-004151 — Norfolk and Suffolk NHS Foundation Trust
Mrs Y complains about the mental health care provided to her late daughter Ms B, by the Norfolk and Suffolk NHS Foundation Trust. Specifically, she complains about a lack of communication, poor risk management and record keeping, poor care plan management, an incorrect diagnosis, and unwarranted medication changes.
NHS in England
Partly Upheld
Oct 2025
P-004484 — Lincolnshire Partnership NHS Foundation Trust
Mr A and Mrs B complaint about the care and treatment he received from the Trust while an inpatient on two separate occasions between September 2020 and April 2021, and the way in which the Trust communicated with his family and involved them in his care.
NHS in England
Not Upheld
Dec 2025
P-002332 — Nottinghamshire Healthcare NHS Foundation Trust
Mr A complains the Trust failed to put a plan in place for his brother when it was clear his parents could not care for him, failed to make sure his brother was taking his medication correctly and made no effort to contact his brother shortly before his death.
NHS in England
Sep 2023
LGO / SPSO Decisions (138)
24-007-618b — North London NHS Foundation Trust (24 007 618b)
LGO (Local Government & …
Health
Upheld
24-007-618a — NHS North Central London ICB (24 007 618a)
LGO (Local Government & …
Health
Upheld
21-014-685a — Oxford Health NHS Foundation Trust (21 014 685a)
Summary: We will not investigate this complaint about the circumstances surrounding Dr A’s detention under Section 2. The Trust and Council have already investigated the matter and acted to improve their services. It is unlikely an Ombudsmen’s investigation would achieve more.
LGO (Local Government & …
Health
Mar 2022
21-007-637a — NHS East Sussex Clinical Commissioning Group (21 007 …
Summary: Mrs B complained about the care provided to her late husband, Mr B, by a care provider commissioned by the Council and the CCG to meet his aftercare needs. We found the care provider failed to properly record Mrs B’s late husband’s needs around eating and food consistency. As …
LGO (Local Government & …
Health
Upheld
Mar 2022
21-003-925a — Cambridgeshire and Peterborough NHS Foundation Trust (21 003 …
Summary: We found fault with the Trust; it did not allocate Mr Q a new care coordinator, did not conduct a S117 review or formally discharge him, and it was not clear with Mr P during the complaints process. We also found the Council did not understand the care package …
LGO (Local Government & …
Health
Upheld
May 2022
18-006-752b — South West Yorkshire Partnership NHS Foundation Trust (18 …
Summary: We found fault by the Council, Trust and ICB in terms of the care and support they provided to a man with complex needs. We recommend these organisations carry out a thorough reassessment of his needs and put in place a comprehensive care plan that sets out how they …
LGO (Local Government & …
Health
Upheld
Jul 2022
18-006-752a — South West Yorkshire Partnership NHS Foundation Trust (18 …
Summary: We found fault by the Council, Trust and ICB in terms of the care and support they provided to a man with complex needs. We recommend these organisations carry out a thorough reassessment of his needs and put in place a comprehensive care plan that sets out how they …
LGO (Local Government & …
Health
Upheld
Jul 2022
21-012-907 — Southampton City Council
Summary: Mr B complained on behalf of Miss X and Mr Y that the Council failed to notify them of their right to appeal a housing allocation decision and failed to deal with reports of mould. Mr B said this impacted on the physical and mental health of Miss X, …
LGO (Local Government & …
Housing
Upheld
Sep 2022
21-018-569b — NHS Norfolk and Waveney ICB (21 018 569b)
Summary: We found fault with the Care Home who did not keep accurate or up-to-date records. We also found fault with the Integrated Care Board who do not keep a register of patients receiving s117 aftercare in its area. We found no fault with the actions of the Council or …
LGO (Local Government & …
Health
Upheld
Oct 2022
22-010-012a — Leeds & York Partnership NHS Foundation Trust (22 …
Summary: The Ombudsmen will not investigate this complaint about a decision to detain someone under the Mental Health Act. We are unlikely to find fault in the actions of the Trust’s mental health team before the assessment. Investigation into the actions of the Approved Mental Health Professional is unlikely to …
LGO (Local Government & …
Health
Dec 2022
22-002-090c — Cumbria, Northumberland, Tyne & Wear NHS Foundation Trust …
Summary: We found fault in the way a Council, Mental Health Trust and GP Practice supported a vulnerable man in the community for over two years. Each of the organisations has accepted its failings and the impact of them and has taken steps to prevent recurrences, so we have not …
LGO (Local Government & …
Health
Not Upheld
Dec 2022
23-015-462 — London Borough of Enfield
Summary: Mrs Y complained about the way the Council decided she was not entitled to an extra bedroom. Mrs Y says sharing a bedroom will have a negative impact on her health. The Council was at fault for not assessing Mrs Y’s care needs after being asked to. It was …
LGO (Local Government & …
Housing
Upheld
Apr 2024
23-009-939a — East London NHS Foundation Trust (23 009 939a)
Summary: We will not investigate this complaint about the decision to detain a patient under the Mental Health Act, because of concerns they were refusing treatment for their physical health. This is because there was a right to appeal the assessment outcome through a tribunal and it would have been …
LGO (Local Government & …
Health
Apr 2024
22-009-742b — NHS Northamptonshire ICB (22 009 742b)
Summary: Miss D complained about the lack of mental health and social care provided to her son, Mr B, when he was discharged from hospital. She said this led to a lack of joint working between the Council, the Trust and the Integrated Care Board (ICB). She said they did …
LGO (Local Government & …
Health
Upheld
Apr 2024
22-009-742a — NHS Northamptonshire ICB (22 009 742a)
Summary: Miss D complained about the lack of mental health and social care provided to her son, Mr B, when he was discharged from hospital. She said this led to a lack of joint working between the Council, the Trust and the Integrated Care Board (ICB). She said they did …
LGO (Local Government & …
Health
Upheld
Apr 2024
22-009-742 — West Northamptonshire Council
Summary: Miss D complained about the lack of mental health and social care provided to her son, Mr B, when he was discharged from hospital. She said this led to a lack of joint working between the Council, the Trust and the Integrated Care Board (ICB). She said they did …
LGO (Local Government & …
Adult Care Services
Upheld
Apr 2024
22-009-742d — Northamptonshire Health Care NHS Foundation Trust (22 009 …
Summary: Miss D complained about the lack of mental health and social care provided to her son, Mr B, when he was discharged from hospital. She said this led to a lack of joint working between the Council, the Trust and the Integrated Care Board (ICB). She said they did …
LGO (Local Government & …
Health
Upheld
Apr 2024
22-009-742c — Northamptonshire Health Care NHS Foundation Trust (22 009 …
Summary: Miss D complained about the lack of mental health and social care provided to her son, Mr B, when he was discharged from hospital. She said this led to a lack of joint working between the Council, the Trust and the Integrated Care Board (ICB). She said they did …
LGO (Local Government & …
Health
Upheld
Apr 2024
23-017-445a — South West London & St. Georges Mental Health …
Summary: We will not investigate Mr X’s complaint about the decision to detain him under Section 2 of the Mental Health Act 1983. This is because Mr X appealed this decision to the First Tier Tribunal (Mental Health). This means we are prevented from investigating this complaint.
LGO (Local Government & …
Health
May 2024
23-017-881b — NHS Gloucestershire ICB (23 017 881b)
Summary: Mrs A complains about the section 117 aftercare being provided to her sister, Ms B. We should not investigate this complaint because the Trust has already admitted fault and taken steps to remedy the injustice to Ms B. Further investigation would not achieve anything more.
LGO (Local Government & …
Health
May 2024
23-017-881a — Gloucester Health & Care NHS Foundation Trust (23 …
Summary: Mrs A complains about the section 117 aftercare being provided to her sister, Ms B. We should not investigate this complaint because the Trust has already admitted fault and taken steps to remedy the injustice to Ms B. Further investigation would not achieve anything more.
LGO (Local Government & …
Health
May 2024
23-005-445a — Norfolk & Suffolk NHS Foundation Trust (23 005 …
Summary: We investigated a complaint about the care and support provided to Mr O’s late brother Mr K by a Council and NHS Trust. We found fault by both organisations. The Council took too long to allocate Mr K a social worker and too long to respond to Mr O’s …
LGO (Local Government & …
Health
Upheld
Jul 2024
24-001-919a — Devon Partnership NHS Trust (24 001 919a)
Summary: Mr X complains about the way Devon County Council and Devon Partnership NHS Trust acted in relation to a hospital detention. We will not investigate this complaint. This is because an investigation is unlikely to find fault in the organisations’ actions.
LGO (Local Government & …
Health
Jul 2024
24-003-061b — NHS South West London ICB (24 003 061b)
Summary: Ms M complains about the way her son’s care was managed by the Trust after he left hospital in June 2021. We will not investigate this complaint because the organisation has already admitted fault in several areas of Mr N’s care. It has investigated several times, provided five written …
LGO (Local Government & …
Health
Sep 2024
24-003-061a — South London and Maudsley NHS Foundation Trust (24 …
Summary: Ms M complains about the way her son’s care was managed by the Trust after he left hospital in June 2021. We will not investigate this complaint because the organisation has already admitted fault in several areas of Mr N’s care. It has investigated several times, provided five written …
LGO (Local Government & …
Health
Sep 2024
24-004-207b — East London NHS Foundation Trust (24 004 207b)
Summary: Ms A complains about the care provided to her sister at Bridgeside Lodge Care Home (the Care Home). We will not investigate this complaint because the Care Home is willing to reinvestigate. There is nothing more we can achieve by looking at the complaint before the Care Home completes …
LGO (Local Government & …
Health
Sep 2024
24-004-207a — NHS North Central London ICB (24 004 207a)
Summary: Ms A complains about the care provided to her sister at Bridgeside Lodge Care Home (the Care Home). We will not investigate this complaint because the Care Home is willing to reinvestigate. There is nothing more we can achieve by looking at the complaint before the Care Home completes …
LGO (Local Government & …
Health
Sep 2024
24-021-993 — Staffordshire County Council
Summary: We will not investigate Ms X’s complaint about Staffordshire County Council, North Staffordshire Combined Healthcare NHS Trust and NHS Staffordshire and Stoke-on-Trent Integrated Care Board. She says they ignored her views when it moved her brother, Mr Y, to a care home, which cannot meet his mental health needs. …
LGO (Local Government & …
Adult Care Services
Apr 2025
24-001-411a — NHS Humber and North Yorkshire Integrated Care Board …
Summary: We do not uphold G’s complaint about City of York Council and NHS Humber and North Yorkshire Integrated Care Board’s decision to reduce their section 117 aftercare in December 2023. However, the Council and ICB should have reviewed G’s aftercare need before they left hospital in March 2024. That …
LGO (Local Government & …
Health
Upheld
Jun 2025
24-005-064b — NHS South East London ICB (24 005 064b)
Summary: Mrs H complained about the care provided to her son, Mr G, by London Borough of Bromley, NHS South East London Integrated Care Board and Oxleas NHS Foundation Trust. We found fault by these organisations for their handling of Mr G’s discharge from hospital. This caused Mr G and …
LGO (Local Government & …
Health
Upheld
Aug 2025
24-005-064a — Oxleas NHS Foundation Trust (24 005 064a)
Summary: Mrs H complained about the care provided to her son, Mr G, by London Borough of Bromley, NHS South East London Integrated Care Board and Oxleas NHS Foundation Trust. We found fault by these organisations for their handling of Mr G’s discharge from hospital. This caused Mr G and …
LGO (Local Government & …
Health
Upheld
Aug 2025
23-012-177a — Avon & Wiltshire Mental Health Partnership NHS Trust …
Summary: Avon & Wiltshire Mental Health Partnership NHS Trust did not appropriately record Miss X’s reasonable adjustments during a meeting. That did not cause her an injustice but the Trust should still take action to stop similar fault happening to others. Also, an Approved Mental Health Professional for North Somerset …
LGO (Local Government & …
Health
Upheld
Oct 2024
24-009-187a — Derbyshire Healthcare NHS Foundation Trust (24 009 187a)
Summary: Ms X complains about Derbyshire County Council and Derbyshire Healthcare NHS Foundation Trust. She says the organisations acted with fault when she was detained in hospital under the Mental Health Act in 2022. Ms X’s complaint is late and there are not enough good reasons for the Ombudsmen to …
LGO (Local Government & …
Health
Nov 2024
23-010-463b — Cheshire & Wirral Partnership NHS Foundation Trust (23 …
Summary: We uphold Mr X’s complaint about his brother, Mr Y’s, care and treatment. There was a short break in Mr Y’s medication management. We also found Mr X was not informed about one of Mr Y’s Mental Health Act assessments. However, we have not found a significant injustice arising …
LGO (Local Government & …
Health
Upheld
Dec 2024
23-010-463a — Cheshire & Wirral Partnership NHS Foundation Trust (23 …
Summary: We uphold Mr X’s complaint about his brother, Mr Y’s, care and treatment. There was a short break in Mr Y’s medication management. We also found Mr X was not informed about one of Mr Y’s Mental Health Act assessments. However, we have not found a significant injustice arising …
LGO (Local Government & …
Health
Upheld
Dec 2024
24-003-060b — NHS Buckinghamshire, Oxfordshire and Berkshire West ICB - …
Summary: Mrs X complained about top-up fees for accommodation without being offered of a suitable and affordable alternative. We did not find fault with the accommodation the Council offered. We found fault with some communication and recommended the Council and the NHS Trust apologise for any distress this caused to …
LGO (Local Government & …
Health
Not Upheld
Dec 2024
24-003-060a — Oxford Health NHS (24 003 060a)
Summary: Mrs X complained about top-up fees for accommodation without being offered of a suitable and affordable alternative. We did not find fault with the accommodation the Council offered. We found fault with some communication and recommended the Council and the NHS Trust apologise for any distress this caused to …
LGO (Local Government & …
Health
Upheld
Dec 2024
25-005-077b — NHS North West London ICB (25 005 077b)
LGO (Local Government & …
Health
Not Upheld
25-005-077a — West London NHS Trust Headquarters (25 005 077a)
LGO (Local Government & …
Health
Upheld
NIPSO-202001941 — Southern Health and Social Care Trust
A complainant raised concerns about how the Southern Trust cared for her vulnerable sister. Our investigation found a number of failings by the Trust.
NIPSO (NI Public Service…
Health & Social Care
Upheld
Jun 2024
PSOW-202000537 — Hywel Dda University Health Board
Ms D complained that the Hywel Dda University Health Board (“the Health Board”) failed to provide her partner, Mr B, with appropriate care and treatment. In particular, Ms D complained that the Health Board failed to provide Mr B with appropriate mental health support and treatment and that Mr B …
PSOW (Public Services Om…
Health
Upheld
May 2021
PSOW-202208324 — Cardiff and Vale University Health Board
Miss X complained about the alleged change to her son’s placement who is currently a patient at an assessment and treatment unit for learning disabilities under section 3. Miss X alleges that the change in placement may not meet his care and treatment needs. The Ombudsman decided that due to …
PSOW (Public Services Om…
Health
Apr 2023
PSOW-202304142 — Betsi Cadwaladr University Health Board
Mr C complained about the standard of mental health care provided to his nephew, Mr B, by Betsi Cadwaladr University Health Board (“the Health Board”). Mr B, a 50 year old man, had schizophrenia and lived with and cared for his elderly mother, who had dementia. She entered full time …
PSOW (Public Services Om…
Health
Upheld
Dec 2024
PSOW-202406503 — Cwm Taf Morgannwg University Health Board
Mrs B complained about the care and treatment provided by the Health Board for her mental health and neurological condition. In addition, Mrs B raised concerns about not receiving responses from the relevant team involved in her care. The Ombudsman found that although the Health Board had provided a response …
PSOW (Public Services Om…
Health
Jan 2025
PSOW-202305228 — Cardiff and Vale University Health Board
Ms A’s complaint centred on whether the care and treatment provided to her by the Health Board, and specifically its assessment and management of her risk of suicide and self-harm, on specified dates was appropriate. The Ombudsman’s investigation found that broadly the assessment and management of Ms A’s risk of …
PSOW (Public Services Om…
Health
Not Upheld
Feb 2025
PSOW-202500676 — Aneurin Bevan University Health Board
Mrs A complained because she was unhappy with Aneurin Bevan University Health Board’s care and treatment of her late son. Mrs A’s son sadly died in September 2023. The Ombudsman noted that the Health Board had completed a Serious Incident Report which identified points of learning. The Ombudsman decided that …
PSOW (Public Services Om…
Health
Jul 2025
21-002-440a — Hertfordshire Partnership University NHS Foundation Trust (21 002 …
Summary: Mr E has complained about the mental health and social care of his sister, Mrs F, by the Council and Trust. We find fault with the mental health and social care of Mrs F but not with her mental health assessment or the Trust’s complaint handling. The Trust and …
LGO (Local Government & …
Health
Upheld
Jan 2022
19-018-519a — Sussex Partnership NHS Foundation Trust (19 018 519a)
Summary: The complainant, Ms B, said she learnt in 2020 the Council, the Trust and two Clinical Commissioning Groups did not properly consider her daughter’s, Miss G’s, entitlement to free aftercare following her detainment under the Mental Health Act 1983. She also complained about the care and support provided to …
LGO (Local Government & …
Health
Upheld
Mar 2022
21-013-253b — North East London Clinical Commission Group (21 013 …
Summary: Ms B complains on behalf of her mother, Ms A, about her care and treatment. We will not investigate the complaint as we are not satisfied Ms A has fully consented to Ms B complaining to us on her behalf. We do not therefore consider Ms B suitable to …
LGO (Local Government & …
Health
Mar 2022
21-013-253a — NHS East London NHS Foundation Trust (21 013 …
Summary: Ms B complains on behalf of her mother, Ms A, about her care and treatment. We will not investigate the complaint as we are not satisfied Ms A has fully consented to Ms B complaining to us on her behalf. We do not therefore consider Ms B suitable to …
LGO (Local Government & …
Health
Mar 2022