Hertfordshire Partnership University NHS Foundation Trust

3. Mr L complains about the Trust’s care and treatment of his attention deficit hyperactivity disorder (ADHD).

4. He says the Trust: • prescribed him Concerta (a brand of methylphenidate which is a stimulant ADHD medication) despite knowing he had a negative reaction to this before • did not offer him an appointment at a psychiatric hospital for 18 months after his referral in September 2018, during which time he had no mental health support • discharged him after he was transferred from a hospital (which is not part of this Trust) in January 2020, despite him still being unwell and hallucinating • did not prescribe him guanfacine (a non-stimulant ADHD medication) until March 2022, despite a consultant at the psychiatric hospital recommending this in February 2020 • stopped his support in March 2022, without considering his circumstances.

5. Mr M also complains about how the Trust treated him during the local resolution (complaints) process.

6. Mr M says the Trust: • stopped his advocate from attending a meeting with him in October 2020 • took four months to send him the minutes of the meeting • stopped his advocate from attending a local resolution meeting in October 2022 • produced inaccurate minutes of the local resolution meeting.

7. Mr L says the Trust has made him feel ignored, stressed and unsupported, and his mental health got worse and he has was sectioned.

8. Mr L and Mr M want the Trust to acknowledge its mistakes and explain and apologise for what went wrong. They also want the Trust to make service improvements to raise its standards. Mr L wants the Trust to add an addendum (amendment) to his records if we find what is in them to be factually untrue.

9. Mr L was diagnosed with ADHD in 1998, when he was a teenager.

10. Mr L was prescribed methylphenidate in the past and again in 2017 and experienced side effects both times. Mr L was prescribed atomoxetine (a non-stimulant ADHD medication) in 2015, which he said had no benefit.

11. Mr L also has a history of obsessive-compulsive disorder (OCD) and psychosis, and was previously prescribed sertraline (an antidepressant used to treat OCD) and quetiapine (an antipsychotic).

12. Mr M supported Mr L when he complained to the Trust and us.

Time limit consideration

16. The law says a person needs to make a complaint to us within one year of becoming aware of the problem. We cannot investigate complaints brought to us after this time, unless we consider there is a good reason to do so.

Prescribing Concerta

17. Mr L complains that the Trust prescribed him Concerta despite knowing he had experienced a negative reaction to this before.

18. Mr L’s records show this happened in October 2017. Mr L would have known about the problem with this prescription straight away. To be in time, Mr L needed to bring us this part of his complaint by October 2018. Mr L brought us this complaint in December 2022, over four years outside of our time limit.

19. We cannot say the Trust’s complaint handling delayed Mr L from bringing this part of the complaint to us sooner. It does not seem that Mr L raised this complaint with the Trust.

Appointment at the psychiatric hospital

20. Mr L complains the Trust did not offer him an appointment at the psychiatric hospital for 18 months after his referral in September 2018, during which time he had no mental health support.

21. Mr L’s consultation with the psychiatric hospital was in February 2020. Mr L could have made a complaint about the delay sooner because he was likely unhappy with the delay at the time. Mr L also says he had no support during this time, which would have been ongoing up to and including February 2020.

22. Because Mr L would have been unhappy about what was happening in February 2020, to meet our time limit he would need to bring us this part of the complaint by February 2021. Mr L brought us the complaint in December 2022, making it almost two years out of time.

23. Mr M complained to the Trust on Mr L’s behalf on 14 December 2020 and it responded on 16 February 2021. Mr M went back to the Trust with outstanding concerns and it responded to these on 18 March. The complaints process took a total of three months.

Discharge from hospital

24. Mr L complains the Trust discharged him after he was transferred from hospital in January 2020, despite him still being unwell and hallucinating.

25. Mr L was transferred in January 2020 and he would have been unhappy about this at the time. To be in time, Mr L needed to bring us this part of the complaint by January 2021. Mr L came to us in December 2022, making this part of the complaint almost two years out of time.

26. Mr M complained to the Trust on Mr L’s behalf on 14 December 2020 and it responded on 16 February 2021. The complaints process took a total of two months.

Complaint handling in 2020

27. Mr M complains that the Trust stopped his advocate from attending a meeting with him in October 2020. Mr M also complains the Trust took four months to send him the minutes of this meeting.

28. The meeting was in October 2020 and the Trust took until February 2021 to send Mr M the minutes. Mr M complained to the Trust on 14 December 2020. To be in time, Mr M needed to bring us this part of the complaint by December 2021. Mr M came to us in December 2022, which was 12 months out of time.

29. Mr M complained to the Trust on 14 December 2020 and it responded on 16 February 2021. The complaint handling took a total of two months.

Our decision on the time limit

30. We asked Mr M why he did not contact us until December 2022 with his concerns about what happened in and before 2020. Mr M said he was trying to give the Trust the chance to put the complaints right. Mr M said the Trust kept telling him it would fix things and they should move on, without ever fixing anything. Mr M also added that he had no faith in us due to his experience with us before.

31. We have seen that parts of the complaint are between one year and over four years out of time. In all cases, the complaint handling took no longer than three months. We understand what Mr M has said about hoping the Trust would put the complaints right for him. We would have expected Mr M to come to us sooner than he did, once he realised the Trust had not done anything. We would not consider a lack of faith in our service to be a reasonable cause for delay in contacting us.

32. We understand these parts of Mr L and Mr M’s complaint are important to them, and we thank them for bringing them to our attention. We have not seen good reason to put our time limit to one side. We will not consider these parts of the complaint any further.

Prescribing guanfacine

33. Mr L complains the Trust did not prescribe him guanfacine until March 2022, despite a consultant at the psychiatric hospital recommending this in February 2020.

34. The Trust said the psychiatric hospital recommended Mr L first be prescribed mood stabilisers. The Trust said it followed the applicable NICE guideline in its approach to his treatment and prescribed guanfacine once Mr L’s mood had stabilised.

35. The letter from the psychiatric hospital dated 19 February 2020 says, ‘Should [Mr L] continue to suffer with cognitive and hyperactivity/impulsivity problems, once he has his sleep and mood problems addressed, given his poor response on stimulants and Atomoxetine, he may benefit from treatment with guanfacine starting at 1mg daily.’

36. Mr L’s records show that the Trust prescribed him sodium valproate (a mood stabiliser), in March. Mr L reported that the sodium valproate was making him feel depressed so he stopped taking it. The Trust then prescribed Mr L with carbamazepine (another mood stabiliser) in October.

37. Mr L had medication reviews in February and August 2021. The Trust decided Mr L needed to continue with mood stabilisers before it could prescribe guanfacine.

38. The Trust reviewed Mr L again in November and made enquiries with the pharmacy about prescribing him with guanfacine. Following an ECG (a test that records the electrical activity of your heart, including the rate and rhythm) and cardiology review, on 24 February 2022 the Trust agreed to prescribe Mr L with guanfacine.

39. NG87 gives guidance on the use of medication in managing ADHD. It explains that clinicians should offer adults with ADHD lisdexamfetamine or methylphenidate as first-line treatment. It also explains that clinicians should not offer guanfacine without advice from a ADHD service.

40. Our adviser told us that the steps the Trust followed before it prescribed Mr L with guanfacine were in line with NG87.

41. The recommendation from the psychiatric hospital was that Mr L may benefit from guanfacine, if needed, when his mood had stabilised. Its recommendation was not for Mr L to start on guanfacine right away.

42. We understand it would have been frustrating for Mr L to have to wait to start taking a medication which he thought would help his ADHD. We have seen from Mr L’s records that the Trust was doing as the psychiatric hospital recommended by stabilising his mood before prescribing guanfacine. We have also seen that the Trust’s actions were in line with guidance. We will not consider this part of the complaint any further.

Discharge from Adult Community Mental Health Service

43. Mr L complains the Trust stopped his support in March 2022, without considering his circumstances. These circumstances include Mr L’s physical mobility, depression and a period when he had COVID-19.

44. The Trust said it discharged Mr L due to his lack of meaningful engagement with its service. The Trust added it feels it made every effort to encourage Mr L to engage with it.

45. Mr L’s records and the Trust’s discharge letter include a number of times where he did not attend appointments over a period of ten months. These include where Mr L cancelled or rearranged appointments.

46. The missed appointments also include 11 times where Mr L did not attend without cancelling or rearranging the appointments.

47. The DNA policy ‘sets out the action to be taken by the staff of [the Trust] when an adult service user does not attend an appointment with a health or social care professional.’ It explains that DNA ‘excludes events when an appointment is cancelled in advance by the service user at least by the day before appointment or by the Trust.’

48. The DNA policy explains what staff must do. It also says a service user will be discharged after three DNAs. Our adviser told us the Trust’s decision to discharge Mr L was sound and in line with the DNA policy.

49. The 11 missed appointments do not include the times when Mr L was unable to attend due to his circumstances. The Trust continued to try to support Mr L despite him missing more appointments than allowed for in the DNA policy. The Trust also tried to contact Mr L after each missed appointment. This suggests the Trust was being considerate of Mr L’s circumstances, but he continued to miss appointments and it eventually needed to address this formally.

50. We understand how important it is for someone to feel they are getting support for their mental health. We have seen that the Trust’s decision to discharge Mr L was in line with the DNA policy. We have also seen that the Trust was considerate of Mr L’s circumstances. We will not consider this part of the complaint further.

Complaint handling in 2022

51. Mr M complains the Trust stopped his advocate from attending a local resolution meeting in October 2022. Mr M explains his advocate was unavailable due to the short notice of the meeting and says the Trust told him if he did not attend, it would not offer him another meeting.

52. The Trust said at the top of the minutes of the meeting, ‘[Mr M]'s advocate was unable to attend due to short notice. [Mr M] was displeased about the fact that he was informed that if he did not attend, he wouldn’t be given another date for this meeting.’ This seems to support what Mr M says.

53. An organisation should do what it can to allow for advocacy support for a complainant who needs it. We are unsure why this could not be the case here but we need to consider the impact on Mr M.

54. Mr M says his dealings with the Trust caused him stress, which affected his mental health.

55. The minutes of the meeting detail Mr M and the Trust discussing different parts of Mr L’s care and treatment. The Trust accepts that for a lot of the issues it can only explain decisions made based on the records, because the doctor involved no longer works at the Trust. And the Trust had already dealt with most of the issues discussed in its previous written responses.

56. We recognise the effect stress can have on a person’s mental health and we are sorry this was the case for Mr M. We have not found any other impact on Mr M from the lack of advocacy support. This is mostly because we cannot say how the outcome of the meeting could have been different if his advocate was there.

57. When we consider complaints, we must focus on the most serious matters. This is because we are publicly funded and must work fairly and focus on issues that have the biggest impact. We realise this issue had an impact on Mr M but, because it was relatively minor, we are not considering it further.

58. Mr M also complains the Trust wrote inaccurate minutes of the meeting. Mr M explains that his memory of what was discussed is very different to what the Trust wrote.

59. The Trust has not addressed this specific part of the complaint in its complaint handling and we cannot see that Mr M raised it with the Trust. It would not be right for us to tell Mr M to go back to the Trust and ask it to address this concern, as we can look at it now.

60. When coming to a decision on any part of a complaint, we need to fairly balance the evidence and consider all information available to make sure our decisions are impartial and evidence-based.

61. The Trust’s minutes provide a written record of the meeting with Mr M, but he has a different memory of the discussion. We do not dispute Mr M’s memory. We were not at the meeting, so we cannot say exactly what happened.

62. We understand if Mr M’s advocate had been there, they would have been able to give us their account. This may have led to us being able to reach a decision about what happened in the meeting.

63. We realise this likely added to the stress Mr M felt. We are sorry if this was the case. Because the impact of this is relatively minor and there is no other evidence for us to consider, we are not looking at this part of the complaint further.

1. We have carefully considered Mr L and his father’s, Mr M, complaint about Hertfordshire Partnership University NHS Foundation Trust (the Trust). We understand how difficult it can be when you do not think you are getting the right level of support from a care provider. We also understand how frustrating it can be when a complaints process does not go how you want it to.

2. We have decided not to consider Mr L and Mr M’s complaint further. This is because some of the concerns are outside of our legal time limit and we have not seen a good reason to put this to one side. With the concerns that we can look at, we have either seen that the Trust did not make a mistake or the impact of any mistake was relatively minor.