South West London and St George's Mental Health NHS Trust

3. Ms A complains about the following aspects of Mr B’s care and treatment at South West London and St George's Mental Health NHS Trust between May 2023 and January 2024. She complains the Trust:

• failed to respond when notified of his declining mental health between August 2023 and January 2024 • ignored a request for a second opinion in January 2024 • failed to inform him he was eligible for Section 117 extra support and funding • refused home team support in January 2024, despite this being requested from the psychiatric team • failed to follow its 5-star standard of care (sharing a care plan, explaining the triangle of care and sharing the contact details of a person working with him.)

4. She says this meant he was left without additional help, and his treatment did not progress or change as much as it could have.

5. Ms A would like to see service improvements.

6. Mr B suffered with mental health problems following an injury which prevented him from working.

7. Mr B’s depression resulted in him being detained under the Mental Health Act 1983 to receive treatment.

Declining health not taken seriously August 2023 to January 2024

11. Ms A says the Trust failed to react when it was aware that Mr B’s mental health had declined and he was expressing more suicidal thoughts.

12. The NICE CG 136 guidelines says ‘1.5.10 consider the support and care needs of families or carers of service users in crisis. Where needs are identified, ensure they are met when it is safe and practicable to do so.’

13. We discussed Mr B’s treatment at the Trust during this time with our adviser and reviewed what happened.

14. Mr B’s notes show that during this time there was frequent contact with Ms A. We have documented below that Mr B’s condition was always taken seriously and he had access to the home treatment team when this was required.

15. In October 2023 the Trust spoke to Mr B regarding his mood and discussed his medication and how he was feeling. There was no indication that any intervention was needed. The Trust made amendments to his medication and referred this to his GP.

16. He was reviewed again on 2 November 2023. During this review the consultant conducted a risk assessment which concluded that he was not suicidal or at risk of self-harm.

17. There was no further interaction with the Trust until January 2024.

18. There is no indication that the Trust failed to take any changes in Mr B’s health seriously or failed to act in line with the NICE guidance. Mr B was not considered high risk at this time and the Trust always made him aware of contact details anything changed.

It ignored a request for a second opinion in January 2024.

19. Ms A says they asked for a second opinion on Mr B’s treatment and the Trust did not follow this up.

20. We have reviewed Mr B’s records and we are unable to locate any reference to a request for a second opinion.

21. However, in its response letter of September 2024 the Trust acknowledged that it had made an assumption that the request was no longer needed following contact with Ms A. It apologised to her for this confusion and it suggested that it should be discussed whilst he was an inpatient (which he was at the time).

22. We do not know how the confusion about a second opinion arose. But in this instance the Trust recognised it made an error in believing that the second opinion was no longer needed and it offered a solution to try and resolve this at the time.

23. Our NHS complaint standards say an effective complaint handling system enables staff to give a fair and balanced account of what happened and the conclusions they have reached. Organisations openly identify instances when things have gone wrong, or where services have had an unfair impact, and take responsibility for these. They make sure staff can offer a range of ways to put things right for the individual.

24. Wherever possible, staff explain why things went wrong and identify suitable ways to put things right for people. Staff give meaningful and sincere apologies and explanations that openly reflect the impact on the people concerned.

25. In this instance the Trust recognised that it had misunderstood that a second opinion was still sought by Mr B. It apologised for the error and offered a solution (discuss with doctors where was at the time of the response) to resolve this issue.

26. We consider that this is sufficient to resolve this aspect of the complaint as the Trust could not do more to remedy it. We will therefore not consider it further.

Inform him he was eligible for Section 117 support

27. Ms A say that the Trust should have made her aware that Mr B was eligible for additional financial support under section 117 of the Mental Health Act 1983 (a legal duty in England and Wales requiring NHS and local authorities to provide free aftercare to patients previously detained in hospital under certain sections of the Mental Health Act). She says that she was not aware of this for 11 months after he was discharged.

28. Chapter 33 of the Mental Health Act Code of Practice looks at after-care in detail including who is eligible for section 117 aftercare and who is responsible for providing it. This eligibility confers to the patient a legal right to receive appropriate aftercare funded by health and social care services if they have been detained at any point on certain sections of the Mental Health Act.

29. This is an automatic eligibility not dependent on diagnosis or any other factors. The Code of Practice states that chapter 33 must be read in conjunction with chapter 34 which describes the Care Programme Approach (CPA) and its implementation. The CPA is an overarching system for co-ordinating the care of people with mental health issues. It requires close engagement with service users and their carers and includes arrangements for assessing, planning and reviewing care. Relevant parts of chapters 33 and 34 are as follows:

‘Ch 33.11 Some discussion of after-care arrangements involving local authorities, other relevant agencies and families or carers (where appropriate) should take place in advance of the Tribunal hearing.’

‘Ch 34.10 Most importantly, the care plan should be prepared in close partnership with the patient from the outset, particularly where it is necessary to manage the process of discharge from hospital and reintegration into the community.’

‘Ch 34.17 The planning of after-care needs to start as soon as the patient is admitted to hospital. [The NHS] and local authorities should take reasonable steps to identify appropriate after-care services for patients in good time for their eventual discharge from hospital.’

30. The guidelines do say that the Trust was required to consult families or carers about this.

31. On 16 June 2023 the Trust wrote to Mr B to tell him of his rights under section 3 of the Mental Health Act including his right to receive section 117 aftercare. It said:

‘The right to aftercare provision – Section 117 Detention under Section 3 entitles you to receive aftercare services under the Mental Health Act. These services must be provided by the South West London and St. George's Mental Health NHS Trust and the local Social Services Authority, in cooperation with any other relevant agencies’

32. A similar letter containing the same information was sent to Ms A along with a leaflet detailing the patient’s and relative’s rights of appeal and s117 aftercare.

33. Whilst there is no absolute instruction regarding formal consultation with families or carers, it is indicated in other parts of the code. It does not appear the Trust mentioned this to Mr B at the time of discharge. However, the Trust did make Mr B, and Ms A, aware of section 117. We therefore cannot say the Trust did not tell him about his eligibility for support under that Section and we will not consider the complaint further.

Refused home team support in January 2024

34. Ms A says that whilst he was an inpatient at the Trust in January 2024, it recommended that Mr B was referred to the Home Treatment Team (HTT).

35. The Trust has acknowledged that the referral was received but says that the HTT does not have to accept the referral and it was declined as it assessed him as low risk. We discussed this with our adviser to see if the Trust failed to offer him suitable home support.

36. The referral was raised as low risk and was due to Mr B having problems with his memory, and not due to his mental health, or any urgent concerns of harm.

37. The Trust has previously accepted requests from the HTT and we can see that it has been very active in his care. We could not find any evidence that the HTT refused to support the patient at home when it was needed. He had been under the care of the HTT since being referred by the Rapid Assessment Clinic on 11 February 2023 due to concerns raised by Ms A.

38. We can see evidence of how the HTT supported him when on 20 February 2023 when medication changes were made. He was admitted to a crisis centre for crisis containment in April 2023 and further deteriorated in early May 2023, spending a few nights in respite care. Continued deterioration in mental state and suicidal thoughts eventually led to detention under the Mental Health Act.

39. NICE CG 136 guidelines says ‘1.5.10 consider the support and care needs of families or carers of service users in crisis. Where needs are identified, ensure they are met when it is safe and practicable to do so.’

40. In this instance the referral was not made as urgent and was not seen a as time of crisis.

41. We can see that Ms A is concerned that a referral was not accepted on one occasion. But we cannot see that this was incorrect as the Trust continued to have in place regular assessments of his condition. During the period of care we have reviewed we can see that the Trust were active in making sure Mr B had home support whenever it was required.

42. Although the Trust rejected one referral, it continued to provide him with home care as we cannot see that the Trust failed to provide Mr B with sufficient home care, we cannot progress further with this aspect of the complaint.

Trust Failed to Follow its 5 Star Standard of Care

43. Ms A says the Trust failed to provide her with any correct details relating to who the contacts were at the Trust until February 2024 and she only received details of the care plan in April 2024.

44. The Trust 5 star standard of care includes its Triangle of care which is used to link the patient, the carer and the healthcare professional together. It says ‘The Triangle of Care transformed the care of our carers...our ongoing commitment to the Triangle of Care ensures this continues to develop and evolve going forward, keeping carers at the heart of our delivery.’

45. The Trust said the information was shared in November 2023 according to its records, so it was not aware that she had not received this information.

46. We discussed this with our adviser and reviewed Mr B’s records. We will also consider what is required in line the MHA for Mr B.

47. Chapter 34 in the MHA code deals with Care Programme Approach (CPA) Care Planning, and says who should be involved and how this must be shared with the patient:

‘34.10 Most importantly, the care plan should be prepared in close partnership with the patient from the outset, particularly where it is necessary to manage the process of discharge from hospital and reintegration into the community.’

‘34.14 The care plan should be recorded in writing and a copy given to the patient. Once plans are agreed, it is essential that any changes are discussed with the patient as well as others involved with the patient before they are implemented.’

48. A CPA Care Plan would include details about what to do in a Crisis such as who to contact, how to do this and what response may be expected.

49. In 2021 the CPA was superseded by the Community Mental Health Framework but the MHA Code of Practice continues to refer to CPA. The principles of a personalised Care Plan continue into the new legislation.

50. In the Discharge Summary dated 30 June 2023, ten days after Mr B’s discharge, the Trust noted important elements of the Care Plan. For example:

‘Collaborative Crisis Planning: Mr B, today we completed a collaborative crisis plan, a copy of which is attached to this discharge summary. This includes information about your specific relapse indicators and strategies to manage these concerns.

‘Accessing Rapid Support in a Crisis: As we discussed in our last contact, the MHTT offer a 2 week discharge window. This means you are able to contact RHTT in order to seek advice, support and discuss rereferral to our service in the 14 days following your discharge. The following are useful numbers to access support should you feel you require the support of services outside of this window.’

51. The Trust also provided details of other contacts including for urgent psychiatric support outside working hours, community crisis services and a Mental Health Support Line.

52. Overall, we cannot see any indication that the Trust failed to follow relevant guidelines or live up to its own 5 star standard of care.

53. We understand that this has been difficult for Ms A and we hope our decision does not undermine the difficulties she and Mr B have faced over the previous years.

1. We have carefully considered Ms A’s complaint about South West London and St George's Mental Health NHS Trust (the Trust). We have decided to take no further action on Ms A’s complaint as we can see no indication that the Trust failed to follow guidelines in its care of Mr B.

2. We are sorry to hear of Mr B’s death in November 2025. We recognise that this has been a difficult and upsetting time for Ms A and her family and we offer her our sincere condolences.