Cornwall Partnership NHS Foundation Trust

7. Ms R complains on behalf of her son, Mr R, that Cornwall Partnership NHS Foundation Trust (the Trust) failed to provide appropriate mental health care and support to him in February 2023. She complains the Trust:

• did not have adequate provision for her son to appropriately transition from child to adult mental healthcare • refused to provide support to her son while he was experiencing psychosis in February 2023 • said it would contact police and an ambulance for her but failed to do so • refused to accept her son for a mental health assessment • refused to meet with her about her complaint and • incorrectly said her complaint was about its Early Intervention in Psychosis Team when this was not the case.

8. Ms R says the lack of mental healthcare provision led to her son’s episode of psychosis in February 2023 and that this was avoidable. She says its lack of provision also meant he was put on a dangerous ward where he was assaulted by an adult patient. She says the Trust’s failure to contact police meant his episode of psychosis went unchecked and allowed him to cause property damage and her to feel threatened. Ms R says the Trust’s handling of her complaint and refusal to meet left her and her family feeling exasperated and that it did not care. She says the Trust’s actions overall caused her and her son significant trauma and upset.

9. Ms R would like the Trust to explain what happened and for it to understand and recognise the significant trauma and upset its actions caused. She is seeking improvements to its mental health services to prevent other families from experiencing similar issues.

10. Mr R was originally referred to the Trust by the Child and Adolescent Mental Health Service (CAMHS) Crisis Team in August 2019 with symptoms of psychosis. Mr R’s community care was under the Trust’s Early Intervention Service. It was medically led by a consultant psychiatrist for Early Intervention for Psychosis. He also saw a consultant in Child and Adolescent Psychiatry and a support worker from the EIPT. Mr R was discharged from the service in August 2022.

11. Mr R presented at a different Trust on 18 January 2023 after jumping down eleven steps and injuring his foot. Its Psychiatric Liaison Team assessed him and suggested a medication review to prevent further deterioration in his mental state. A mental health practitioner at a GP Practice reviewed Mr R on 19 January 2023 and referred him to the Single Point of Assessment (SPoA) Team on 6 February 2023. SPoA forwarded the referral to the Trust’s North Cornwall Integrated Community Mental Health Team on 7 February 2023, which contacted him on 10 February 2023. It agreed to further contact with him.

12. The GP mental health practitioner received an appointment request form from Mr R and re-referred him to the SPoA on 21 February 2023. Mr R went into crisis on the same day, and his family called the Trust for support. Mr R’s presentation was discussed during the North Cornwall Integrated Community Mental Health Team Multi-Disciplinary Team meeting on the same day. It agreed to arrange a face-to-face review with Mr R. When informing Mr R’s family of this, the team became aware that his condition had deteriorated throughout the day, he required restraint, and that his family was fearful of its safety. Mr R was taken by ambulance to hospital and assessed under the Mental Health Act the following day. Mr R was detained under section 2 of the Mental Health Act and admitted to the Trust’s Psychiatric Intensive Care unit.

Transition from child to adult mental healthcare

16. Ms R says the Trust did not have adequate provision for her son to appropriately transition from child to adult mental healthcare. She says this led to his episode of psychosis in 2023 and him being admitted to a dangerous mental health ward.

17. In its complaint response dated 29 September 2023, the Trust said its Early Intervention in Psychosis (EIP) pathway has embedded links with other Community Mental Health Teams (CMHT) in both adult and children’s services. It said its service model is based on National Institute and Health and Care Excellence (NICE) guidance and works for up to three years with patients who present with their first episode of psychosis.

18. The Trust said Mr R completed the three years of care on the EIP pathway and showed no evidence of psychosis during his assessment in July 2022. It said there were concerns around Mr R’s presentation in August 2022 but that he was 18 years of age at that point and declined to meet with the EIPT. The Trust explained there were no concerns around his capacity. It said he suffered from low mood but showed no evidence of psychosis at that time. As such he did not meet the criteria for onward referral. It said it provided Mr R with the details of third-party mental health support groups and crisis contact numbers and that he had a relapse plan in place. It acknowledged it could have communicated more with his family about this and apologised for any distress caused.

19. We refer to NICE guideline NG43 (Transition from children’s to adults’ services for young people using health or social care services) which sets out general guidance on the period before, during, and after a young person moves from children’s to adults’ health services. Its purpose is to ensure a better experience of transition. NG43 says transition planning should be person-centred and occur early. It says there should be a joint responsibility across child and adult services, a named worker and post‑transfer support, including explicit re‑engagement routes if the young person disengages.

20. We asked our adviser for their opinion on whether the Trust had adequate provision in place for Mr R’s transition from child to adult mental healthcare. Based on the records available, Mr R was managed jointly by the Early Intervention in Psychosis Team (the EIPT) and the Child and Adolescent Mental Health Service (CAMHS). Our adviser said that in their view the care and treatment provided was of good quality and Mr R’s discharge in September 2022 was planned after a good and thorough review.

21. At the time of Mr R’s discharge, the records demonstrate he appeared settled and there was no evidence of psychotic symptoms. Our adviser explained there was clear advice given to Mr R about his ongoing low mood and potential relapse. Our adviser said there is evidence of a joint working relationship between CAMHS and the EIPT and the transition was planned appropriately. Our adviser said there was a missed consultant review but that in their opinion this would not have contributed materially to Mr R’s transition to adult mental healthcare.

22. We understand the events of Ms R’s complaint and how they affected her and Mr R will have been distressing. We can also see how these events will have caused Ms R concern about her son’s transition from child to adult mental healthcare. Based on the information we have seen and taking into account the clinical advice we have received, we consider the Trust did have adequate provision for Mr R’s transfer to adult mental healthcare and that this was in line with relevant clinical standards.

Assessment

23. Ms R complains the Trust failed to assess her son leading up to his episode of psychosis in February 2023. Specifically, she complains her son was showing signs he was going to experience an episode of psychosis. She also complains a mental health unit at the Trust should have accepted her son for assessment.

24. In its complaint response dated 29 September 2023, the Trust said Mr R had been reviewed as being low risk in January and early February 2023. It said it re-referred him to its service once Mr R and his family were in crisis on 21 February 2023. The Trust acknowledged it did not communicate effectively with Mr R’s family who were seeing his deterioration.

25. The Trust also explained the mental health unit complained about is not a public facing resource or a bookable service. It said where required, the relevant mental health helpline would make a referral to the unit for assessment. It said on 21 February 2023, Mr R and his family were in crisis. It said the police would have needed to make a referral to the unit. It said a mental health practitioner made an urgent referral to its CMHT on the same day and this led to an urgent multidisciplinary team meeting being held. The Trust said when it had attempted to contact Mr R’s family later in the day he had already deteriorated and needed police intervention.

26. We have considered the Trust’s local guidance, ‘Mental Health connect helpline and crisis hub standard operating procedure’. This sets out the role of its mental health helpline and its crisis hub. It says:

‘The Crisis Hub is professional facing, not public facing, and provides access to emergency face to face mental health assessments for over 18s. The Crisis Hub does not replace urgent referrals for which the current process (refer to Single Point of Access Policy) should be followed.’

27. The records show that at the time of Mr R’s crisis, the GP mental health practitioner made an urgent referral to the Trust’s CMHT on 21 February 2023. Due to the speed of Mr R’s deterioration on the same day, its crisis hub did not receive a referral in time to be able to assess Mr R. We have seen no evidence the Trust failed to follow its operating procedure on dealing with urgent referrals.

28. We have further considered whether Mr R could have been referred to the CMHT earlier. The records show that in August 2022, Mr R’s family raised concerns about his condition with the EIPT. At that time, the EIPT contacted Mr R who declined to meet. The EIPT extended its monitoring of Mr R for six weeks. The Trust recorded that he showed no signs of psychosis and that he had capacity to make decisions. As noted earlier in this report, the Trust discharged Mr R on 9 September 2022 as he did not meet the criteria for onward referral to the CMHT.

29. Our adviser says based on the records, there was no indication for a formal CMHT assessment between his discharge in September 2022 and January 2023. Particularly as the EIPT had extended its followup of Mr R and had documented a relapse plan.

30. The records show Mr R was seen by a Trust psychiatric liaison nurse on 18 January 2023. This review detailed that Mr R had injured himself jumping down some stairs as an angry response to a relationship issue. It also noted he had poor sleep, was acting more aggressively towards his parents and feeling irritable, which were early warning signs of deterioration noted in his care plan. The review also included information from Ms R who raised concerns that her son’s mental state had been deteriorating over the last month and that he was showing early signs of psychosis.

31. At this point the psychiatric liaison nurse decided that no CMHT referral was necessary but discharged him to the care of his GP for a medication review, with parental support, and gave him contact details for a crisis support line and signposted him to other resources.

32. Mr R was then seen by a mental health practitioner on 19 January 2023 at his GP Practice who referred him for a review of his medication on 6 February 2023.

33. We have not identified any clinical standards which could be applied here and our adviser has referred to their own professional clinical opinion. They say following the appointment on 18 January there was a missed opportunity as Mr R reported psychotic symptoms during his review. They say these symptoms, Mr R’s history of psychosis and the presence of high-risk behaviour should have prompted an urgent assessment instead of a routine referral. Our adviser says an urgent referral at that time could have led to earlier treatment which could have prevented the deterioration in Mr R’s condition.

34. We can see Mr R and his family were significantly affected by his deterioration. We consider there was a missed opportunity for an urgent referral to be made earlier and which might have prevented his episode of psychosis.

Lack of support

35. Ms R complains the Trust failed to provide appropriate support to her son while he was experiencing psychosis in February 2023. Specifically, she complains there was inadequate support as he was not under a named consultant. She also complains the Trust said it would contact police and an ambulance for her but did not do so.

36. In its complaint response dated 29 September 2023, the Trust said at the time of Mr R’s psychosis on 21 February 2023, his father called its mental health helpline. It said it listened to the calls with Mr R’s father and that it had not refused support. The Trust said it provided advice to Mr R’s father.

37. The records show a CMHT duty social worker documented calling Mr R’s father back on 21 February 2023 and speaking to Ms R who answered the call. They say the call was passed to Mr R’s sister due to Ms R needing to help restrain him. They say they called the police and an ambulance during this call. They say they remained on the phone with Mr R’s sister until the emergency services arrived.

38. We have not identified any standards in relation to this point. Our adviser says in their clinical opinion this action was appropriate and proportionate to the risk posed at the time. We acknowledge Ms R’s account of events and the distress caused to her at the time. We have not identified any evidence to support Ms R’s view that the Trust failed to contact emergency services during her son’s crisis. We do not doubt that this was a very distressing experience for Ms R, Mr R and their family and it is clear that Mr R was very unwell at this point. As an independent organisation, we are unlikely to be able to reach any further conclusion on this point and hope that our consideration of her son’s records will provide her with reassurance of the Trust’s actions.

39. We have considered the support provided to Mr R which Ms R does not believe was adequate. She says this was due to him not being under a named consultant. As set out earlier in this report, we have seen no evidence that the Trust failed to support Mr R in line with relevant clinical standards. We also consider that Mr R was being reviewed by the Trust and his GP mental health practitioner leading up to his episode of psychosis. We have found no failings in this part of Ms R’s complaint.

Complaint handling

40. Ms R complains the Trust refused to hold a local resolution meeting with her about her complaint. She also complains the Trust misinterpreted her complaint and recorded her complaint as being about the EIPT when it was not.

41. In its complaint response of 29 September 2023, the Trust acknowledged Ms R’s request for a meeting about her complaint. It also said Ms R had wanted a written response first, before meeting with the Trust. It confirmed it would be able to arrange a meeting at a later date.

42. On 19 December 2023, the Trust wrote to Ms R and said it could arrange a meeting but that due to Winter pressures at that time and the personnel needed to be involved, it would be unlikely to arrange a meeting before February 2024. It advised Ms R to approach our office due to our time limit in looking at complaints, as it did not want to delay the progress of her complaint. It also said it would discuss arranging a meeting with us if we considered it appropriate.

43. After receiving Ms R’s complaint, we asked the Trust in June 2024 whether it would agree to our mediation process. This involves our office facilitating a conversation between both parties in a complaint, who would then be responsible for negotiating a resolution themselves. The Trust refused to become involved in our mediation process. There does not appear to have been any discussion in relation to the Trust arranging a local resolution meeting as an alternative.

44. Our Principles of Good Complaint Handling set out our views on what we consider to be good complaint handling. They say:

‘We understand there is often a balance between responding appropriately to complaints and acting proportionately within available resources. However, prompt and efficient complaint handling can save the public body time and money by preventing a complaint from escalating unnecessarily. Learning from complaints can reduce the number of complaints in the future.’

45. There is no mandatory requirement for an organisation to meet with a complainant to attempt to resolve a complaint. Organisations have discretion as to how to handle a complaint as long as they follow any relevant complaint standards or guidelines. We generally consider local resolution meetings to be a productive way to attempt to resolve a complaint.

46. We can see Ms R feels strongly about her complaint and wanted an opportunity to meet with the Trust with a view to seeking meaningful changes to its mental health service. We consider it unfortunate that a local resolution meeting did not take place and that the Trust refused to become involved in our mediation process, although there is no requirement for organisations to become involved in mediation if they do not feel it to be appropriate and not every complaint we consider will be suited to mediation. We cannot say this was a failing by the Trust or that it failed to handle Ms R’s complaint within our own Principles. We consider the Trust exercised its own discretion while also considering its own resources when it referred Ms R to our office in December 2023.

47. In its letter of 19 December 2023, the Trust acknowledged Ms R’s comments that her complaint was not about the EIPT specifically and that she wanted this noted. The Trust said it had included the EIPT as it was involved in her son’s treatment. It said her overall complaint sat with the Trust. It also said complaints are not viewed negatively and contribute to positive change.

48. We appreciate Ms R’s feelings towards the EIPT and that it has supported her son. We consider the Trust’s response on this point was reasonable and line with Our Principles. It is for the Trust to associate specific issues to specific areas within its organisation depending on its own findings. We consider the overall responsibility for any issues raised fall to the organisation itself and we do not investigate specific departments within a Trust. We do not uphold this part of Ms R’s complaint.

Impact

49. We have found that the Trust should have made an urgent referral to the CHMT, based on Mr R’s presentation on 18 January 2023. When we find that something has gone wrong, we then go on to consider whether this had a negative impact and what the organisation has already done to put things right.

50. Ms R told us the lack of mental healthcare provision led to her son’s episode of psychosis in February 2023. She told us events caused her and her son significant trauma and upset.

51. We cannot say exactly what would have happened had Mr R been referred urgently to the CMHT on 18 January 2023. However, it is clear from the records that his health was deteriorating at this time and there was evidence that he may relapse. It is possible that his deterioration could have been slowed or stopped had the CHMT intervened sooner, although we cannot say for certain whether his psychotic episode and subsequent sectioning would have been avoided. What we can say is that there was a missed opportunity to intervene and provide more support to Mr R during this time. We can see how Ms R has been left with the feeling that not enough was done to support her son and her family and that the traumatic events of 21 February could have been avoided.

52. We have not seen that the Trust has acknowledged this missed opportunity or the impact to Ms R and her family. We therefore partly uphold this complaint and make recommendations to put this right.

1. Ms R complains Cornwall Partnership NHS Foundation Trust failed to provide appropriate support and care to her son, Mr R, and about how it addressed her concerns.

2. We were sorry to learn about the events of Ms R’s complaint and their impact to her son and the rest of her family. We can see Ms R’s complaint is motivated by concerns about the provision of mental health services and how they can be improved for the wider public.

3. We have carefully considered Ms R’s complaint about the Trust. We consider the Trust’s provision for her son to transition from child to adult mental healthcare was appropriate and in line with relevant clinical guidelines. We consider the support it provided during his episode of psychosis was appropriate and in line with relevant guidelines.

4. We consider it was unfortunate the Trust failed to hold a local resolution meeting with Ms R but that this was not a failing in complaint handling. We also consider its response in relation to it including the Early Intervention in Psychosis Team (the EIPT) in her complaint was reasonable.

5. We do not consider the Trust appropriately assessed Mr R in January and February 2023 and it missed an opportunity to make an urgent referral sooner. In our view, we consider it likely that an earlier urgent referral might have prevented the episode of psychosis Mr R experienced. We partly uphold Ms R’s complaint.

6. We recommend the Trust complete an action plan to show how it will prevent further opportunities being missed in similar circumstances.