Avon and Wiltshire Mental Health Partnership NHS Trust

9. Mrs E complains about the care her daughter, Ms C, received from Avon and Wiltshire Mental Health Partnership NHS Trust. She says the Trust:

•wrongly removed Ms C’s CETR and additional educational support packages in 2022 when she transitioned to AMHS •wrongly insisted Ms C gain full control over her finances in 2022 and did not provide adequate support •wrongly discharged Ms C from her CPA in August 2023.

10. Mrs E says the treatment her daughter received damaged her mental health and prevented her from living a normal life. She says the inappropriate decision to give Ms C full control over her compensation without adequate support resulted in the money being wasted. Finally, she says she has suffered significant distress as a mother. She says she now suffers with symptoms of anxiety which she is receiving treatment for.

11. Mrs E is seeking an apology, acknowledgement of failings, service improvements and financial remedy of at least £10,000 for her daughter.

12. Ms C is a woman with a complex medical history, including diagnoses of avoidant/restrictive food intake disorder (ARFID), a previous diagnosis of anorexia, attention deficit hyperactivity disorder (ADHD) and mental health difficulties.

13. In 2022, Ms C transitioned into AMHS from Child and Adolescent Mental Health Services (CAMHS). During this period, the Trust facilitated Ms C gaining access to her own independent bank account. This was to facilitate a compensation payment and to allow her to claim benefits independently.

14. In 2022, as Ms C transferred into AMHS, the Trust removed her existing CETR and other educational support packages, particularly equine therapy.

15. In August 2023, the Trust discharged Ms C from her CPA and stepped her care back to her GP.

The Trust wrongly removed Ms C’s CETR and additional educational support packages in 2022 when she transitioned to AMHS

19. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone wrong.

20. The records show that in August 2022, Ms C’s transition worker documented there was a risk of duplication of services with the teams involved in Ms C’s care, and that Ms C needed to be at the centre of her care when she transitioned to AMHS. In September 2022, Ms C’s transition worker recorded their view that Ms C had a lot of different services involved in her care and the Trust should not overwhelm Ms C with input.

21. In October 2022, when she turned 18, Ms C’s equine therapy sessions were reduced from twice to once per week. In August 2023 she was discharged from mental health services. During her CPA meeting in August 2023, Ms C emphasised that the ‘Make It Mentoring’ service was very helpful for her, which was funded via a separate Education, Health and Care Plan (EHCP).

22. NICE guideline NG43 says clinicians should offer young people the chance to familiarise themselves with the services available to them through adult care. It says clinicians should be clear with young people about which services and support is available to them.

23. NICE QS140 says involving young people in planning for their transition to adult services and involving them in decisions gives more time to adjust. It says a sudden change can lead to young people losing confidence in the service and ceasing their use of the services.

24. Our adviser said it was appropriate and in line with guidance for the Trust to amend Ms C’s support packages when she transferred to AMHS. They said Ms C had expressed a wish not to attend as many sessions and clearly expressed her desire to prioritise ‘Make It Mentoring.’ They said she had been with mental health services for a long time and it was natural that she may have wished to make changes as she became an adult.

25. Our adviser said the Trust had discussed the upcoming changes with Ms C prior to her turning 18, and documented this in her medical records. They said this was in line with relevant guidance.

26. Our adviser said the records suggest funding for some of the services Ms C was attending, including equine therapy, was only available under CAMHS and would no longer apply when Ms C transferred to AMHS. They said funding streams and access criteria for services change significantly from CAMHS to AMHS. They said it was always likely there would have been a change in the support offered to Ms C at this point, as AMHS is often not able to access the same services as CAMHS. They said this is a matter of policy, which is decided at Trust and national level.

27. Our adviser said that from the email exchanges between Trust staff, it appeared staff had made significant efforts to bridge this funding gap and had sought to ensure the highest possible level of support for Ms C.

28. In summary, our adviser said it was appropriate and in line with guidance for the Trust to amend Ms C’s support packages.

29. We recognise Mrs E’s concern that the Trust wrongly removed Ms C from her support packages when she turned 18 and transferred to AMHS. Having reviewed the evidence, we are satisfied the Trust’s communication with Ms C and its decision to remove or change some elements of Ms C’s support was in line with relevant guidance. We will therefore not be looking at this part of the complaint further.

The Trust wrongly insisted Ms C gain full control over her finances in 2022 and did not provide adequate support

30. The records show that when Ms C began transitioning to AMHS from CAMHS in 2022, she said she wished to become more financially independent from her mother. In July, it was noted she had never managed money. In September, it was noted she had a need for a bank account of her own, as she was turning 18.

31. At Ms C’s CPA meeting in November, Trust staff noted Ms C had opened a bank account to allow benefit payments to paid into. They identified and documented a need for this account to allow a compensation payment of £11,000 to be paid to her. Staff also noted that Ms C’s residence in supported living accommodation would allow her to learn to budget and manage her finances.

32. During this CPA meeting, Mrs E said Ms C was not able to manage her money and felt she had to administer Ms C’s financial affairs for her. The compensation payment of £11,000 was also discussed in this meeting.

33. In March 2023, the records show Ms C was upset at what she saw as her mother’s control over her finances. In her CPA review in August 2023, the records show Ms C had her own account and her mother was no longer an appointee for her benefits.

34. The Mental Capacity Act 2005 says a person is assumed to have capacity to make specific decisions regarding their care, treatment and finances unless proven otherwise.

35. GMC ‘Professional Standards: Decision Making and Consent’ says medical professionals must start from the presumption that all adult patients have capacity to make decisions about their treatment and care.

36. Our adviser said it was appropriate for the Trust to assist Ms C in opening her own bank account. They said Ms C was turning 18 and legally becoming an adult, and appeared to have capacity to manage her finances, alongside assistance the Trust offered at her supported living accommodation and through ‘Make It Mentoring.’

37. The records show Ms C had expressed a desire to become more financially independent and to manage her own finances. Our adviser said the Trust decision to assist Ms C in opening an independent bank account was in line with the relevant legislation and GMC guidance around the presumption of consent. They said there were no concerns about her capacity raised in her medical records.

38. The records do not show that the Trust completed a thorough capacity assessment specifically discussing Ms C’s financial capability. Our adviser said this should have been completed, as there was a documented concern from Mrs E about Ms C’s capability to manage her finances, coupled with long standing clinical (ADHD) and mental vulnerabilities. They said this context should have meant that the Trust completed and documented a thorough capacity assessment.

39. Our adviser said the Trust should have assessed and monitored Ms C’s capacity with a higher level of scrutiny, given the large amount of money she was about to receive and her existing vulnerabilities. They said the Trust should have offered Ms C more support to aid her in managing her financial affairs.

40. Our adviser said while there is no specific guidance on this point, it was standard practice to complete a detailed capacity assessment in unusual circumstances such as this and the Trust should have documented it once completed. They said better support from the Trust may have enabled Ms C to manage her money better, although it is not possible to know for sure. She may still have chosen to use her money in the way she did. We therefore cannot link the identified shortcoming with the financial impact Mrs E has claimed.

41. Our Severity of Injustice scale allows us to ensure the recommendations we make are consistent and transparent for everyone who uses our service. The scale represents the Ombudsman’s judgement about the sort of remedies that are both appropriate and proportionate for us to recommend. The scale contains six different levels of injustice that a complaint could fall into, which increase in severity.

42. Our Severity of Injustice scale identifies a level one injustice as annoyance, frustration, worry or inconvenience typically arising from a single incidence, where there is no adverse effect or ongoing impact on care. We normally consider an apology sufficient to remedy this level of injustice.

43. We have concluded the worry and inconvenience caused to Mrs E was the result of a single incident where there was no ongoing impact. This is because we cannot link the identified shortcoming with the financial impact Mrs E has claimed and do not think it had an impact on Ms C’s ongoing care. We acknowledge this would have been concerning to Mrs E in the context of Ms C’s clinical history and ongoing vulnerabilities.

44. We contacted the Trust to discuss this and other elements of Ms C’s care which indicated shortcomings. The Trust agreed to make a further apology to Mrs E to acknowledge the distress and anxiety caused to her and Ms C. It also agreed to outline the learnings it will implement to prevent this happening again. We consider this sufficient to resolve this part of the complaint. We will therefore not be considering this part of the complaint further.

The Trust wrongly discharged Ms C from her CPA in August 2023

45. The records show Ms C had a CPA meeting in August 2023 and was discharged from CAMHS. The records show Ms C told clinicians she did not want support from AMHS and wished to prioritise her ‘Make It Mentoring’ work. The records show Ms C was told she would be able to access support in the future if and when required.

46. RCP guidance says young adult mental health services should be young adult centred and prioritise shared decision making between clinicians and young people. NHS England guidance says the NHS has broadly moved away from CPAs since 2022, in favour of meaningful intervention based care.

47. Our adviser said the Trust decision to discharge Ms C from her CPA was in line with RCP and national guidance. It took her opinions into account and signposted towards future interventions should they be necessary, as per the guidance.

48. Our adviser also said the discharge could have been handled better, and the verbatim record of Ms C declining assistance during the meeting should have been viewed in the context of her known and long-standing vulnerabilities.

49. They said that given the long relationship between the Trust and Ms C, the Trust should have shown a higher level of professional responsibility and should have facilitated a gradual stepping down process from CPA support over several months. In addition, they said the Trust rationale to support the decision to discharge Ms C had been poorly documented.

50. In summary, our adviser said that while the Trust decision to discharge Ms C from her CPA was in line with guidance, it should have arranged a gradual discharge and maintained poor records.

51. Our Severity of Injustice scale identifies a level one injustice as annoyance, frustration, worry or inconvenience typically arising from a single incidence, where there is no adverse effect or ongoing impact on care. We normally consider an apology sufficient to remedy this level of injustice.

52. We have concluded the worry and inconvenience caused when the Trust discharged Ms C from her CPA without additional support was the result of a single incident where there was no ongoing impact. We acknowledge this would have been concerning to Mrs E in the context of Ms C’s clinical history and ongoing vulnerabilities.

53. We contacted the Trust to discuss this and other elements of Ms C’s care which indicated shortcomings. The Trust agreed to make a further apology to Mrs E to acknowledge the distress and anxiety caused to her and Ms C by these shortcomings. It also agreed to outline the learnings it will implement to prevent these happening again. We consider this sufficient to resolve this part of the complaint. We will therefore not be looking at this part of the complaint further.

54. We thank Mrs E for taking the time and effort to bring her complaint to our attention. We recognise this was a very difficult and distressing period for her and Ms C. We hope our explanation and resolution provides some degree of reassurance and explains the care and treatment Ms C received. We wish Mrs E and Ms C the best for the future.

1. We have carefully considered Mrs E’s complaint about the care the Trust provided to her daughter, Ms C, between 2022 and 2023.

2. We were very sorry to hear Mrs E’s experience with the Trust caused her and Ms C distress and anxiety.

3. Mrs E told us the Trust wrongly removed Ms C’s Care, Education and Treatment Review (CETR) and additional educational support packages in 2022 when she transitioned to Adult Mental Health Services (AMHS). She said the Trust wrongly insisted Ms C gain full control over her finances in 2022 without adequate support and wrongly discharged Ms C from her Care Programme Approach (CPA) in August 2023.

4. We consider the Trust acted in line with guidance when it amended Ms C’s support packages on transition to AMHS.

5. We consider the Trust assisted Ms C in obtaining an independent bank account in line with relevant legislation and guidance, but should have completed a thorough capacity assessment specifically discussing her financial capability, in order to support Ms C and aid her in managing her financial affairs.

6. Similarly, we consider the Trust discharged Ms C from her CPA broadly in line with guidance, but should have considered a more gradual discharge process, given Ms C’s longstanding vulnerabilities. We also consider the Trust’s record keeping in relation to Ms C’s discharge from her CPA was below the expected standard.

7. We contacted the Trust to discuss the complaint. Following our contact, the Trust agreed to make a further apology to Mrs E for the distress and anxiety caused to her and Ms C by these shortcomings. It also agreed to outline the learnings it will implement to prevent the mistakes happening again. We consider this sufficient to resolve this complaint in full. We explain this in more detail below.

8. We hope our explanation and resolution provides a degree of reassurance for Mrs E and Ms C and explains the care and treatment Ms C received.