East London NHS Foundation Trust

4. Ms O complains about the lack of mental health support provided to her by East London NHS Foundation Trust (the Trust) between 2015 and 2024. She complains;

• the Trust discontinued her cognitive behavioural therapy (CBT therapy) which started in August 2014 after only 3 sessions • she was misdiagnosed with borderline personality disorder in 2015 • the Trust discontinued her cognitive analytic therapy (CAT) in 2015, after 7 sessions • when she called the crisis line on 22 April 2024, the staff member who answered was dismissive towards her • the Trust inappropriately referred her for psychodynamic therapy in February 2024 and she had to wait 6 months to then be told it was not suitable.

5. Ms O says the prolonged lack of support has had a lasting negative impact on her wellbeing. She feels isolated, abandoned and unsupported and her mental and physical health continue to decline leaving her in repeated crisis. She says her ability to complete everyday tasks has been severely affected and she feels hopeless about the future. She says her misdiagnosis meant she was excluded from treatment due to this being on her record and prevented her from accessing care for 10 years. Ms O says her call to the crisis line left her feeling invalidated and unsupported in a time of crisis.

6. As a result of bringing this complaint to us, Ms O is seeking service improvements, an apology and financial remedy.

7. Ms O was first referred to the Trust in 2014 due to suffering with anxiety and depression. In the years since, she has had a variety of treatments including CBT and CAT therapy.

8. Mr O was referred for psychodynamic therapy in February 2024, but after having some telephone assessments for this between July and August 2024 she was discharged and the sessions never went ahead.

9. Ms O called the Trust’s crisis line on 22 April 2024 seeking support with her mental health as she felt in crisis.

10. Ms O complained to the Trust about its lack of mental health support on 12 February 2024. She complained to the Trust about her misdiagnosis and inappropriate psychodynamic therapy on 10 July 2024. The Trust sent its final response to all of these concerns on 10 February 2025.

11. Ms O complained to the Trust about her experience calling the crisis line on 23 April 2024. The Trust sent its response to this on 13 May 2024. Ms O brought all complaints to us on 6 March 2025.

The Trust discontinued Ms O’s cognitive behavioural therapy (CBT therapy) which started in August 2014 after only 3 sessions

Ms O was misdiagnosed with borderline personality disorder in 2015

The Trust discontinued Ms O’s cognitive analytic therapy (CAT) therapy in 2015, after 7 sessions 15. The law says the complainant must refer the complaint to us within one year of the day they became aware they had reason to complain. This comes from the Health Service Commissioners Act 1993 section 9 (4), which says: ‘The commissioners shall not entertain the complaint if it is made more than a year after the day on which the person aggrieved had first notice of the matters alleged in the complaint, unless he considers it reasonable to do so.’

16. In the complaint form, Ms O says her date of knowledge is January 2024. In our telephone calls we talked about this, and I asked why she felt this was her date of knowledge and it was not earlier, given that she had felt she was unhappy about the CBT and CAT therapies being discontinued at the time they were stopped in 2015.

17. She explained in January 2024 she was having private counselling and the counsellor reassured her that the Trust’s lack of support was not her fault. Whilst we understand that this might have been the reason why Ms O decided to complain in February 2024, we consider her date of knowledge was much earlier and as early as 2015 when she was aware that the therapies had been discontinued, and she was unhappy with this. We consider the date of knowledge for the discontinued therapies can be taken as early as 2015.

18. This means to be within our time limit Ms O needed to have complained to us within a year of 2015. Ms O complained to us in March 2025, around 10 years after her date of knowledge. This means the complaint about the discontinued therapies is out of time by around 9 years.

19. We asked Ms O about her date of knowledge for the misdiagnosis of borderline personality disorder, and she explained she only discovered this upon reading the Trust’s complaint response that she received dated 29 April 2024 as the diagnosis was mentioned on there.

20.From reviewing the records, we consider she had awareness of this diagnosis much earlier. There is a telephone note within the records dated 9 July 2021 following a call Miss O had with a community mental health nurse in which she says, “I would like a review of my diagnosis, which I have been given over many years, including OCPD, avoidance and borderline personality disorder, dependence amongst other things like anxiety and depression”. This shows an awareness of the diagnosis and that she was seeking clarity on this much earlier than 2024.

21. As we know Ms O was aware of this diagnosis and was questioning it in July 2021, we will take this to be her date of knowledge for this aspect of her complaint. To be within our time limit, Ms O needed to have complained to us within a year of July 2021. Ms O complained to us about this in March 2025, more than 3 years later. This means the complaint about the misdiagnosis is out of time by around 2 years and 8 months.

22. During our telephone call and emails, Ms O explained she had concerns about the Trust’s lack of mental health support from as early as 2015, the year after she was referred to them. She felt they did not offer therapies as she expected, or if they did the course of therapy sessions were too short and did not go on long enough to help her in any way and she just felt abandoned.

23. I asked why she waited until February 2024 to raise her concerns with the Trust and if anything had changed in her circumstances for her to be able to do so. Ms O says her mental health got progressively worse over that time and she ‘does not really know’ why she did not complain to the Trust until February 2024 but feels it could be because she had the help of an advocate by that point.

24. The records from 28 May 2015 labelled ‘review of therapy’ show Ms O had an in-person meeting with a psychotherapist in which she let Ms O know the CAT therapy would be stopped. The notes show she immediately became angry and defensive and asked to see the manager of the department. At this point she was given contact details or who to write to with her concerns, but it appears she did not follow through with this.

25. We have seen evidence on our case management system Ms O contacted us about a separate complaint regarding a different Trust and we can see she had made this complaint to that Trust in July 2023. There does not appear to have been an advocate involved in helping Ms O with this other complaint.

26. As Ms O demonstrated she was able to progress her other complaints during this time, we can see no reason she could not have made her complaint to the Trust about her concerns about the lack of mental health support and her perceived misdiagnosis earlier. Had she felt the need, she could have sought help from an advocate earlier than she did.

27. Ms O complained to the Trust about its lack of mental health support in February 2024 and the Trust sent its final response on 10 February 2025, following an initial response and local resolution meeting. Ms O complained about her misdiagnosis on 10 July 2024 and the Trust sent its response to this on 10 February 2025. Even if we put the time taken for local resolution to conclude to one side, Ms O’s complaint is still significantly outside of our time limit.

28. We consider Ms O could have complained sooner about the discontinued therapies and as early as 2015 when she first became aware she was unhappy with the service the Trust was providing. We also consider she could have complained sooner about her BPD diagnosis, as early as 2021/2022.

29. She says her circumstances over the years have not changed and her mental health has just progressively deteriorated since before she was even referred to the service in 2014. She says she was unhappy throughout the period from 2015 to 2024 when she faced a continual lack of support from the Trust. We can see she complained to another organisation about a different matter in July 2023 and brought that complaint to us in February 2024, at the same time she decided to complain to complain to this Trust about mental health support.

30. Ms O submitted her complaints to the Trust years after she became aware she had reason to complain. We have seen no strong reason to set aside our time limit on these parts of the complaint.

31. Having carefully considered Ms O’s explanations for not complaining sooner, we do not consider there are sufficient grounds to exercise discretion here. For this reason, we will be taking no further action on these parts of her complaint. We understand this decision will be disappointing news for Ms O.

When Ms O called the crisis line on 22 April 2024, the staff member who answered was dismissive towards her 32. Ms O says when she called the crisis line on 22 April 2024, she needed someone to reassure her calmly and to arrange ongoing help, but her crisis was dismissed. She says the crisis line team member who answered the call did not introduce themselves, she felt they were hostile and was dismissive, telling her the crisis line were not there for ‘a chat’. She says she was left feeling invalidated and unsupported in her time of crisis. She feels the Trust complaint response dismissed this and that it was not taken seriously at all.

33. In its complaint response, the Trust says it listened to the call and learned from it as a result. The Trust says the call handler fell far short of the expectations it has for those in contact with service users in crisis. It says it profusely apologises Ms O was made to feel dismissed and unheard and this should not be the experience of anyone calling the crisis line.

34. The Trust agreed that it would take the call recording to the call handler’s supervision with her senior and would use this time to encourage her to reflect on what she could have done differently so that nobody else is left feeling the way Ms O was. It says it will be offering further training to the call handler to better equip herself to answer calls. The Trust also says Ms O’s feedback has prompted it to reflect, and it would be auditing calls more regularly in the coming weeks to ensure all staff consistently meet the standards it expects.

35. We have considered the NHS resolution guidance which says an apology should show sincere regret that something has gone wrong, or where services had an unfair impact, and take responsibility for this.

36. We have also referred to our Principles of Good Complaint Handling. These Principles state that organisations should view complaints as an opportunity to develop and improve services. They state organisations should openly identify where things have gone wrong, or where services have had an unfair impact, and take responsibility for this.

37. We can see the Trust has acted in line with NHS resolution and Our Principles in providing sincere apologies and taking action to improve its service.

38. Our role at the Ombudsman is to look at whether organisations have put right the claimed injustice as a result of any failings. As an outcome to her complaint, Ms O wants apologies and service improvements. We recognise Ms O is also seeking financial remedy and have given consideration to this.

39. Ms O says this incident left her feeling invalidated and unsupported in her time of crisis.

40. Our guidance on financial remedy contains our severity of injustice scale. This scale contains six different levels of injustice that a complaint could fall into, which increase in severity. Each level is then linked to a range of the financial amounts we would usually recommend in those circumstances.

41.We believe the impact Ms O experienced from this incident does not exceed level 1 of our severity of injustice scale which says these types of injustice are caused by a one off incidence of service failure, where the effect on the person is of short duration, and where there are no other adverse effects or ongoing wider impact.

42. We consider this to be a one-off incident and the effect on Ms O was short lived and did not have any adverse ongoing effect. Ms O complained to the Trust about this the day after the incident happened, and the Trust promptly acknowledged failings and apologised less than three weeks later.

43. We consider the prompt remedial action taken by the Trust to apologise and implement further training and call auditing is a reasonable and proportionate remedy. The actions the Trust has taken as a result of this complaint are in line with Our Principles and Our severity of injustice scale, and we would not recommend any further action. Based on this we will take no further action on this part of the complaint.

The Trust inappropriately referred Ms O for psychodynamic therapy in February 2024 and she then had to wait 6 months to then be told it was not suitable

44. Ms O says she agreed to be referred for psychodynamic therapy in February 2024, and then when it came to the first session in July 2024, she discovered it was unsuitable as she did not feel comfortable talking about her past and the therapist would be silent and this was not helpful for her.

45. Psychodynamic therapy is a therapeutic approach that focusses on understanding how unconscious thoughts and past experiences shape current feelings, behaviours and relationships. It emphasizes exploring early life experiences and their impact on present-day self-perception and interpersonal dynamics. The therapeutic relationship is also a key component, as it helps individuals gain insight into their emotional struggles and patterns. Overall, psychodynamic therapy aims to bring awareness to the unconscious processes that influence behaviour, facilitating personal growth and emotional healing.

46. Dynamic Interpersonal Therapy (DIT) is a time limited, structured psychotherapy typically delivered over 16 weekly sessions. It focuses on understanding emotional patterns and relationships to treat mood disorders such as depression and anxiety. DIT is designed to help individuals change their patterns of interactional behaviour, thereby improving their social functioning. It draws on psychoanalytic and psychodynamic principles, making it a semi structured treatment protocol.

47. DIT involves periods of silence to allow the patient to process their thoughts and feelings. DIT therapists often use a non-directive approach, allowing patients to lead the conversation and provide space for clients to reflect on their experiences. The aim of this is to help patients gain insight into their emotional patterns and relationship dynamics, which can lead to improved emotional regulation and better coping strategies.

48. The records show Ms O called the service on 21 February 2024 saying she was angry at having to wait until July for her assessment and that she did not want psychodynamic psychotherapy to be offered to her. However, the notes show she agreed to a telephone call on 1 July to conduct the initial assessment.

49. The call notes from 1 July telephone consultation with the Trust’s psychotherapist show Ms O spoke for 40 minutes to express her dissatisfaction with the service over the last 10 years and about the ongoing complaints she had with the Trust. She said she did not trust them to respond to her needs appropriately and that she could not talk to someone psychodynamically trained about her longstanding personal concerns and the psychotherapist was unable to agree a way forward with her.

50. A different psychotherapist called Ms O again on 9 July to offer a consultation appointment. They explained the purpose of this was to meet and think about the treatment options available. Ms O said she found psychodynamic psychotherapy ‘disturbing’ and did not wish to see a psychodynamic therapist as she did not want to be with someone who does not ask questions. She agreed to the assessment appointment the following week.

51. Ms O had an assessment appointment by telephone on 18 July. During the appointment, the psychotherapist talked about treatment options and Ms O refused group treatment and psychodynamic treatment. She said she could not attend sessions in person and would not be willing to have video sessions. The psychotherapist explained that would significantly limit what the service could potentially offer. The psychotherapist then talked about the option of DIT. Ms O expressed her dislike for silence in therapy and the psychodynamic approach but with further explanation from the psychotherapist Ms O agreed to try this.

52. The next appointment took place on 1 August 2024 and Ms O talked about her ongoing complaint with the Trust about lack of support over the last 10 years. The psychotherapist tried to bring the conversation round to discussing what type of therapy/support the service could offer.

53. The team had a meeting on 6 August (an assessment workshop discussion). The team decided it should respect Ms O’s wishes not to receive treatment and that she should be discharged from the service. The team felt it would not be possible to give Ms O a recommendation for treatment with the information available. It noted she finds it distressing to think about her past and about her current difficulties and therefore psychotherapy treatment would not be recommended.

54. The psychotherapist called Ms O on the same day to discuss the outcome of the assessment consultation. They explained it had been agreed that psychotherapy would not be helpful to her at that time and recommended she seek practical support via the neighbourhood team.

55. We asked our advisor whether given Ms O’s circumstances and mental health conditions at the time, she was appropriately referred for psychodynamic therapy in February 2024.

56. In 2015 Ms O received the diagnosis of mixed and other personality disorder. Ms O also received a diagnosis of Complex PTSD and potential autism in 2022. Our advisor says this more recent diagnosis should also have informed decisions regarding referral for appropriate therapy. Given this NICE Guidance for PTSD should have been followed.

57. The guidance says

‘consider eye movement desensitisation and reprocessing therapy (EMDR) for adults with a diagnosis of PTSD or clinically important symptoms of PTSD’

It also says

‘consider supported trauma-focussed computerised Cognitive behavioural therapy (CBT) for adults with a diagnosis of PTSD or clinically important symptoms of PTSD who have presented more than 3 months after a traumatic event if they prefer face-to-face trauma-focused CBT or EMDR as long as:

• they do not have severe PTSD symptoms, in particular dissociative symptoms and • they are not at risk of harm to themselves or others.

58. Our advisor says as the previous diagnosis of personality disorder was still on record the addition of dialectic behaviour therapy (a form of CBT) should have been considered. Although this is a treatment specifically for borderline personality disorder, the mixed or other diagnosis contains a reference to borderline features which should have led to consideration of this type of therapy.

59. Our advisor says that although psychodynamic psychotherapy has its place it is not a first line treatment for these clearly identified presenting problems (PTSD and OCD and possible personality disorder respectively).

60. NICE guidance is clear that CBT or EMDR should have been offered for PTSD. Within the records, there is no clear rationale for offering psychodynamic approaches instead of CBT or EMDR particularly as the Ms O was clear that CBT had been useful for her in the past (2013) when support was discussed in 2024. We consider the decision to refer Ms O for psychodynamic psychotherapy was not in line with the NICE guidance.

61. Ms O says the prolonged lack of support has had a lasting negative impact on her wellbeing. She feels isolated, abandoned and unsupported and her mental and physical health continue to decline leaving her in repeated crisis.

62. We consider the indications of failings we found will likely have contributed to the impact she describes. Our advisor said the failure to provide EMDR or CBT for her presenting problems would have meant that her psychological distress she was experiencing would have been prolonged. Our adviser also said Ms O would likely have benefitted from a referral to a specialist CBT therapist who is experienced in delivering treatment for complex PTSD and OCD.

63. Ms O was referred for psychodynamic therapy in February, and she was told in August that psychotherapy would not be helpful to her and recommended she seek practical support via the neighbourhood team. Therefore, we consider the duration of this impact to be approximately six months whilst she waited to be told the therapy would not be helpful for her. After this, she was advised to seek further support from the neighbourhood team, so she did have a means to access support or request more appropriate therapy.

64. Ms O would like an apology, service improvements and financial remedy.

65. Our Principles for Remedy say where maladministration or poor service has led to injustice or hardship, public bodies should try to offer remedy that returns the complainant to the position they would have been in otherwise. If that is not possible, financial remedy should compensate them appropriately.

66. An appropriate range of remedies will include: an apology, explanation, and acknowledgement of responsibility, remedial action or financial compensation, or any combination of these.

67. We asked the Trust whether it would be willing to provide an apology letter to Ms O for being incorrectly referred for psychodynamic therapy and for the impact this caused and provide explanations of how service improvements will be made in this respect. As well as this we asked the Trust if it would pay Ms O a financial remedy of £600. The Trust agreed to this.

68. Our guidance on financial remedy says:

Level 3 £600 - £1200 - Level 3 cases would have a moderate impact on the person affected (for example, in terms of distress, worry or inconvenience). For a case to be level three, that impact would usually have been experienced over a significant period of time (6 to 12 months). A case may also be level three if the impact on the person affected was significant but was only sustained for a short period of time.

69. We think the lower end of level 3 financial remedy is appropriate as the impact to Ms O was sustained over a six-month period.

70. We consider the Trust has agreed to provide an appropriate resolution, in line with Our Principles of Remedy, and as such, we will take no further action on Ms O’s complaint. We are sorry to hear about her distressing experiences with the Trust. Complaints give us a valuable insight into the organisations we investigate, so we would like to thank Ms O for sharing her experience with us.

1. We have carefully considered Ms O’s complaint about the Trust. We were sorry to hear about her concerns and distressing experiences.

2. We have decided the first three parts of her complaint about discontinued therapies and misdiagnosis fall outside of our time limit. We have seen the Trust has already acknowledged and apologised regarding her complaint about her call to the crisis line. In view of this we have decided no further action is needed on this part.

3. In relation to the last part of Ms O’s complaint about her referral for psychodynamic therapy, we have decided the Trust has now done enough to resolve this as it agreed to provide a letter of apology, explanations of service improvement made and financial remedy of £600. As such, we will not consider this complaint any further.