Black Country Healthcare NHS Foundation Trust

7. Miss U complains that, despite expressing suicidal thoughts, and without her input, the Trust:

• assigned her four different care coordinators between January and April 2024 and poorly communicated these changes • discharged her from her support time and recovery (STR) worker in April 2024 • discharged her from her psychologist in May 2024, despite there being ten remaining sessions • withdrew its offer and decided not to give her DBT in July 2024 • did not thoroughly assess her for hospitalisation between June and October 2024 • discharged her from her new psychiatrist in October 2024 without prior discussion or completion of a care plan.

8. Miss U complains that her recovery from borderline personality disorder has been negatively affected by these changes. For example, she has not received the tools she needs to regulate her emotions, such as those taught in DBT. She also says her life has been put at risk as she experiences suicidal ideation, and the constant transitions have been unsettling for her.

9. Miss U would like an apology, service improvements, and a financial remedy.

10. Miss U has a history of emotionally unstable personality disorder (also known as borderline personality disorder), anxiety, depression, an eating disorder, self-harm and suicidal thoughts. Borderline personality disorder is a mental health condition where a person experiences intense emotions which can often change and can be hard to control.

11. In November 2023 the Trust admitted Miss U to hospital due to her mental health and discharged her home in December 2023. Miss U was under the care of Trust’s the community mental health team at the time of the events she is complaining about.

Care coordinators

15. Miss U complains that the Trust assigned her four different care coordinators between January and April 2024. A care coordinator helps organise a person’s mental health care and is the main contact for everyone. They are important because they help the person stay supported and engaged.

16. While Miss U understands and fully empathises that staff sickness and turnover can happen, she feels the Trust used this as an excuse and failed to manage the situation properly.

17. She says the Trust told her there would be a transition meeting with her new care coordinator and her previous care coordinator, which she thinks would make the transition easier. However, this meeting never happened. Instead, Miss U tells us new care coordinators frequently contacted her unexpectedly.

18. During this period, Miss U explains she felt unsupported, confused about who her point of contact was. She was also disappointed by the absence of continuity in her care. She explains this matters even more because the Trust knew she finds change difficult to manage.

19. The Trust acknowledged that unfortunately there were several changes in Miss U’s care coordinators due to staff sickness and staff leaving for other roles.

20. NICE is the organisation which writes guidelines on best practice in health care. NICE guidelines say services should make sure transitions are ‘discussed carefully beforehand […] and are structured and phased’.

21. Our adviser highlights there is a significant national shortage of qualified mental health staff. As the Trust has explained this was the reason for the frequent changes in care coordinators it may be difficult for the Trust to comply with the NICE guidelines.

22. Miss U’s clinical records support her account that the Trust allocated her four different care coordinators between January and April 2024.

23. In January the Trust sent Miss U a letter explaining her care coordinator would be changing and her new care coordinator would contact her. After this Miss U’s care coordinator attended a medical review with her. At the end of January, the Trust cancelled the joint meeting with her current and new care coordinator as her new care coordinator was no longer available to attend.

24. Miss U’s new care coordinator then contacted Miss U to arrange a meeting at the beginning of February. They agreed to meet again in March. The Trust sent Miss U a letter in February telling her that her care coordinator had changed again and her new care coordinator would contact her. Two days after this letter Miss U’s new care coordinator called her and apologised for the impact the staff changes had had.

25. Unfortunately, in March her new care coordinator went on sick leave and in April the Trust sent Miss U a further letter telling her of another change. Her new care coordinator contacted her a week later to arrange their first appointment at the end of May. In this respect the Trust made efforts to act in line with NICE guidelines by notifying Miss U.

26. We recognise that ideally Miss U would have had one care coordinator. At the same time, we acknowledge due to unforeseen circumstances and constraints on the Trust’s resources unfortunately this was not possible.

27. We do not think the unavoidable changes in staff indicates a failing on the Trust’s part.

28. We have considered if, in line with NICE guidelines, the Trust tried to manage Miss U’s expectations and communicate these changes with her.

29. We note the Trust did not rearrange the meeting to discuss the first change of care coordinator. There were gaps in the Trust returning Miss U’s calls in January and in March there were gaps in the Trust updating Miss U about the availability of her care coordinator. We appreciate how such a disruption can impact someone’s confidence in their care.

30. However, we note that Miss U’s records show the Trust wrote to Miss U before or soon after each change in care coordinator and provided a duty service for Miss U to contact in the meantime. Also, during this time, the Trust continued to offer Miss U ongoing support from other professionals such as a psychologist, the eating disorder service and an STR worker.

31. Overall, we do not think this amounts to a failing. We also note the Trust apologised to Miss U for the distress caused by experiencing multiple changes in care coordinators.

STR worker

32. An STR worker supports people with mental health conditions by providing companionship and helping them live independently. For example, they can help people make lifestyle changes or find community groups to participate in. They are important for building a person’s confidence, reducing isolation, and guiding recovery.

33. Miss U complains the Trust discharged her from her STR worker in April 2024. She feels she faces many daily challenges which a support worker can help with such as managing finances, as well as social and physical health.

34. The Trust says it discharged Miss U from her STR worker as it identified that there was no further role for the STR worker in her care.

35. In our review of Miss U’s records we can see she had a telephone conversation and two meetings with the STR worker. The STR worker introduced themselves in the first phone call and arranged a meeting. In the meeting the STR worker agreed to help Miss U with her voluntary work referral. They agreed to create a safety plan in the next meeting.

36. During the next meeting the following week Miss U’s records says she was in a low mood and was experiencing thoughts about suicide and self-harm. The STR worker discussed coping strategies with her. Miss U’s records say she felt there was nothing she had not tried and she wanted the Trust to admit her to hospital.

37. Miss U’s records say the Trust then discussed her case at a multidisciplinary team (an MDT) meeting. An MDT is a group of professionals from different fields working together to make holistic decisions about someone’s care.

38. Miss U says her records do not reflect what happened. She says her STR worker spoke to her psychiatrist who recommended referring her to the home treatment team and starting the hospital bed assignment process but no one followed this up.

39. The Trust decided Miss U had ‘exhausted all of the goal setting options’ and this was the reason it discharged her from her STR worker. Miss U’s records say the STR worker then called Miss U the week after to tell her they were not going to be her STR worker anymore. They explained the Trust did not feel she needed an STR worker and highlighted she had lots of other support from the Trust and her mother and brother. Miss U says this phone call did not happen.

40. It appears that in her final appointment with the STR worker Miss U was discussing her challenges with her mental health and how she felt at the time she had exhausted options for coping. We note the MDT concluded that Miss U was being supported with her mental health by her psychologist and family.

41. Our adviser tells us there is no specific guidance on STR workers.

42. The NHS Constitution sets out the NHS’ values and explains that the NHS promises to be open and transparent about its decisions, so people can understand how services are run.

43. We are unclear what the goal setting options were nor why the Trust felt having other support from the Trust and her family meant there was no role for Miss U’s STR worker. Miss U’s circumstances had not changed so it does not seem there is a clear rationale about why the Trust initially provided Miss U with a STR worker and then decided she did not need one.

44. She says she repeatedly tried to contact her STR worker to understand the change and discuss her options but was unable to speak to them. She is concerned this happened at a similar time to her making a formal complaint about the Trust. While we cannot determine why the Trust made its decision, we understand Miss U’s concern.

45. In line with the NHS Constitution, NHS discharge decisions should be transparent and evidence based. Patients should understand the rationale for discharge. A lack of clear rationale prevents a patient from understanding why care ended. Without this information it is not possible to verify that the discharge decision was appropriate.

46. For this reason, we have decided there is a failing in the Trust not providing a clear rationale for discharging Miss U from her STR worker in April 2024. We will address the effect of this in the ‘impact’ section below.

Discharge from psychologist

47. We went on to consider Miss U’s concern that the Trust discharged her from her psychologist, in May 2024, despite there being ten remaining sessions.

48. The Trust says it discharged Miss U due to inappropriate and abusive behaviour. Its examples were her covertly recording the session, attempting to entrap the psychologist, and acting in a coercive and intimidating manner by refusing to leave the room. It cites its zero-tolerance policy towards such behaviour.

49. The incident report refers to Miss U being ‘very angry and confrontational about her care’ and an impression she was trying to record a session.

50. The report says, ‘Her questioning became overly insistent, critical, cross examining and threatening in tone and content leading me to feel increasingly uncomfortable and distressed’. The report says the psychologist wanted to end the session but Miss U refused to leave.

51. Miss U denies recording the appointment, refusing to leave, or being rude, abusive, or aggressive. She says the Trust has no evidence to support its claims. She highlights the Trust’s discharge letter made no reference to these claims and that the Trust did not send her a zero-tolerance letter. She told us this experience left her feeling confused.

52. We could not find a zero-tolerance letter in Miss U’s records so we approached the Trust about this. It confirmed the letter it is referring to is the one to Miss U from her psychologist discharging her from the service.

53. We have reviewed this letter. It says, ‘As a result of the difficulties that occurred in your last session I [the psychologist] no longer feel that it is appropriate or productive to continue to offer you any further sessions with psychology.’ This letter gives no description of Miss U’s behaviour in the appointment and does not contain a warning to Miss U.

54. The Trust’s management of violence and aggression policy says after giving a verbal warning to someone who is acting unacceptably the Trust should give them a written warning.

55. The policy includes an example warning letter which says the Trust will continue to provide support if the person is no longer verbally aggressive or threatening.

56. The Trust’s policy says the Trust can consider discharge from services ‘Following incidents of violence or aggression’. This wording along with the wording of the example warning letter suggests in most cases there would need to have been more than one incident for the Trust to consider discharging someone from its services.

57. Miss U’s and the psychologist’s account of what happened are conflicting and as we were not present during this appointment it is difficult for us to impartially conclude exactly what happened.

58. We acknowledge that in its discharge letter to Miss U’s GP, Miss U’s psychologist commented that Miss U had had 60 sessions which were ‘only partially successful’. This is different from the reason the Trust gave Miss U in June and when she complained to the Trust about it. The Trust told Miss U her behaviour in her last session with the psychologist was the reason it discharged her from her psychologist. It gave her no other reason.

59. It is reasonable to say Miss U’s behaviour was the reason it discharged her from her psychologist. This is because this is the reason the Trust gave at the time, and in its formal response to Miss U’s complaint a year later. Also, the psychologist had not previously discussed a plan to end Miss U’s psychology sessions early.

60. We know Miss U had an established relationship with her psychologist after having 60 sessions with them. We appreciate the psychologist left the appointment feeling uncomfortable and distressed. They believed Miss U’s behaviour warranted action under the Trust’s management of violence and aggression policy.

61. We have considered whether the Trust acted in line with this policy. After this one incident the Trust immediately discharged Miss U from her psychologist without a warning letter. This is not in line with the steps recommended in the Trust’s management of violence and aggression policy.

62. Our decision is there is a failing in the Trust discharging Miss U from the psychology service in May 2024 without warning. We will address the effect of this in the ‘impact’ section below.

DBT

63. We next considered Miss U’s complaint that the Trust withdrew its offer and decided not to give her DBT.

64. DBT teaches skills like mindfulness and distress tolerance and it can help people to manage intense emotions. Miss U says she was willing and eager to engage in DBT and the thought that she would be able to have DBT gave her hope that she would learn ways to cope with her mental health.

65. The Trust says it offered Miss U one to one psychology appointments instead of DBT. It explains during these sessions Miss U’s psychologist helped her to internalise DBT based coping skills for her emotional instability.

66. The Trust says Miss U was very familiar with DBT techniques, wrote her own notes from a DBT book and was very knowledgeable about them. It explains sometimes it is safer and more effective to explore such complex difficulties within a long term and consistent one to one therapy relationship.

67. Miss U’s records show in April 2024 she asked to go on the waiting list for DBT.

68. Miss U says her records do not reflect what happened. She says she initially asked her STR worker for an update on her referral for DBT because she believed she would be getting DBT. When her STR worker said they were not sure about this she asked if she could go on the waiting list. Miss U says the STR worker told her they would do this because the DBT manager said they would be happy to have her after her sessions with her psychologist had ended.

69. Her records describe how her support worker told her they would discuss with an MDT whether she could be referred for DBT. Miss U says it was the psychiatrist rather than her STR worker who said this.

70. Miss U’s records in July show she asked her consultant psychiatrist and later her community psychiatric nurse if she could have DBT. They agreed to discuss with the DBT lead if it would be appropriate for her. The Trust’s MDT notes from the beginning of August 2024 say it decided Miss U did not meet the criteria for DBT and had not had enough time between being discharged from her psychologist in May 2024.

71. NICE guidelines say treatment for borderline personality disorder depends on a person’s specific circumstances and queries about specific treatment and options should be discussed with a member of the healthcare team.

72. In line with this, we can see evidence the Trust considered whether DBT would be appropriate for her. Our adviser tells us that the reason the psychiatrist gave to Miss U in October 2024 (after the decision had been made in August) that Miss U ‘needs time to process and use the skills in psychology before referring again’ is clear and clinically appropriate.

73. NICE guidelines indicate that people with borderline personality disorder should be offered therapy tailored to their needs. We would expect this to include thinking about any therapies the person has already received. It appears DBT is not a guaranteed treatment and whether it is the right treatment for someone depends on their individual circumstances and the clinical judgement of the healthcare team.

74. Our adviser explained that completing 60 sessions of psychotherapy shows Miss U’s willingness to engage with her recovery. Miss U understandably may have expected DBT to be the next step and it is completely valid for her to feel disheartened by the Trust’s decision.

75. We recognise Miss U believed the Trust offered her DBT. As we were not present for the discussions we cannot be certain what was discussed. The records suggest the Trust considered DBT as a potential option. We have not seen evidence the Trust ever made a formal offer of DBT which it withdrew.

76. We have concluded there is not a failing in this part of the complaint. We have not seen evidence to show the Trust withdrew an offer of DBT in 2024. Also, we do not think the Trust’s decision not to give Miss U DBT at that time was wrong.

Hospitalisation

77. Being detained under the Mental Health Act is where healthcare professionals keep someone in hospital without their agreement because they need treatment for a mental health condition and are at risk of harm to themselves or others.

78. NICE guidelines recommend the community mental health team should work on managing crisis in the community and that hospitalisation for people with borderline personality disorder should be avoided as much as possible. This is because it can potentially worsen symptoms of the disorder.

79. Miss U complains the Trust did not thoroughly assess her for hospitalisation between June and October 2024. Miss U says she told the Trust she was suicidal and wanted to be hospitalised but the Trust did nothing to mitigate her suicide risk. The Trust says regular outpatient appointments would indicate whether hospitalisation was required.

80. NICE guidelines say people with borderline personality disorder should be supported by the community mental health team. Hospitalisation should be rare and alternatives should be explored first. They recommend healthcare professionals should only consider admitting someone to hospital if they need to be detained under the Mental Health Act or if managing a mental health crisis involves ‘significant risk to self or others that cannot be managed within other services’.

81. Between June and October Miss U reported thoughts of, or actual self-harm to the Trust on several occasions.

82. For example, in an appointment in June she said she reported self-harming in the previous week in response to intense feelings. Miss U’s records say she did not have further thoughts of self-harm at that time. She felt hopeless and had suicidal thoughts but was waiting for her mother to return to work before carrying out any plans. Her mother kept extending her leave from work.

83. Miss U’s records say in a call to the crisis team later that month Miss U reported thoughts of self-harm due to muscle pain. Her records say the crisis team agreed a plan for Miss U to collect a new increased prescription of painkillers from the pharmacy. They also planned for her care coordinator to call her the following day to check she had received her prescription.

84. Her records say her care coordinator called her as planned and she had collected her prescription and was with her mother, anticipating her family visiting. Miss U says her records are incorrect and she did not call the crisis team about muscle pain and her care coordinator did not call her.

85. In an appointment in July Miss U reported having self-harmed since her last appointment but having no thoughts of self-harm at that moment. She reported ‘fighting’ these thoughts when they did occur. Miss U created a safety plan describing ways she can lift her mood and people she can go to for support. Her care coordinator also provided her with contact details for out of hours mental health support.

86. During Miss U’s appointment with a consultant psychiatrist in July, they identified she had chronic suicidal thoughts. They noted no active suicidal thoughts or intent and no concern of risks towards others.

87. Miss U’s records say in August she had an appointment with her care coordinator following a call to the crisis team. In this appointment Miss U discussed an increase in self-harm and that she had a suicide plan. They discussed using strategies from her safety plan and the contact details for the crisis team, emergency services and community mental health team.

88. Following this Miss U asked to speak to someone other than her care coordinator as she felt unsupported. A doctor called her and discussed with her how her suicidal thoughts had increased and she did not feel the Trust was managing her suicidal thoughts. The doctor arranged for the crisis team to contact her over the weekend.

89. After disclosing in August that she had visited a location for her suicide plan but did not carry out the plan, the Trust’s home treatment team assessed Miss U. A home treatment team provides intensive mental health care to people in their home to help them manage a mental health crisis and avoid being admitted to hospital.

90. At the time of the assessment the home treatment team did not identify any psychotic symptoms or active suicide plans. The team decided Miss U would be best supported by the community mental health team instead.

91. Miss U says this did not happen. She says the home treatment team said they would request her care coordinator see her more frequently. She says she saw her care coordinator no more frequently than usual and no change was made to mitigate any risks.

92. In September Miss U spoke to her care coordinator about her suicidal thoughts but did not disclose any active plans. They discussed things she could do to distract herself from these thoughts and the availability of crisis support. Throughout this time, she was also discussing her feelings with an eating disorder specialist and working on self-compassion.

93. At the beginning of October, the police detained Miss U under the Mental Health Act after she called the crisis team threatening to carry out her suicide plan. After a mental health assessment, she was discharged the same day as she reported no longer feeling suicidal. She did not want to be admitted to hospital, agreed to support from the home treatment team and to contact the mental health team if her mental health deteriorated.

94. The home treatment team visited and called Miss U in October. In its risk assessments it found she continued to have suicidal thoughts. Her records say she shared no active suicide plans during the assessments and the team advised her to seek additional support if needed. Miss U says her records are incorrect and she did share active suicide plans during the assessments.

95. At the end of October following Miss U disclosing a suicide plan on two occasions the Trust conducted two mental health assessments. Miss U’s records say after the first one it decided it would not admit her to hospital. Her records say this is because Miss U was no longer feeling suicidal during the assessment. She said she was able to keep herself safe at home. Miss U says she did not have this assessment because she left the hospital to get food and medication once the police left her.

96. It was only during the second assessment when Miss U disclosed she did not think she could keep herself safe at home. After that assessment the hospital staff admitted her to an acute mental health unit.

97. Our adviser told us although Miss U presented with suicidal thoughts, actual self-harm was rare. This means in-patient admission is unlikely to have alleviated risk significantly. It puts more weight on the potential for harm of admission to outweigh any benefit.

98. NICE guidelines acknowledge that people with borderline personality disorder are very likely to experience suicidal thinking and self-harm. These guidelines do not say that these behaviours automatically mean someone requires hospitalisation. In fact, they recommend hospitalisation only as a last resort.

99. It is very clear Miss U thinks the Trust did not take her risk seriously and we are sorry to hear that. We appreciate that feeling unheard is incredibly difficult.

100. Our decision is the Trust did adequately assess Miss U in line with NICE guidelines. We have determined there is not a failing in the Trust’s assessment of Miss U for hospitalisation between June and October 2024.

Discharge from psychiatrist

101. Miss U complains the Trust discharged her from her new psychiatrist in October 2024 without prior discussion or completion of a care plan.

102. The Trust explains a care plan was already in place and Miss U may have been unprepared for the discharge due to missed appointments with her care coordinator.

103. Miss U says she did not miss any appointments with her care coordinator before October. She says she saw her care coordinator as usual and they did not mention discharge until she was discharged in October.

104. NICE guidelines say healthcare professionals should discuss discharge beforehand. They should expect this might bring up strong emotions for people with borderline personality disorder and discharge should be ‘structured and phased’.

105. NICE guidelines say when discharging someone back to their GP, healthcare professionals should agree a care plan. This should set out how someone can manage their distress, and how to cope with a future mental health crisis. It should also explain how to seek support from the community mental health team if needed.

106. In the appointment with the psychiatrist, they concluded that Miss U ‘wants to get better, and the Trust has given her extensive care and support over the years to achieve that.’ Our adviser told us the Trust’s reason for discharge was clear and comprehensive.

107. We can see in summer, after it stopped her psychology sessions, the Trust had planned to eventually discharge Miss U.

108. Contrary to NICE guidelines, we have seen little evidence that the Trust completed a care plan with Miss U or that it communicated the plan to discharge Miss U before it did so at the beginning of October. We can understand how this was sudden for Miss U and we think considering the NICE guidelines the Trust should have managed this more gradually.

109. Miss U’s records show the Trust formally discharged Miss U at the beginning of October. This is evidenced in the discharge letter her psychiatrist sent to her GP at the same time. While the Trust later offered Miss U an appointment with her care coordinator to create a care plan this was at the end of October after the Trust had formally discharged her. Miss U did not attend this appointment.

110. We have decided inviting Miss U to complete a care plan after discharge does not meet the principle of proactive and collaborative care planning recommended in NICE guidelines.

111. While the Trust gave Miss U the opportunity to create a discharge care plan, owe have decided there is a failing in the Trust not discussing the discharge with her in advance. It also appears it did not complete a care plan before discharging Miss U from her psychiatrist in October 2024.

Impact

112. Miss U considers the Trust’s actions have negatively affected her recovery from borderline personality disorder.

113. We recognise how sharing these kinds of experiences is not always easy. We appreciate how open Miss U has been with us about how her experience has affected her. We have carefully considered what Miss U has told us. Considering her pre-existing mental health condition, we are unable to determine this negatively impacted her recovery.

114. Our adviser explained it is very difficult to say what impact any departures from standards had, beyond causing distress, which may have happened anyway as it is a core part of Miss U’s borderline personality disorder.

115. We do not have any impartial evidence to show what Miss U’s recovery would have looked like had the Trust managed her discharges differently. Because of this we cannot reliably isolate the effect of the failings we have identified.

116. We also considered how Miss U says her life has been put at risk as she experiences suicidal ideation. We cannot be certain, if the failings had not occurred, Miss U would not experience any suicidal ideations or that her recovery from borderline personality disorder would be different. This is because NICE guidelines are clear that harming yourself or thinking about harming yourself are common symptoms of borderline personality disorder.

117. From reviewing her records, we note that Miss U was experiencing suicidal ideations throughout the time that support from her STR worker, psychologist and psychiatrist were in place and before she was discharged from them.

118. Miss U explained that the constant transitions have been unsettling for her. We recognise suddenly discharging Miss U from her psychologist and not discussing discharging her from her psychiatrist before October and not providing a clear rationale for its decision to discharge her from her STR worker, was undoubtedly unsettling for her.

119. We appreciate Miss U may have experienced distress which is consistent with the nature of borderline personality disorder regardless of the Trust’s actions. However, her distress may have been reduced with better management of the discharge process. This is why NICE guidelines emphasise the importance of carefully planned and well-communicated discharge to reduce the likelihood of exacerbating distress at points where distress can reasonably be anticipated.

120. We have found failings in the Trust discharging Miss U from her psychologist, not providing a clear rationale for discharging her from her STR worker, and not completing her care plan or discussing discharging her from her psychiatrist before discharging her at the beginning of October. We think this contributed to Miss U’s distress which left Miss U feeling unsettled.

121. We can see the Trust has not yet taken any action to address the impact on Miss U. We have decided it needs to take steps to put things right.

1. Miss U has complained about aspects of mental health care the Trust provided to her in 2024. Our decision is there was not a failing in the Trust deciding not to hospitalise Miss U between June and October 2024.

2. We have also not seen failings in the Trust assigning Miss U four different care coordinators between January and April 2024 and its overall communication of this. We have not seen sufficient evidence to show the Trust withdrew an offer of dialectical behaviour therapy (DBT) in 2024 or that it was wrong for the Trust not to give her DBT at that time.

3. We have found failings in the Trust: • not providing a clear rationale for discharging Miss U from her STR worker in April 2024 • discharging Miss U from her psychologist in May 2024 without warning • not discussing the discharge with her in advance or completing a care plan before discharging Miss U from her psychiatrist in October 2024.

4. Miss U has clearly articulated how these issues left her feeling unsupported. We have concluded that these failings will have made her feel unsettled at a time when she was already trying to manage her mental health. As the Trust has not acknowledged this we will partly uphold Miss U’s complaint.

5. We recommend by Thursday 28 May 2026 the Trust apologise to Miss U and pay her £300 in recognition that this experience has caused her to feel unsettled.

6. We also recommend by Thursday 23 July 2026 the Trust writes an action plan to let us and Miss U know what it will do differently to prevent other people having the same experience.