Norfolk and Suffolk NHS Foundation Trust

5. Mr L complains about care and treatment the Trust has provided for his mental health between July 2023, and the end of 2024. In particular Mr L complains the Trust: • failed to make a referral to autism and complex emotions services.

• did not provide a care coordinator • did not follow recommendations made by a third party therapist • did not provide adequate support during a mental health crisis.

6. Mr L tells us he has struggled with his mental health for many years and feels the lack of support from the Trust has meant he has struggled to recover. He has struggled to maintain employment. This has also affected his personal relationships.

7. Mr L would like an apology, the Trust to acknowledge and take accountability for the mistakes it made and financial remedy.

8. In summer of 2023 Mr L received a letter from his psychologist which said he had complex PTSD, and suspected autism. The letter said that a specialist service needed to diagnose autism. The letter advised he was to be referred for additional therapy and an autism assessment.

9. At the end of 2024 Mr L contacted Autism Norfolk for an update on his referral. He expected a delay of up to 4 years which is why he waited till then. They informed him they had not received such a referral.

10. He was given therapy sessions with a third party provider ‘HelloSelf’ which ended in mid 2024. This therapist recommended the Trust give him a psychiatric diagnosis and asked if the autism assessment could be given sooner.

11. Mr L finished his sessions but had no communication from the Trust regarding further assessments or a care coordinator.

12. The Trust informed him they had no capacity to offer further support, and would refer him to Complex Emotional Needs pathway. He was later told that there was no record of this referral.

16. 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 we have not seen any indication that something has gone wrong for most of the issues Mr L has brought to us. We have explained our decision on each point below.

Failed to make a referral to autism and complex emotions services.

17. Mr L complains that the Trust failed to arrange a referral to autism services.

18. The NICE Autism guidelines says clinicians should consider autism assessment when an adult has care autistic features plus functional difficulties such as problems sustaining employment or relationships, has had previous contact with mental health services, or a history of neurodevelopmental/mental disorder, and difficulties in social interaction, communication or stereotypic behaviours, resistance to change or restricted interest. A person should be offered a comprehensive autism assessment if clinical judgement suspects autism or if a Autism Quotient-10 (AQ-10) screening is positive. The AQ-10 is a quick self reporting questionnaire used by clinicians to identify if an adult needs a formal comprehensive diagnostic assessment for Autism.

19. The GMC Guidelines say that practitioners should give patients information the want or need to know in a way they can understand. It also says that they should share all relevant information with colleagues involved in patient care, and check when practical that a team has taken over responsibility when their role has ended.

20. We can see that Mr L attended an appointment in summer 2023. A letter following this appointment detailed that he had scored 8/10 on the AQ-10 screening which indicates an assessment was appropriate. The letter also says that a referral to Autism Norfolk had been completed. There is no indication in the records that the Trust completed this referral.

21. Further, our adviser has said this was the incorrect referral pathway. The correct pathway was for Mr L’s GP to refer him to Psychiatry UK. We cannot see that Mr L was given the correct information in 2023, and there was no communication, that we can see, with the autism service about his referral.

22. In the summer of 2024 the records show that Mr L had a further review with mental health services. He then sent emails to the mental health service which discuss autism referrals and websites the Trust provided.

23. Our adviser has said that Psychiatry UK was the provider for Mr L’s area at this time. They have said that a GP referral was required for Psychiatry UK to provide an assessment.

24. We cannot see that this information was communicated to Mr L, until the link to Psychiatry UK was sent to him in the summer of 2024.

25. Mr L told us he had expected to wait around 4 years for an appointment with autism services. It is understandable that Mr L would be frustrated when he realised the referral he had been waiting for over a year had not been sent. He has also mentioned that this caused him to lose trust in the mental health services.

26. It appears that after the correct information was provided to him in 2024, he was open to autism services and was being supported. Therefore whilst we can see he waited a year for a referral that had not been made we are pleased to note the speed of services here means he has not experienced additional wait beyond what he was expecting. For this reason, we do not think the Trust’s error has had disadvantaged his access to autism services.

27. The Trust accepted the failing to refer in 2023. It acknowledged the Trust had since provided the information to Mr L, and he had been open to autism services and was currently being supported. It said it was disappointed to hear of these issues, noted the staff concerned no longer worked for them so they could not add any more explanation, and apologised it could not provide more information on the actions taken at the time. Having reviewed the files we are unable to add any more about whether this was a human error or something to do with their systems at the time. The Trust’s response suggests they believe it may be linked to the staff.

28. Our NHS complaint standards set out expectations for complaint handling. They detail that organisations should see complaints as an opportunity to develop and improve its services and people. It says responses should be fair and accountable, setting out what happened and whether mistakes were made. It should set out how the organisation is accountable and take action to make sure any learnings are identified and used to improve services.

29. We consider the Trust’s response to be in line with our complaint standards. It has apologised to Mr L for the frustration he has felt, attempted to provide an explanation on the evidence it had but has not been able to explain more or undertake further change as the staff are no longer part of the Trust.

30. Mr L also complains that the Trust failed to refer him to a complex emotional needs pathway. The Trust acknowledges the referral to the complex emotional needs pathway was not done but notes they could not see why when reviewing the records.

31. The NICE mental health guidelines say that when referring a patient for an assessment in other psychological services they are supported during the referral period and arrangements for support are agreed beforehand.

32. The Trust completed a review with Mr L in summer 2024. The outcome of this review was the Trust agreed to refer Mr L to a complex emotional needs pathway via MIND. MIND is a leading mental health charity that provides information, support and campaigns for better mental health.

33. There is no evidence in the records that this referral was sent. There is no record of the referral beyond the letter. We are unable to determine the reason why the referral was not sent. It does not appear that the Trust’s actions when referring Mr L to another psychological service is in line with guidelines. We cannot see that the Trust sent the request, or supported Mr L in the referral period.

34. Mr L told us he contacted MIND to follow up on his referral. It informed him the service had not received any referral. However, it also informed him that this referral would be rejected until he had completed the autism assessment process.

35. As above, this is likely to have caused Mr L frustration when he was told the referral had not been received, and added to his mistrust of the mental health services. Whilst it is clear there was a failing in completing the referral, we do not think that the Trust failing to send this referral had any detrimental effect on the mental health support Mr L received as the referral was not being made at the appropriate time and therefore he would not have received any additional support if it had been made.

36. We do note that Mr L is likely to be have been particularly frustrated to find another referral had not been successfully completed, but as we have seen above we are unable to understand why this occurred as there were no records to help us understand.

37. We have gone on to consider the Trust’s response to this issue, and whether it has done enough to remedy the impact of this identified failing. Our NHS complaint standards set out how organisations providing NHS care should approach complaint handling.

38. These standards say that organisations should see complaints as an opportunity to develop and improve its services and people. It says responses should be fair and accountable, setting out what happened and whether mistakes were made. It should set out how the organisation is accountable and take action to make sure any learnings are identified and used to improve services.

39. As mentioned above, the Trust has apologised that Mr L has had cause to raise concerns and the Trust uses feedback to improve the services it provides. It could not find any evidence that this referral was sent. It stated that it could not enquire about the member of staff’s actions as they no longer work at the Trust, but it was disappointed to hear of Mr L’s experience. It explained it would expect clinicians to ensure they had followed the correct referral route. It said that it would ask the team to ensure the referral was completed.

40. We consider the Trust’s response to be in line with our complaint standards. It has apologised to Mr L, it attempted to provide an explanation on the evidence it had. It was not able to provide feedback to the staff directly as they were no longer part of the Trust, but it has explained this. It has also said it would complete the referral that it had failed to do. Whilst we appreciate a second occurrence of a failing of this nature would be frustrating we have no basis to suggest it was anything more than human error.

41. We understand why Mr L felt frustrated when he was told his referrals had not been completed. We hope we have explained why we have decided not to consider this part of his complaint further.

Did not provide a care coordinator or follow recommendations made by a third party therapist.

42. Mr L complains he was not given a care coordinator, even though this was recommended by his third party therapist.

43. Our adviser has said there are no specific guidelines on when a care coordinator should be allocated.

44. The NICE mental health guidelines say that any changes in care, such as discharge, are discussed and planned carefully beforehand. There should be a care plan in place that supports effective collaboration with other care providers.

45. We can see that when Mr L finished his allocated therapy sessions, the Trust held multidisciplinary meetings to discuss his treatment, the recommendations included in the third party therapist’s report, and what could be offered to Mr L going forward. The recommendation from the third party was that Mr L was to be allocated a care coordinator due to the complexity of his presentation and several agencies currently involved. The Trust decided that it was not appropriate to allocate Mr L a care coordinator at this time as there were not several agencies involved in his care.

46. Our adviser has confirmed that the discussion of Mr L’s suitability for care coordination was reasonable.

47. It appears the actions of the Trust when considering whether to implement the third party’s recommendation of a care coordinator are in line with guidelines.

48. We understand Mr L was concerned that the Trust was not following the advice of a mental health professional. We hope we have explained why we will not consider this aspect of his complaint further.

Did not provide adequate support during a mental health crisis.

49. Mr L complains that the Trust did not adequately support him with his mental health.

50. The NICE mental health guidelines set out how Trust’s should support a patient in the event of a crisis. The guidelines say that when assessing a patient in crisis medical professionals should provide clear information about the process and its possible outcomes, taking care to understand and emotionally support the patient. The assessment should include the patients relationships, social and living circumstances, level of functioning, symptoms, behaviour, diagnosis and current treatment. The health care provider should provide local 24 hour helplines, ensure that crisis resolution and home treatment teams are accessible.

51. The records show that Mr L’s therapist contacted the Trust to inform them of an incident where Mr L had a mental health crisis, and had intentions to take his own life. The therapist informed the Trust they had spoken with Mr L and he had said he did not feel suicidal anymore, and did not require any further crisis intervention but was keen to continue with his therapy. The therapist was satisfied the risk had been contained.

52. The Trust contacted Mr L and he confirmed he did not need further input.

53. It appears the Trust’s actions when Mr L was in crisis was in line with guidelines. Mr L’s therapist had followed up with Mr L, and supported Mr L after the incident. Mr L informed the Trust he did not require further support, and therefore the Trust did not need to take further action.

54. We understand that Mr L felt unsupported at this time. We hope we have explained why we will not be considering this part of his complaint further.

1. We have carefully considered Mr L’s complaint about Norfolk and Suffolk NHS Foundation Trust. We are sorry to hear of Mr L’s experience and the distress and worry this has caused him.

2. We have seen an indication of a failing when the Trust failed to refer Mr L to other services. We think the Trust has already done enough to put this right.

3. We have not seen an indication of a failing in how the Trust considered Mr L for allocation to a care coordinator which was recommended by a third party therapist. We also have not seen an indication of a failing in the support the Trust gave Mr L when he was in crisis.

4. Because of the reasons set out above, we have decided not to take further action on Mr L’s complaint. We recognise the importance of these matters for Mr L. We hope our explanation below provides him with some reassurance.