South West Yorkshire Partnership NHS Foundation Trust

5. Miss K complains about aspects of the care and treatment she received at The Charity and SW Yorkshire Trust between January 2021 and December 2022.

6. Miss K complains between January 2021 and December 2022, The Charity did not adequately refer her to CAMHS and closed her file without appropriate psychological assessments. She also complains the allocation of an emotional health worker in October 2022 was not a suitable intervention.

7. Miss K complains between January 2021 and December 2022, SW Yorkshire Trust failed to accept her onto CAMHS programme until December 2022, and its emotional health worker incorrectly concluded her needs were being met. She says this meant she was not accepted onto the CAMHS programme sooner.

8. Miss K says the delay in accessing CAMHS tier three psychological therapies has resulted in her anxiety worsening and having a significant impact on her daily life and education.

9. Miss K believes she is likely to take these issues into adulthood. She also says the effect of managing her symptoms without support has been extremely difficult for her family

10. Miss K says the frustration and demoralisation from repeated rejections has also been mentally damaging.

11. Miss K is seeking an acknowledgement, apology and financial remedy.

12. In 2014, Miss K was first referred for tier two CAMHS support for which she received one to one support for emotional well-being, help with anxiety and challenging behavioural issues. After this assessment Miss K was referred for tier three CAMHS support. In 2015, SW Yorkshire Trust’s CAMHS declined tier three support and suggested family support was tried before additional referrals were submitted.

13. There were several referrals made between 2014 and 2021 from the family, school and disability services on behalf of Miss K for additional CAMHS support which were rejected.

14. Between 2016 and 2017, Miss K had two autism assessments. In April 2017, Miss K had a neurodevelopmental review and met the criteria for an autism diagnosis.

15. In 2021, two requests for additional CAMHS support were made by local the Charity services on behalf of Miss K. The outcome was CAMHS did not feel there was a mental health need for support at the time.

16. On 7 February 2022, Miss K’s GP made a referral requesting consideration of medication to support her anxiety. The evidence available indicates this referral was considered within the wider Thriving Kirklees partnership arrangements rather than directly by SW Yorkshire Trust’s Core CAMHS team at that stage. A discussion later took place regarding whether there was a role for Core CAMHS support, and it was concluded that support through the Children’s Emotional Wellbeing Service (ChEWS) was the most appropriate intervention at that time.

17. ChEWS provides short-term emotional health and mental health support for children and young people in Kirklees whose emotions are impacting their ability to function or causing them distress daily.

18. On 19 October 2022, The Charity informed Miss K the outcome of the referral process recorded there was ‘no role’ for further specialist CAMHS involvement at that stage.

19. On 15 November 2022, West Yorkshire ICB (formally Kirklees Clinical Commissioning Group – CCG) said it would undertake a full complex case review.

20. In December 2022, Miss K was accepted for CAMHS support. In February 2023 Miss K was seen by specialist at CAMHS and in May 2023 she had a psychiatric review and prescribed medication.

The Charity Referral History

21. The Charity received a family referral on 27 July 2014 regarding Miss K’s behaviour and concerns of social isolation and anxiety. This referral was closed on 1 December 2014 with ten counselling sessions provided.

22. On 21 September 2015, The Charity received a referral from Miss K’s school regarding Miss K’s self-harming, bedwetting and violent interactions with siblings.

23. This referral was closed on 30 September 2015 as The Charity considered there was appropriate support in place through the school. This was agreed by the referrer who had informed The Charity an Early Help Assessment (EHA) and S47 was in place. A S47 is a section 47 enquiry under the Children Act 1989 which is a statutory duty for local authorities to safeguard children it believes are at risk of harm. The Charity noted it spoke with Miss K’s mother, Mrs L, at the point of this referral regarding exploring autism pathway which she confirmed Miss K was on.

24. On 27 March 2017, The Charity received a referral from a social care provider regarding Miss K’s anxiety, aggression to others and self-harm. This referral was closed on 4 June 2018 following nine sessions with a senior social work practitioner.

25. On 30 July 2018, The Charity received a referral from Miss K’s mother which noted the family were struggling with Miss K’s behaviour and escalating aggression. This referral was closed on 9 August 2018. The Charity noted advice and strategies were given to the family.

26. On 7 November 2018, The Charity received a referral from Miss K’s school. This referral detailed Miss K’s anxious behaviour and how this would manifest as aggressive and violent behaviours. This referral was closed as The Charity could not offer any more specialist support. The Charity noted it would see if Miss K met the criteria for CREATE. Create is a term-time workshop for children and young people with learning disabilities.

27. On 13 February 2019, The Charity received a referral from Mrs L which described ongoing issues brought to the Trust’s attention previously. This referral was closed on 18 February 2021. The Charity noted there were no options for further support from the Trust at the time. It noted Miss K was on the CREATE waiting list and an Emotional Health Support Worker would engage with the family.

28. On 11 September 2020, The Charity received a referral which was jointly submitted by Miss K’s school and family. This referral noted the family are struggling to manage Miss K’s ongoing and escalating behaviour. It also noted this has been an ongoing matter for six years. This referral noted social workers were involved and The Charity closed this referral having ‘appropriate support in place’ on 30 September 2020.

29. On 7 October 2020, The Charity received a referral from Miss K’s school which requested a neurological assessment. This was closed on 15 February 2021 once it was transferred to CAMHS.

The Charity

34. Miss K complains about The Charity’s inadequate management of her CAMHS referrals between 2021 and 2022 and the decision to later close her file without appropriate psychological assessment. Miss K also complains the allocation of an emotional health worker in October 2022 was not a suitable intervention.

35. Miss K explained her concerns and difficulties with accessing appropriate care and referrals had been an ongoing challenge for several years prior to bringing her complaint to us. We understand prior to being accepted for CAMHS support in December 2022, Miss K and her family had made several attempts to secure further support at tier three which they explained had been declined without psychological assessment.

36. Miss K and her family say there was a disregard for the accounts and opinions of several health and education professionals who have assessed and provided support to her.

37. We have listened to the family when they have told us of their experience and the frustration as well as the emotional and mental distress, they have suffered since 2014 when Mrs L first requested CAMHS support. As the last stage in the complaint’s process, we must make difficult decisions. Whilst we have been unable to consider referrals and complaints outside our time limit, we do recognise the concerns brought to us are part of a much longer period of care. We do not wish to diminish what Miss K has told us about her experience. We understand that for six years the family faced significant personal challenges without tier three CAMHS support.

38. We also recognise the local resolution of this complaint was managed by the West Yorkshire ICB (was previously Kirklees CCG). During our investigation, we learnt the responses from the CCG and ICB were issued without involvement from SW Yorkshire Trust.

39. We understand the local resolution was a considerably long process and the response the family received from the CCG and ICB did not fully address their concerns. We recognise this would have added to the frustration they had experienced over the eight years they had been trying to secure tier three CAMHS support for Miss K.

40. The Charity provided us with a timeline of its service and management of Miss K’s referrals. In its response The Charity provided a referral history to ensure context and understanding. This information dates from 2014 to 2020. We have summarised the information and we have included this in the background section as it forms part of the history of this complaint.

41. We cannot consider it in the rationale of our decision making and are unable to make any decisions or comments on the information provided. It is included in our report for context only. The information provided by The Charity that falls inside our scope of investigation will be included in the rationale of our decision below.

42. On 19 February 2021, The Charity received a referral from children’s disability services. The referral noted Miss K was self-harming, and her behaviour was becoming difficult for her family to manage and her ‘violent outbursts’ were directed mainly toward her siblings. The referral noted support was being provided to the family by an agency worker for up to four hours a week to reduce the stress on the family.

43. Following this referral, The Charity provided tier two care which included parenting support, liaison with social care and education services. The records indicate concerns about Miss K’s presentation were discussed with specialist CAMHS services on several occasions during this time. The referral was closed on 12 October 2022 with the outcome recorded as ‘No Role Specialist CAMHS Routine’ after specialist CAMHS determined there was no ongoing role for further specialist intervention at that stage.

44. On 4 November 2022, The Charity received a referral from Miss K’s GP. It requested mental health input and potential medication prescription. This referral was closed on 9 December 2022 when it was transferred to a specialist CAMHS route.

45. The Charity says Miss K’s care was managed as part of the Thriving Kirklees Mental Health Partnership (Thriving Kirklees Service) which is no longer in place. The Charity explained it has provided all relevant support and interventions available within the scope of its tier two service. It noted its records evidence Miss K engaged well with majority of support offered. The Charity says it referred Miss K to the specialist CAMHS service when appropriate and when other avenues of support had been implemented.

46. The Charity says under the Thriving Kirklees Service there were several referrals to SW Yorkshire’s CAMHS. It says Miss K was referred to: • the CAMHS Neuro Developmental Team/Service in February 2021 • the Specialist CAMHS Learning Disability team on 23 March 2021 and • specialist CAMHS on 28 April 2021, 5 October and in December 2022.

47. The Charity says it was not responsible for the psychological assessments. It explained this was the responsibility of SW Yorkshire Trust. The Charity noted it did not make clinical assessments or decisions in relation to Miss K.

48. The Charity agreed a ChEWS emotional health worker was allocated to Miss K though it wanted to note the decision was made in discussion with SW Yorkshire Trust. The Charity noted the ChEWS staff member was allocated on 14 April 2022 and the service ended on 30 September 2022. The Charity says the ChEWS emotional health worker was intended to create a space for Miss K to explore what she was feeling and understand how to implement successful coping strategies. It says the support provided by The Charity was patient led and implemented alongside Miss K’s needs.

49. The Charity says the support provided was done so in collaboration with SW Yorkshire Trust under the Thriving Kirklees Service which included regular meetings and discussions.

50. Miss K’s clinical records, supported by The Charity’s referral history, indicate Miss K was considered through the Thriving Kirklees Service with significant input and intervention from The Charity under its tier two service.

51. Our adviser explained tier two CAMHS is an important and essential part of supporting the needs of children and young people. RCP CAMHS Report explains tier two services, such as those provided by The Charity, play an important role in supporting children and young people with mild to moderate emotional and behavioural difficulties. However, it is essential services recognise when a young person’s needs exceed this level of support and require escalation to specialist tier three CAMHS.

52. Our adviser noted Miss K received appropriate care under tier two which included family support and one to one counselling. However, they noted there are limits to the support tier two can provide.

53. Our adviser explained, given the escalation of Miss K’s behaviour and needs, a referral to tier three specialist CAMHS should have been made at an earlier stage. This is in line with CG133 which requires a holistic assessment of children and young people, including family context and wider vulnerabilities, and supports timely escalation to specialist CAMHS where needs are complex or increasing.

54. Our adviser explained that, given the escalation of Miss K’s behaviour and needs, earlier specialist CAMHS assessment and intervention should have been secured. We have listened when The Charity has told us concerns were escalated to specialist CAMHS services on several occasions, our adviser noted there is insufficient evidence of escalations or that these escalating concerns resulted in comprehensive specialist clinical assessment or review.

55. Our adviser says there were factors beyond Miss K’s behaviour, such as the family’s collective additional needs and vulnerabilities, which should have been considered when determining whether she met the threshold for specialist support.

56. We consider the earliest opportunity for this comprehensive specialist reassessment was in February 2021 when The Charity received a referral from Children’s Disability Services describing escalating concerns regarding violent outbursts and self-harm.

57. We have also considered NICE Clinical Guideline CG170, which highlights the importance of considering the impact of a young person’s needs on their wider family. From the records available, it is not clear whether The Charity completed a holistic assessment of the family’s needs at the time decisions were made about ongoing support. We consider this represented a gap in the assessment process.

58. We have listened when The Charity told us it communicated concerns regarding the escalating needs of Miss K in February 2021. We understand The Charity provided tier two care to Miss K which it felt was a suitable intervention. We are not satisfied this was an appropriate intervention or that it was fully in line with relevant guidance.

59. In February 2022, Miss K was referred by her GP. This referral was considered through a Single Point of Access (SPA) process, which concluded there was no role for CAMHS at that time. Instead, Miss K received support through ChEWS, a tier two service. We note Miss K engaged with this support between April and September 2022, although anxiety remained a concern.

60. Our adviser says the decision there was no role for CAMHS does not appear to have been supported by a documented comprehensive clinical assessment. They also noted the request for medication indicated a potentially unmet mental health need that may have warranted further specialist assessment. Instead, the available records suggest support remained at tier two level without clear evidence of specialist input. We consider this was a missed opportunity to reconsider referral to specialist CAMHS.

61. We recognise the allocation of an emotional health worker through the Children’s Emotional Wellbeing Service was intended to provide support to Miss K. However, this decision is not in line with NICE CG133 which indicates Miss K and her family’s needs should have been considered holistically and collectively rather than on an individual basis at each referral point.

62. In October 2022, Miss K’s case was again closed on the basis that there was no role for CAMHS. Our adviser says this decision is not clearly supported by evidence of a documented clinical assessment, as would be expected in line with NICE Guideline NG134. We consider this may represent a further missed opportunity to assess her needs to the standard expected.

63. We acknowledge after this referral was closed and shortly after, in December 2022, Miss K was accepted into tier three CAMHS. We were happy to see Miss K’s risk and needs were recognised and the rejection in the October was put right.

64. We recognise The Charity provided support within the scope of its tier two service and worked with partner organisations as part of a multi-agency model of care.

65. However, on the balance of the evidence available, we consider that despite repeated escalation attempts and referrals to specialist CAMHS from February 2021 onwards, Miss K did not receive timely specialist CAMHS assessment or intervention in response to the clearly recorded concerns regarding risk and escalation.

66. We also consider there is insufficient evidence of documented comprehensive clinical assessment supporting the repeated decisions that there was ‘no role’ for specialist CAMHS involvement, as expected under NG134.

67. Miss K says the delay in accessing tier three CAMHS support led to her anxiety worsening and had a significant impact on her daily life and education. She also says repeated rejections for support were frustrating and demoralising, and managing her symptoms without appropriate support was extremely difficult for her and her family.

68. We recognise the distress Miss K and her family have described. We understand this has been a prolonged and difficult experience. We have listened when the family have told us these decisions and rejections were distressing and frustrating. They say they feel Miss K’s needs were not fully understood and the support offered did not reflect the severity of her difficulties.

69. We were pleased to see once Miss K accessed specialist services, the assessment, diagnosis and treatment was quick and appropriate.

70. We consider an earlier referral would likely have resulted in earlier access to specialist assessment, psychological support and consideration of treatment.

71. On this basis, we believe this resulted in a loss of opportunity for Miss K to access specialist CAMHS support. We think this likely resulted in worsened distress and frustration that contributed to the family’s feelings of helplessness.

72. We are unable to link Miss K’s anxiety and distress completely to the failings identified. It would not be possible to determine Miss K would not have experienced any distress or anxiety as it is documented this was part of her condition. We consider earlier access to specialist support could have reduced some of the distress experienced by Miss K and her family.

73. We consider the distress, frustration, and loss of opportunity to access earlier specialist support flows directly from the failings identified in paragraphs 53 to 66.

SW Yorkshire Trust

74. Miss K complains SW Yorkshire Trust failed to accept her onto the CAMHS programme until December 2022, and its emotional health worker incorrectly concluded her needs were being met. She says this meant she was not accepted onto the CAMHS programme sooner.

75. Miss K says the delay in accessing CAMHS tier three support worsened her anxiety and had a significant impact on her daily life and education. We understand this experience was made worse by the confusion of which organisations held responsibility for her care and treatment. We hope our explanation provides Miss K and her family with a better understanding of their referral journey.

76. SW Yorkshire Trust explained it was not given the opportunity to address these concerns through the local resolution processes. It emphasised referrals to specialist CAMHS services, including the Intensive Support Team (IST), are accepted based on established clinical thresholds.

77. SW Yorkshire Trust outlined its working relationship with The Charity and explained The Charity offers counselling, one-to-one support with mental health practitioners, activity groups, short-term workshops, and telephone advice. SW Yorkshire Trust says if interventions provided by The Charity do not meet a young person’s needs, referral to CAMHS for more specialist support can be considered.

78. SW Yorkshire Trust provided a timeline of its involvement between 2021 and 2022. This included a neurodevelopmental referral multidisciplinary team assessment, involvement of the Intensive Support Team (IST), and later assessments. SW Yorkshire Trust explained the initial rejection of referrals to specialist CAMHS reflected the need to explore recommendations and alternative methods of support.

79. SW Yorkshire Trust said it held no direct records of involvement between late 2021 and October 2022 and stated that the February 2022 medication request appeared to have been managed outside of its Core CAMHS systems. SW Yorkshire Trust noted that it could not confirm the precise interventions delivered during this period by The Charity. SW Yorkshire Trust said the October 2022 referral regarding medication was not accepted because Miss K did not agree to medication at that time and because it considered her presentation was better understood in the context of autism-related behavioural difficulties

80. The records show SW Yorkshire Trust was involved in Miss K’s care at various points between February 2021 and December 2022, through screening referrals, participating in multidisciplinary discussions, and considering access to specialist CAMHS services, including the IST.

81. In February 2021, a referral was received for the neurodevelopmental pathway. In April 2021, Miss K was assessed and diagnosed with autism spectrum disorder. Following this diagnosis SW Yorkshire Trust recommended parenting support, school-based input, and engagement with The Charity services.

82. In September 2021, Mrs L contacted the IST reporting escalating behaviour, difficulty coping at home, and deterioration in parental mental health. The team reviewed the case but concluded the thresholds for specialist services were not met at that time.

83. In May 2022 the records indicate Mrs K asked whether the allocated emotional health worker was providing an appropriate level of intervention for Miss K. Our adviser explained this should have prompted assessment by a team able to prescribe and consider medication. We have not seen an indication this happened.

84. Reliance on the conclusion that Miss K’s needs were being adequately met at tier two contributed to the delay in accessing specialist CAMHS assessment and intervention, as the opportunity to escalate concerns and consider a comprehensive review was missed.

85. In October 2022, a further referral requesting medication was made. This was not accepted, in part because Miss K did not agree to medication at that time. The records indicate while Miss K engaged with tier two support, our adviser noted the Trust’s assessment of her referral did not fully meet the expected standards as the available records do not demonstrate evidence of a comprehensive specialist clinical assessment or review. A second referral followed eight weeks later in December which we consider put right this failing.

86. On 17 November 2022, a CAMHS assessment was performed which concluded Miss K’s difficulties were linked to her autism diagnosis and suggested intervention from specialist services should be considered. Miss K was later accepted for tier three support on 1 December 2022.

87. Our adviser explained specialist CAMHS services, including teams such as the IST, are designed to support children and young people with more complex or high-risk presentations. Access to these services is usually determined by defined thresholds, and it is appropriate to consider whether needs can be met at a lower tier before accepting a referral.

88. Our adviser emphasised where a young person presents with indicators of escalating risk including self-harm, aggression, or significant deterioration in functioning, services should ensure a full clinical assessment is undertaken to determine the appropriate level of intervention.

89. Our adviser explained Miss K’s presentation included escalating aggressive behaviour which should have promoted a referral for specialist CAMHS involvement. Our adviser explained while it is appropriate to consider alternative interventions, such as parenting programmes or tier two support, NHS England explains this should not delay referral to specialist services where needs are persistent or escalating.

90. As explained in our consideration of the care and service provided by The Charity, we consider Miss K’s requests for medication should have been recognised as potential indicators of unmet mental health need and should have prompted consideration of a comprehensive CAMHS assessment rather than being considered in isolation.

91. We have seen evidence that Miss K’s views about medication were discussed during the October and November 2022 discussions and assessments. However, our adviser noted that there remained evidence of ongoing difficulty despite interventions at a lower tier, which indicated there should have been reconsideration of the need for specialist intervention regardless of whether medication was ultimately appropriate.

92. We recognise SW Yorkshire Trust is a specialist provider and access to its services is based on established clinical thresholds. We understand SW Yorkshire worked in partnership with The Charity in the care and service provided to Miss K. We consider it is for this reason there is a shared responsibility in how her needs were assessed at tier two.

93. The records indicate SW Yorkshire Trust screened referrals, participated in multidisciplinary discussions, and provided input into decisions about appropriate support. A neurodevelopmental assessment in 2021 led to an autism diagnosis and recommendations for ongoing support.

94. Our adviser did not note any concerns in this care though they explained persistent or escalating indicators of risk should have prompted comprehensive assessment and review.

95. Notably, the emotional health worker allocation did not include assessment by a team able to consider medication or escalate care appropriately. We have not seen the February and October 2022 medication requests were used as opportunities for specialist assessment.

96. Miss K says the delay in accessing specialist CAMHS services affected her daytoday life and negatively impacted her mental health challenges. We have seen this impact persisted across the period of 12 months we have considered. While Miss K did receive appropriate assessment and intervention in December 2022, we consider an earlier assessment would likely have resulted in earlier access to specialist support, even if it would not have changed the diagnosis.

97. We consider that the shortcomings identified in the October 2022 assessment and decision-making were remedied within a relatively short period when Miss K was accepted into specialist services in December 2022. However, this did not remedy the wider delay in accessing specialist CAMHS assessment and intervention identified throughout this investigation. We therefore consider the injustice arising specifically from this aspect of the complaint falls at the lower end of our Severity of Injustice (SOI) scale.

98. We have considered the impact of the failing in the delay in accepting Miss K for tier three support separately. We have not seen evidence SW Yorkshire Trust has provided a formal apology or acknowledged the impact of the delay.

99. We have listened to what SW Yorkshire Trust has told us about changes to its current commissioning arrangements. We are pleased to learn it has established a new single, coordinated route for children and young people to access mental health services, identifying immediate need and providing ongoing support.

1. Miss K complains about her Child and Adolescent Mental Health Services (CAMHS) referral journey she received from South West Yorkshire Partnership NHS Foundation Trust (SW Yorkshire Trust) and a The Charity provider in the Kirklees area (the Charity) between January 2021 and December 2022.

2. We understand that each Trust had its own responsibility under the Thriving Kirklees CAMHS. We also recognise The Charity no longer provides care under this service following its decommissioning by the Integrated Care Board (ICB). We consider there is a shared responsibility for the care provided under Thriving Kirklees CAMHS and the care and services were interlinked.

3. We consider both Trusts had a shared responsibility for the assessment, referral and acceptance of Miss K’s CAMHS referral for tier three support. We also consider the use of an emotional health worker was not a suitable intervention at that late stage in Miss K’s referral journey. We consider these failings contributed to unnecessary delays and loss of opportunity for Miss K and her family to receive specialist support sooner.

4. This means we partly uphold Miss K’s complaint. We recognise the delay caused distress and a loss of opportunity for earlier assessment and intervention. We recommend both organisations apologise and make a joint financial payment in recognition of the injustice. We also recommend SW Yorkshire Trust put in place an action plan to explain how it will do things differently to prevent a reoccurrence.