Berkshire Healthcare NHS Foundation Trust

5. Mrs G complains on behalf of her daughter, Miss G, about the care and treatment she received from the Trust between January 2025 and June 2025 for her complex OCD. Specifically, she complains:

• Miss G did not receive the appropriate treatment for her complex OCD. She says the consultant focused on compassion focused therapy (CFT), but Miss G should have received cognitive behavioural therapy (CBT) and exposure response prevention (ERP) • Miss G received no treatment for her paedophilia-related OCD • the complaint response is biased towards the consultant who provided the treatment.

6. Mrs G says the failings caused:

• deterioration in Miss G’s mental health, with an increase in self-harm and serious intent on wanting to end her life • social isolation from family and friends for them as a family • financial loss to Miss G due to dropping out of university and being unable to attend many prebooked trips and events • emotional distress for Miss G, herself and Miss G’s father as parents.

7. As outcomes to the complaint, Mrs G wants: • a face-to-face apology to Miss G from the consultant who provided the therapy, and the consultant who initially handled the complaint, for the psychological injury caused • service improvements to ensure this doesn’t happen to other patients.

8. Miss G is a 25-year-old woman with complex OCD, including contamination OCD (a subtype of OCD marked by intrusive thoughts about becoming contaminated or contaminating others) and paedophilia OCD (a subtype of OCD marked by intrusive thoughts about being or becoming a paedophile). Miss G began therapy at the Trust in January 2025 for her OCD. She initially started therapy with one consultant but changed to a different consultant after two sessions due staff sickness.

9. Miss G had nine sessions with the second consultant. Her last session was on 20 May 2025, after which she requested a new therapist.

10. Mrs G says the sessions focused on breathing techniques and CFT and did not appropriately cover CBT or ERP. She says the consultant did not do collaborative ERP with Miss G, and the ERP was irrelevant for her fears related to children.

11. CBT is a talking therapy used to treat a variety of mental illnesses, including OCD. It focuses on how thoughts and emotions impact behaviours, helping people recognise patterns and change their thinking to a more balanced approach. CBT usually consists of exercises in therapy sessions accompanied by homework and self-monitoring outside of sessions to reinforce the techniques learnt.

12. ERP is a specialised form of CBT. It involves a hierarchy to structure feared situations, thoughts or objects starting from the least distressing one. This triggers their obsessive thoughts, but they learn to resist the urge to perform their compulsive behaviours. They stay on one fear until there has been significant reduction in their anxiety associated with it before moving to the next fear on the hierarchy.

13. CFT is a therapy like CBT but focuses on teaching clients to develop kinder thinking towards themselves using compassionate imagery, attention and feeling.

14. Mrs G is unhappy the consultant made her leave Miss G’s therapy sessions, despite Miss G asking her to stay to support her. She says guidelines say family should be involved.

Issue 1 – The consultant did not provide the appropriate therapy for Miss G’s complex OCD

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

19. Mrs G says the consultant did not deliver the appropriate therapy for Miss G’s complex OCD. She is concerned the consultant focused on CFT but thinks her daughter should have received CBT and ERP.

20. Mrs G says the ERP was not collaborative. She also says the consultant did not allow her to be involved in Miss G’s sessions on multiple occasions which she thinks is not in line with guidance.

21. The Trust said the consultant commenced 20 sessions of CBT with ERP as recommended by the previous consultant who initially saw Miss G. It says this is in line with NICE guidelines. It says there is evidence of both CBT and ERP, and the ERP started at an appropriate step on Miss G’s exposure hierarchy.

22. To consider this part of the complaint, we reviewed the relevant guidance and evidence with our clinical adviser.

23. NICE Clinical Guideline 31: states ‘Adults with OCD with moderate functional impairment should be offered the choice of either a course of an SSRI or more intensive CBT (including ERP; more than 10 therapist hours per patient), because these treatments appear to be comparably efficacious [successful]’ (section 1.5.1.3).

24. The Trust’s guidance for psychological therapies states the first treatment for OCD is CBT including ERP, as well as family psychoeducation and involvement if appropriate.

25. We have seen from Miss G’s therapy records she was to have 20 sessions of CBT with ERP. She had a total of 11 therapy sessions between January 2025 and May 2025 with two different consultant therapists. The consultant changed after two sessions due to staff sickness. Miss G requested to see a different consultant on 3 June 2025 which paused her therapy.

26. The first consultant agreed the initial treatment offer of CBT with ERP for OCD with Miss G, and the second consultant continued this treatment plan.

27. There are no indications of CFT in the clinical notes. We have seen the sessions covered CBT exercises, with some ERP.

28. There is reference to the consultant discussing Miss G’s triggers and negative thoughts with her. They discussed cognitive restructuring to interrupt the negative thoughts and behaviours. The consultant educated Miss G about OCD, breathing exercises and cognitive strategies and set homework for Miss G to practice new techniques independently.

29. On 31 March 2025, the consultant documented Miss G’s exposure hierarchy. The ranking goes from one to ten, with contamination fears at the lower end of the scale, and fears related to children at the higher end of the scale.

30. During this session, the consultant demonstrated touching a door handle for an amount of time. They then set Miss G homework to practice this in her own time and record her observations. The consultant then reviewed this exercise with Miss G in the next session.

31. Our adviser explained the consultant delivered a CBT/ERP model of treatment. We understand this type of therapy was appropriate for Miss G’s OCD as recommended by NICE clinical guideline 31. Therefore, we have not identified any indication something went wrong in relation to this aspect of Miss G’s care.

32. We asked our adviser if the consultant should have done the ERP collaboratively during the session. They say it could have been done in the session, but this is not essential.

33. We understand Mrs G is concerned the consultant removed her from Miss G’s sessions.

34. We have seen evidence Miss G had either her mother or father present at most of her sessions. The consultant provided Miss G’s parents appropriate chances to contribute to the sessions and their reports on Miss G are documented in the clinical notes.

35. Our adviser says Miss G’s parents were more involved than would be expected for adult mental health services.

36. For these reasons, we are satisfied Miss G’s parents were appropriately involved in her therapy.

37. We are sorry to hear Miss G experienced a deterioration in her mental health during this time. We recognise Mrs G and Miss G feel this was due to Miss G not receiving the appropriate therapy.

38. We hope we have clearly explained our decision. We hope they assure Mrs G the therapy Miss G received was appropriate and in line with NICE clinical guideline 31.

Issue 2 – Miss G did not receive any treatment for her paedophilia-related OCD

39. In Mrs G’s complaint, she says Miss G did not receive any treatment for her intrusive thoughts around children.

40. The Trust response says the ERP was pitched at the appropriate step on the ladder based on how Miss G had ranked the steps, and how many sessions she had undertaken. It recognises Miss G wants more of a focus on her intrusive thoughts about children and advises her new therapist will address this.

41. To consider this part of the complaint, we have reviewed the relevant guidance and evidence with our clinical adviser.

42. Our adviser told us there is no specific guidance for paedophilia-related OCD, therefore NICE clinical guidance 31 remains relevant for our consideration.

43. Within ERP therapy, an exposure hierarchy ladder is used. This is a structured step-by-step ranking of anxiety provoking situations which helps to gradually confront fears and reduce compulsions. We understand that progression up the hierarchy depends on the patient and their engagement with therapy exercises and homework.

44. Miss G’s exposure hierarchy grades contamination fears lower down the ladder, and fears around children further up the ladder. Our adviser explained she would not be exposed to the fears higher up the ladder until she had achieved a level of reduction in each of the triggers listed lower down.

45. On 8 April 2025, when reviewing the first ERP homework, the consultant documented Miss G had not recorded details of her progress. On 6 May 2025, the consultant explained to Miss G and her father progress normally occurs when patients rehearse and record their homework exercises so they can be discussed in the next session.

46. We can see some suggestion Miss G may not have been completing homework tasks set properly. We understand this may have delayed progress moving up the hierarchy.

47. During the session on 20 May 2025, there is reference to ‘Theory A/Theory B’ exercise to target thoughts associated with being a paedophile.

48. We are satisfied there were some CBT activities related to managing intrusive thoughts about children. We have also seen evidence of the Trust acknowledging Miss G’s preference for more focus on this going forward.

49. Miss G had not completed the proposed number of therapy sessions when Mrs G complained. We are mindful there may have been more progression on the ERP hierarchy and more focus on intrusive thoughts around children as the sessions progressed.

50. In conclusion, we consider there are indications Miss G received appropriate treatment in line with the exposure hierarchy ladder and NICE clinical guideline 31. We have not identified any indications of service failure related to this part of the complaint. We hope this is reassuring for Mrs G and Miss G.

Issue 3 – The Trust response is biased towards the consultant who provided the therapy

51. Mrs G says the Trust response is biased towards the consultant who provided the therapy.

52. Our ‘NHS Complaint Standards’ say an organisation must be thorough and fair. They say staff should take a thorough, proportionate and balanced look into the issues raised in a complaint. It should give people fair and open answers to their questions based on facts and take full accountability for mistakes identified.

53. After considering the care and treatment provided with our clinical adviser, we are satisfied there are indications it was appropriate and in line with guidance. We are satisfied this part of the Trust response is factual based on the evidence available.

54. We understand a different consultant was initially investigating the complaint. They called Miss G to discuss her concerns.

55. Miss G was unhappy after this call and felt the consultant did not acknowledge her concerns. She sent a further complaint to the Trust detailing this and complaining the consultant did not accommodate time for her father to speak to them.

56. The Trust allocated a different consultant to continue the investigation. In the final response it recognised the original investigating consultant could have given more time or a call back to allow Miss G’s father time to talk. It says the consultant will take this into consideration in future contacts with complainants as part of an investigation.

57. The consultant who provided the therapy wrote a statement detailing Miss G’s presentation, history, therapy plan, goals and response to treatment.

58. In its final response, the Trust acknowledged Miss G wanted more of a focus on her intrusive thoughts around children. It says Miss G’s new therapist will address this as a priority.

59. We consider the Trust has taken a fair and transparent approach in line with our ‘NHS Complaint Standards’. It considered Miss G’s dissatisfaction with the original complaint handler and acted on this. It allowed the consultant who provided the therapy chance to provide a statement and considered Miss G’s want for more focus on her intrusive thoughts around children, advising the new therapist will action this.

60. For these reasons, we have not identified any indications of bias in the way the Trust investigated and responded to Mrs G’s complaint, and we will not be taking any further action on this part of the complaint.

61. In conclusion, while our decision has been made based on the evidence available, we do not intend for this to minimise or dismiss the experience Miss G and Mrs G had or the impact it caused. We appreciate the time and effort Mrs G has taken to bring the complaint to us, and we hope the information provided within this statement provides her with some reassurance about the care and treatment Miss G received.

1. We have carefully considered Mrs G’s complaint, on behalf of her daughter, Miss G, about Berkshire Healthcare NHS Foundation Trust (the Trust).

2. Mrs G raised concerns about the treatment provided to Miss G for her obsessive-compulsive disorder (OCD) and the way in which the Trust handled her complaint.

3. We have reviewed the information provided by Mrs G and the Trust, as well as seeking clinical advice from a psychological therapist and considering the guidance and standards relevant to the care provided. After doing so, we have seen no indication that anything went seriously wrong in the care provided to Miss G or in the way the Trust handled Mrs G’s complaint.

4. We fully acknowledge Miss G’s experience and do not wish to minimise this. We hope our explanation below reassures Mrs G the Trust provided appropriate therapy to Miss G in line with guidance.