An independent provider in the Cornwall area

5. Mx S complains about the care and treatment she received from the Service in June 2025.

6. Specifically, she complains:

• her ADHD assessment did not fully consider her medical history and focused on past trauma which led to a failure to diagnose ADHD

• the assessor requested collateral history she was unable to obtain, which exacerbated her feelings of rejection linked to past trauma

• the assessor made inappropriate comments about her gender identity which she found dismissive and inappropriate.

7. Mx S says this experience has significantly affected her mental health, leaving her feeling distressed, disheartened and excluded from care.

8. Mx S says the assessment outcome delayed her ability to receive appropriate ADHD support, receive workplace adjustments and to develop an understanding of her condition.

9. As outcomes to her complaint, Mx S would like an apology, service improvements, and a financial remedy.

10. Mx S is a transgender woman in her late twenties. She told us she has experienced difficulties with attention and organisation since childhood.

11. Mx S previously received a private ADHD diagnosis in 2022 and was unable to continue with treatment. She then underwent an NHS assessment in 2023 which concluded she did not have ADHD.

12. Mx S's GP made a referral to the Service in February 2025. The assessment took place at the end of June with the assessor concluding an ADHD diagnosis could not be reached.

13. Mx S complained to the Service in July and brought her complaint to us in September.

14. Mx S's GP referred her on the NHS right to choose pathway in November, and she received an ADHD combined-type diagnosis in January 2026.

Assessment

18. ADHD (attention deficit hyperactivity disorder) is a condition which affects how the brain works. It is often diagnosed in childhood as symptoms generally present before the age of 12. There are two main ADHD types which have differing behaviour traits and challenges.

19. Inattentive ADHD presents as difficulties with attention, organisation and managing tasks. Patients may experience difficulties with instructions, get easily distracted and lose items frequently. Hyperactive ADHD is characterised by symptoms of hyperactivity and impulsivity with patients experiencing restlessness, talking excessively and interrupting others.

20. Combined type ADHD is where patients experience a combination of hyperactive and inattentive behaviour. A diagnosis requires at least five symptoms from both inattentive and hyperactive ADHD.

21. NG87 guidelines on attention deficit hyperactivity disorder diagnosis and management state that ADHD assessments should be carried out in a structured way according to DSM-5 or ICD10 criteria. The guidelines also state a full developmental and psychiatric history of the patient should be taken.

22. DSM-5 is an internationally recognised manual used for diagnosing ADHD. DIVA-5 is a commonly used diagnostic interview for adult ADHD assessments with questions based on all 18 ADHD symptoms from the DSM-5 manual. ICD10 (International Classification of Diseases version 10) is an international directory of health conditions and diseases published by the World Health Organisation.

23. Mx S complains the Service failed to provide her with a trauma-informed, neurodiversity-affirming ADHD assessment. She said her assessor dismissed her valid adult symptoms and previous diagnosis without clinical justification.

24. The Service acknowledged her prior diagnosis of inattentive-type ADHD and that her symptoms as an adult aligned with this. It said the absence of early developmental history and the presence of conflicting assessments led to an inconclusive outcome. The Service said DSM-5 criteria states a lifelong pattern of symptoms must be demonstrated when arriving at a diagnostic conclusion.

25. Mx S self-referred to a private ADHD assessment provider and underwent an assessment in November 2022. Mx S’s mother provided an informant report as part of the assessment which was not supportive of her symptoms. Clinicians diagnosed Mx S with ADHD inattentive type and prescribed medication.

26. The private provider informed Mx S’s GP of her diagnosis. She told us her GP Practice would not accept a shared care agreement for prescribing medication as the assessor was not an approved provider. Mx S also said she paid for a private prescription which she did not receive and she did not hear from the private provider again.

27. Several months later, her GP referred Mx S for assessment to the Community Mental Health Team (CMHT) at her local Trust. In September 2023 the CMHT assessment found no evidence of hyperactivity, inattention, or impulsivity that would be suggestive of an ADHD diagnosis.

28. The CMHT assessment reported some of Mx S’s symptoms were indicative of autism spectrum disorder (ASD) and discharged her from its service. It provided her with information and resources about ASD and forwarded the clinic letter to the local ASD service.

29. Mx S told us she went through a very difficult period with her mental health between September 2023 and October 2024 and she said she moved several times. She registered with a new GP around the end of 2024 and in February 2025 her GP referred her to the Service. The ADHD assessment took place in June 2025 via an online appointment with a consultant psychiatrist.

30. Mx S completed the Adult ADHD Self-Report Scale and the Wender Utah Rating Scale (WURS). WURS is a questionnaire used to retrospectively assess childhood symptoms of ADHD in adults and is for patients who cannot get childhood collateral reports due to family conflict. Mx S scored 76 out of 100 with a result above 46 being a strong indicator of ADHD.

31. The assessor concluded they could not diagnose Mx S with ADHD due to conflicting data. They highlighted the difference between her inattentive diagnosis from 2022 and the failure to diagnose in 2023.

32. The assessment also detailed Mx S’s lack of collateral history of her symptoms when she was younger. It referenced her mother’s informant report from her previous 2022 assessment which was not supportive her ADHD diagnosis, as further rationale for its decision.

33. The assessment acknowledged Mx S displayed symptoms of ADHD inattentive type and that she had experienced symptoms for a significant portion of her life. It said Mx S had been assessed against the DSM-5 criteria for ADHD in adults and the inconclusive outcome meant more information was needed.

34. There are specific symptoms set out in DSM-5 criteria: A – presence of childhood inattentive and hyperactive/impulsive characteristics B – signs of a lifelong pattern of symptoms and limitations C – symptoms present in multiple settings D – symptoms interfere with functioning E – symptoms better explained by other disorder / substance abuse.

35. The assessor said school records, third-party observations, further clinical reports or adult friends and colleagues who could report on her adult symptoms could be used as alternatives to early collateral history.

36. Our adviser said the assessor took a comprehensive history of Mx S’s symptoms. Her adult symptoms are recorded in the assessment, which include inattention, hyperactivity, and impulsivity in adulthood, struggling to concentrate on boring tasks, sometimes falling asleep, often zoning out during conversations and anticipating what others will say.

37. The adult self-report score and WURS questionnaires Mx S completed are largely based on the DIVA-5 sections. Our adviser said this indicates the assessor used DSM-5 criteria in the assessment in line with NG87 guidance. This guidance states the criteria must be used but is not prescriptive on how the report should be set out. Our adviser noted the assessor could have been clearer in how they recorded whether the DSM-5 criteria had been met.

38. The assessor refers to the informant report provided by Mx S’s mother for her previous 2022 assessment and stated her childhood symptoms were not supportive of an ADHD diagnosis. We recognise Mx S found the Service decision especially disappointing as the 2022 assessment which obtained the informant report, had still confirmed a diagnosis of ADHD inattentive type.

39. Our adviser said a prior ADHD diagnosis should carry some weight but should not be accepted without question. Each ADHD assessment is a standalone assessment using the same DSM-5 diagnostic criteria. The experience of the assessor may be different and if the assessments are years apart the patient’s personal, medical and social circumstances may have changed.

40. Our adviser said the clinician from Mx S’s 2022 assessment had considered similar information to the current assessment and made an ADHD diagnosis. Our adviser also said as the DSM-5 criteria is incomplete in the assessment we cannot say whether Mx S did not meet just one or multiple criteria.

41. NG87 guidance states an ADHD diagnosis should be based on a full clinical and psychosocial assessment and a full development and psychiatric history. Psychiatric history would include any history of trauma, post-traumatic stress disorder (PTSD), abuse or significant adversity.

42. DSM-5 criteria E states ADHD symptoms should not be explained by other psychiatric conditions. Some trauma symptoms including hyperarousal, intention and impulsivity, anxiety and emotional dysregulation can mimic ADHD symptoms. The criteria also states the assessment should consider when the symptoms started and the timing of the trauma to determine whether this is ADHD or a response to trauma.

43. The assessment records Mx S taking part in talking therapy to address her anxiety and past trauma. Our adviser said this part of her ADHD assessment was sufficiently thorough and in line with NG87 guidance and Mx S’s trauma history was acknowledged as a contributor to her ongoing anxiety and hypervigilance.

44. Our adviser said Mx S’s assessment could have resulted in a diagnosis but could not say whether it should have been made. This is because the assessor’s clinical judgment forms a significant part of any ADHD assessment.

45. ADHD symptoms can differ in severity and are not always measurable. They rely on patients to describe their symptoms which provides variance in how symptoms are reported. Clinicians must accurately evaluate symptoms, exclude conditions where there may be a crossover of symptoms and provide personalised treatment and interventions.

46. Our adviser said the number and intensity of Mx S’s symptoms was less than the threshold a clinician would expect to see in an ADHD patient. Our adviser said it was correct for the assessor to use their clinical judgment to make an inconclusive finding if they were not confident in making a diagnosis.

47. The evidence we have seen suggests the assessor did consider Mx S’s medical history and recorded a comprehensive summary of her symptoms. We consider it was appropriate for the assessor to discuss past trauma with Mx S to ensure her symptoms were interpreted correctly and to rule out any other mental health conditions.

48. It was also appropriate for the assessor to use their clinical judgment in the decision-making process and the differences in her previous assessment outcomes may have been a factor here. We recognise the incomplete DSM-5 criteria may have led to uncertainty for Mx S on the reasons for the decision.

49. Even taking this into consideration, it would be difficult for us to link Mx S’s concerns about the assessment with the failure to make an ADHD diagnosis. We cannot say if the DSM-5 criteria had been completed in full and she was able to provide supporting information that this would have led to an ADHD diagnosis.

50. We hope Mx S is reassured that the assessor did complete her assessment within appropriate guidelines and it was appropriate for them to discuss her past trauma to ensure she received the correct diagnosis.

51. There is no indication of a failing here and we will take no further action.

Collateral history

52. The Service’s guidelines state if a patient can obtain a child collateral report after their appointment, the clinician would arrange a follow-up appointment to complete the assessment. If at the follow-up appointment the patient has been unable to obtain a childhood informant report and has completed the WURS, the clinician will make diagnosis without this information or will not give a diagnosis and document the reason why.

53. Collateral history is evidence required in adult ADHD assessments in the form of reports and/or from the patient’s childhood. The reports are from someone who currently knows the patient and are set out as questionnaires. Obtaining collateral evidence for some patients can be difficult if they do not have any family or they are estranged and seeking this information could be distressing and traumatic.

54. Mx S complains her ADHD assessment relied on early developmental evidence. She said the Trust did not address the core clinical failings of the assessment or offer any solution and she was asked to reapply with evidence she could not provide. Mx S said the assessor told her to ‘get creative’ in finding evidence.

55. Mx S also said the assessment did not recognise the difficulties that patients who have experienced trauma and estrangement from their families, would have in getting this evidence. She said her outcome also ignored barriers experienced by marginalised individuals including those who are autistic, estranged, queer and trauma survivors.

56. The Service acknowledged Mx S’s history of trauma and estrangement limited her ability to get this information. It also recognised Mx S’s concerns on the reliability of the report from her mother and the limitations of a prior NHS assessment which was not conducted by ADHD specialists.

57. Mx S queried the provision of collateral evidence with the assessor who confirmed her case had been discussed with the lead clinician and at a multidisciplinary team meeting. The assessor clarified they were not asking Mx S to contact her immediate family, and they would accept an informant report on her adult symptoms from a friend or colleague.

58. Mx S told us she could not approach the people who had known her as a child. She said she had moved frequently and had to distance herself from people who had caused her difficulties. Mx S also informed the assessor of a potential adult informant she had known only several months and they were therefore unsuitable.

59. Our adviser said the assessor took a reasonable developmental history of Mx S which was limited by the absence of an informant report regarding her early life and milestones. The assessment confirmed that Mx S had a normal birth and that milestones were normal in the first year of her life which our adviser said could be one reason for the clinician requesting collateral information.

60. Our adviser recognised the assessment appeared to have placed a lot of weight on the informant report from Mx S’s mother and noted the answers were somewhat dismissive and brief. The assessor said they felt obliged to ask Mx S to get further information from a friend or colleague about her adult symptoms. Our adviser said it would be up to the patient to decide whether the old informant report was used in the new ADHD assessment in view of the difficulties she had experienced with her family.

61. Mx S clearly stated in an email to the Service after the assessment that she was uncomfortable contacting anyone who could provide information about her at the relevant age. She also said re-establishing contact with people who have caused her harm would cause her significant distress.

62. We acknowledge the difficulties of Mx S’s family estrangement and the challenges of obtaining collateral history especially as her mother was unsupportive of her diagnosis. We do not underestimate how distressing this was for Mx S, and we recognise the barriers this has placed on her ability to provide this evidence to support her assessment.

63. Our adviser said the assessor did not feel confident in diagnosing ADHD without an informant report which was their clinical judgment. As we have seen earlier, clinical judgment is a significant part of the ADHD assessment process. Our adviser said if the severity of Mx S’s symptoms in her home and work life had been clearer or her presentation had been more typical it is possible but not definite that the assessment would have been supportive of a diagnosis.

64. We consider it was appropriate for the provider to ask Mx S for collateral history. The assessor made it clear they did not expect her to contact her family and gave her additional options for the type of information she could provide.

65. We note the Service said that if Mx S could acquire this evidence, it would offer her a follow-up appointment (in line with its own guidance) and a second opinion with a different clinician. This indicates the Service was giving her an opportunity to get this additional evidence and being sensitive and flexible to her needs by offering an assessment with a different clinician.

66. There is no indication of a failing here and we will take no further action.

Comments on gender

67. GMC Trans Healthcare guidance states the way doctors address transgender and gender diverse people is extremely important. It says taking care to use the patient’s right name and title shows they are being treated with respect. The guidance also states every patient has the right to high-quality and inclusive healthcare.

68. Mx S said she experienced inappropriate comments about her gender identity. She said the assessor asked in an offhand manner her gender assigned at birth and followed this with ‘What are you?’. She identified herself as transgender and the assessor followed up with the question, ‘What do you call yourself?’

69. Mx S said this felt dismissive and that her identity was being disrespected. She also felt this questioning was irrelevant to the context of the assessment which detracted from her ADHD symptoms and diagnosis.

70. The Service apologised for the phrasing used in Mx S’s assessment and the reference to her gender identity. It acknowledged these comments may have felt dismissive or awkward and that it was committed to improving the sensitivity and clarity of its communication. The Service said it would share feedback with the clinical team around trauma-informed care and inclusive communication.

71. There is no specific guidance relating to gender identity and ADHD assessments. RCPsych guidance states that information provided to patients with ADHD should be tailored to their individual needs and circumstances, including age, gender, education level and life stage.

72. Our adviser said the Service assessed Mx S in line with this guidance. The assessor wrote the report in the third person, mostly using her name and the pronoun ‘they’ which demonstrated respect for her and a non-judgemental approach.

73. We consider it was appropriate for the assessor to speak about Mx S’s gender identity in the assessment. It was not appropriate for the assessor to address Mx S in the way they did, which was not in line with GMC guidance mentioned earlier.

74. We are pleased the Service has apologised to Mx S, accepted the comments made by the assessor were inappropriate and it has taken remedial action and made a commitment to ensuring communication is inclusive. In line with our principles of good complaint handling this shows the Service putting things right, which we consider it has done.

75. We conduct precedent checks as part of our investigation process, and we have not identified this to be a wider systemic issue. We monitor trends on complaint types and health inequalities, and by bringing the complaint to us, Mx S has assisted us with this work.

76. We acknowledge Mx S’s concerns about her ADHD assessment. We hope she is reassured after our consideration of her case that the Service conducted her assessment in line with guidelines and has taken appropriate steps to address how the assessor spoke to her.

1. We are sorry for the reasons Mx S has brought her complaint to us. We acknowledge her concerns about how the assessor conducted her ADHD assessment and her concerns that this affected the outcome. We also acknowledge the distress she experienced because of how the assessor spoke to her about her gender identity.

2. We have carefully considered Mx S’s complaint about the Service. We saw overall that the assessor completed Mx S’s assessment in line with guidance and that nothing went seriously wrong.

3. We consider the way the assessor addressed Mx S’s gender identity was inappropriate and caused her distress. We think the Service has done enough to put this right and so we will not be investigating this further.

4. Our statement explains the reasons why.