Oxleas NHS Foundation Trust

12. Mr R complains abouts aspects of care and treatment provided by Oxleas in April 2012. Specifically, he says Oxleas: •misdiagnosed him with BPD •did not arrange for a psychiatrist to assess his mental health condition •inappropriately ended his EMDR.

13. Mr R also complains about aspects of care and treatment provided by SLAM between April 2022 and June 2023. He says SLAM did not assess or treat his PTSD in an appropriate and timely manner. He also complains SLAM gave him unnecessary TFP between 27 October 2022 and 23 March 2023.

14. Mr R says as a result he: •experienced a delay in accessing appropriate treatment for his PTSD •experienced more trauma and broke his fifth metacarpal (a bone in the hand) due to the stress of TFP •had to pay for private therapy.

15. Mr R would like a financial remedy.

16. This background is a brief summary of events to put the complaint into context and not a full account of everything that happened.

17. In March 2012, Mr R began attending Oxleas for EMDR treatment. In April he met with a psychotherapist at Oxleas who initially diagnosed him with PTSD. Oxleas later documented that he had traits of a personality disorder.

18. In early June, he attended an appointment at Oxleas and he says a psychotherapist diagnosed him with BPD. He went on to attend psychotherapy group sessions until Oxleas discharged him in October.

19. In November 2016, Mr R witnessed a child fall from a window in his block of flats. Following this, his GP referred him to SLAM for PTSD treatment. SLAM did not accept the referral.

20. In October 2019, Mr R attended ED and a clinician recorded that he had BPD and PTSD.

21. In 2023, Mr R attended TFP sessions at SLAM. In April of thar year, he asked SLAM to stop the TFP. Following a session, he became distressed and broke his knuckle.

22. In June 2023, a consultant psychiatrist at SLAM, said Mr R did not meet the criteria for BPD and diagnosed him with PTSD.

Oxleas

BPD diagnosis and psychiatry assessment

26. Mr R complains Oxleas misdiagnosed him with BPD in 2012. He also complains Oxleas did not provide a psychiatry assessment to formally diagnose him with BPD. He questions whether the psychotherapist who diagnosed him with BPD was qualified to do so and why they did not refer him for a formal assessment.

27. NICE’s ‘Borderline personality disorder: recognition and management’, provides guidelines on how to assess and diagnose patients with BPD. Specifically, the guidelines say: ‘When assessing a person with possible borderline personality disorder in community mental health services, fully assess:

•psychosocial and occupational functioning, coping strategies, strengths and vulnerabilities •comorbid mental disorders and social problems •the need for psychological treatment, social care and support, and occupational rehabilitation or development.’

28. Our adviser helped us to understand the above NICE guidelines and how they applied to Mr R. Mr R was assessed by a psychotherapist at Oxleas in 2012 and he says they diagnosed him with BPD. Oxleas documented PTSD but did not document a formal personality disorder diagnosis in his clinical notes.

29. Mr R remembers the psychotherapist explaining that his was a clear case of BPD. It did not record a clear clinical diagnosis of BPD or the reasoning for the diagnosis in his records.

30. Additionally, Mr R told us he had suffered a reactive hypoglycaemia (a condition characterised by episodes of low blood glucose) which may have affected his behaviour immediately before the diagnosis.

31. Despite no formal diagnosis, Oxleas stopped Mr R’s EMDR therapy following the appointment with the psychotherapist and referred him to a group that was designed to help patients with personality disorders.

32. We have found Oxleas did not carry out a formal structured assessment by an appropriately qualified professional (usually a psychiatrist or a clinical psychologist). Additionally, Oxleas did not provide a clear explanation of his diagnosis or the assessment process to Mr R. We have found the actions of Oxleas were not in line with the following NICE guidelines which say:

33. ‘Mental health Trusts should develop multidisciplinary specialist teams and/or services for people with personality disorders. These teams should have specific expertise in the diagnosis and management of borderline personality disorder and should:

•provide assessment and treatment services for people with borderline personality disorder who have particularly complex needs and/or high levels of risk •provide consultation and advice to primary and secondary care services •offer a diagnostic service when general psychiatric services are in doubt about the diagnosis and/or management of borderline personality disorder’.

34. Our adviser explained Oxleas should have had a collaborative discussion with Mr R and offered him post-assessment support. It did not do this in line with the following guidelines which say: ‘When assessing a person with borderline personality disorder, offer post-assessment support, particularly if sensitive issues (such as childhood trauma) have been discussed.’

35. In line with the above NICE guidelines we have also found, Oxleas should have discussed Mr R’s diagnosis within an MDT. A multidisciplinary team is a group of different clinician professionals who work together to provide care. Within this setting professionals should have considered whether Mr R would have benefitted from a formal psychiatric diagnostic assessment.

36. Our adviser went on to explain that following this, and also in line with the above NICE guidelines, Oxleas should have clearly communicated Mr R’s diagnosis with him. Oxleas did not discuss his diagnosis appropriately or communicate appropriately with him about his diagnosis.

37. If an MDT decided that Mr R likely had a diagnosis of BPD it should then have referred him to a psychiatrist for an assessment. Instead of doing so, Oxleas referred him to personality disorder workshops. Our adviser helped us to understand Mr R’s records show, that despite no formal diagnosis, Oxleas treated him for a personality disorder.

38. We have found Oxleas did not diagnose Mr R in line with NICE guidelines. Additionally, we have found it did not communicate a diagnosis appropriately with Mr R or discuss it collaboratively with him and relevant professionals. For these reasons we have found failings in the process Oxleas’ followed when diagnosing Mr R. We go on to consider the impact of this later in our report.

EMDR

39. Mr R complains Oxleas stopped his EMDR abruptly in 2012, despite it being effective.

40. Mr R started EMDR in March 2012. His notes show this ended abruptly following his appointment in early June.

41. NICE’s ‘Borderline personality disorder: recognition and management’, is very specific regarding the ending of treatments. It says: ‘ending of treatments or services may evoke strong emotions and reactions in people with borderline personality disorder. Ensure that such changes are discussed carefully beforehand with the person and are structured and phased’.

42. Our adviser helped us to understand that ending trauma-focused therapy such as EMDR should be based on clinical evidence. They further explained ending this type of therapy should be collaboratively discussed with the patient, documented with clear rationale, and where possible, planned rather than abrupt.

43. The above NICE guidelines allow for clinicians to change a patient’s treatment if they are deteriorating or not tolerating an intervention. Within Mr R’s medical notes there is no evidence Oxleas discussed the change in treatment collaboratively or that it recorded a clinical rationale for stopping EMDR at the time of the events.

44. We have found the decision to stop Mr R’s EMDR was made by one clinician (rather than collaboratively) who did not document it in line with the above NICE guidelines.

45. We acknowledge earlier in our report, we have not been able to say whether Oxleas incorrectly diagnosed Mr R with BPD. As such we cannot say whether Oxleas should have ended EMDR in favour of the psychoeducational group.

46. However, we have found the way in which it ended EMDR was a failing. We go on to address the impact of this later in the next section of our report.

Oxleas Impact

47. Mr R shared with us a detailed description of the impact of the diagnosis on him. Specifically, Mr R describes being ‘denied the ability to define my own reality’.

48. We have found Oxleas did not follow NICE guidelines when it diagnosed Mr R in June 2012. Additionally, we have found it did not communicate this with Mr R or involve him and relevant professionals collaboratively in the decision.

49. We have also found Oxleas stopped his EMDR therapy inappropriately.

50. We acknowledge a significant length of time has passed since this diagnosis and there is a lack of complete records available to us. As such we cannot be sure whether, had Oxleas correctly assessed Mr R, it would have diagnosed him with BPD or not.

51. We also acknowledge there is no formal documented diagnosis of BPD in Mr R’s records. Despite this there is evidence from Mr R that a psychotherapist told him he had BPD and, in the treatment, Oxleas provided to Mr R following this appointment. Treatment specifically designed to treat personality disorders.

52. Despite this lack of certainty on diagnosis, we have found the failings left Mr R with significant doubt about this diagnosis and his mental health pathway for the 11 years.

53. A different Trust told Mr R he did not have BPD in June 2023. This led him to question his historic treatment. We have found the failings in Oxleas’ diagnosis of Mr R has meant he has been unable to clarify his historic diagnosis or understand if his treatment could have been different. We have found he is left not knowing if his diagnosis, treatment or mental health outcome could have been different.

54. Our adviser went on to explain the psychological impact of prolonged confusion about a diagnosis such as the confusion Mr R experienced, includes self-doubt, and a deterioration in a persons’ ability to make choices and act independently in their daily life.

55. Mr R also explained he feels unsafe using mental health services, unable to trust therapists, and fears using the NHS in the future. We accept these are potential impacts of the failings we have found.

56. Additionally, we must consider that Oxleas stopped Mr R’s EDMR immediately after the diagnosis. We have found failings in the way Oxleas managed this. The impact of these failings was that he was unable to continue with a therapy that he was engaging with or understand the reasons behind ending it.

57. As we cannot say whether Oxleas incorrectly diagnosed Mr R with BPD, we cannot be sure that continuing with EMDR had Oxleas ended it in line with guidelines would have provided a benefit to him. We have found he is left not knowing whether he could have benefited from a continuation of this treatment.

58. As above, we have found Mr R is left not knowing what his diagnosis should have been and whether he could have had different treatment and an improvement in his mental health.

59. We also acknowledge Mr R is left with further questions about Oxleas’ management of his PTSD. Our adviser helped us to understand that Mr R’s underlying condition of complex PTSD requires treatment by trained mental health professionals.

60. Oxleas diagnosed Mr R with PTSD in early 2012. Following the appointment in which he says Oxleas diagnosed him with BPD, it referred him to psychoeducational workshops on personality difficulties and continued his group psychotherapy. We have found this was the incorrect treatment for his diagnosis of PTSD. We cannot say this had a negative effect on him as we cannot be sure Oxleas misdiagnosed him with BPD. We have found it meant he did not receive timely treatment for PTSD.

61. We acknowledge NICE guidelines on PTSD state that earlier intervention is associated with better outcomes in PTSD, and untreated PTSD tends to lead to chronic PTSD. We cannot say for sure this was the case with Mr R but again it leaves unanswered questions for him regarding a better mental health outcome.

62. Oxleas’ ongoing care of Mr R from 2012 onwards was based on the diagnosis of BPD. We have found this diagnosis entered his medical notes through his understanding and influenced his treatment at multiple Trust’s from 2016 onwards. This leaves further unanswered questions for Mr R about whether his diagnosis and treatment could have been different over a period of 11 years before a different Trust told him he did not have BPD.

63. In its complaints response Oxleas did not acknowledge any failings in the diagnosis and treatment it provided to Mr R. It did acknowledge failings in how it communicated the diagnosis to Mr R and that it did not provide an opportunity for him to discuss his diagnosis and formulation. We go on to consider recommendations later in our report.

SLAM

Assessing and treating PTSD and TFP treatment

64. Mr R’s GP referred him to SLAM in 2016, following a traumatic incident and it refused the referral. The referral was to address his diagnosis of PTSD. SLAM did not accept a referral until April 2021.

65. Our adviser explained the reasoning for this refusal was likely in part because of his history of extensive psychological input for BPD from another Trust. Mr R was not accepted for this treatment until April 2021, five years later. He started TFP treatment in October 2022.

66. NICE’s ‘Post-traumatic stress disorder’ guidelines recommend trauma-focused psychological interventions such as trauma-focused CBT or EMDR, as first-line treatments for PTSD. Cognitive behavioural therapy is a talking therapy that helps people to change thoughts feelings and behaviours.

67. The above NICE guidelines recommend these treatments are offered within one month of assessment and diagnosis where possible. NHS England access standards generally expected assessment and treatment commencement within six weeks of referral. There is a maximum waiting time of 18 weeks.

68. SLAM accepted Mr R for ‘Trauma Work’ in April 2021 but did not provide an assessment until June 2022 (14 months later). This is not in line with the above NHS England 18-week guidelines.

69. When Mr R started treatment with SLAM it recorded that he had a diagnosis of both PTSD and BPD. NICE’s guidelines on the management of BPD says: ‘It is usual for treatment to be for both difficulties, such as EMDR for PTSD, and a more relational approach in the case of BPD,’

70. Our adviser explained, standard clinical practice requires treating the primary or acute condition first. A Trust should therefore complete a comprehensive assessment to establish primary and secondary diagnoses and provide treatment matched to the primary diagnosis.

71. Nice’s guidelines on BPD say: ‘Before starting treatment for a comorbid condition in people with borderline personality disorder, review:

• the diagnosis of borderline personality disorder and that of the comorbid condition, especially if either diagnosis has been made during a crisis or emergency presentation • the effectiveness and tolerability of previous and current treatments; discontinue ineffective treatments. Treat comorbid depression, post-traumatic stress disorder or anxiety within a well-structured treatment programme for borderline personality disorder.’

72. Our adviser helped us to understand that SLAM’s assessment process did not clearly establish the prime diagnosis Mr R needed treatment for in line with the above NICE guidelines. SLAM also accepted Mr R’s historic diagnosis of BPD without questioning or confirming it. We have decided this is a failing by SLAM. We go on to consider the impact of this on Mr R later in our report.

73. Following its assessment of Mr R in June 2022, SLAM recommended ‘Psychodynamic/TFP’ as treatment and documented the clinical reasoning as: ‘given the complexity of your traumas - dating back to childhood/attachment, it would be helpful to explore the impact of early experiences which has been triggered by the event in 2016.’

74. Our adviser explained this is a difficult recommendation to understand because TFP is specifically designed for BPD, and not PTSD, which was the main reason for Mr R seeking help.

75. SLAM started TFP in October 2022 (four months after it assessed Mr R). Mr R attended 19 sessions over approximately five months. Our adviser helped us to understand that Mr R’s notes show evidence that the treatment was a poor fit quickly.

76. A clinician noted that Mr R's understanding was ‘largely based on external issues’, ‘as well as a traumatic incident from 2016’, and Mr R ‘often expressed a desire for trauma-specific therapy’.

77. The notes show sessions left him in ‘a highly activated state’ and he experienced ‘marked deterioration in his mood and an increase in suicidal feelings’ following sessions. In April 2023, Mr R stopped TFP after breaking his fifth metacarpal bone.

78. We have found SLAM’s decision to provide TFP was inappropriate as it did not address Mr R’s diagnosis and the reason for his referral, PTSD. The treatment is not supported by NICE guidelines on the treatment of PTSD. We go on to consider the impact of this later in our report.

SLAM Impact

79. We have found failings in SLAM not assessing Mr R appropriately for PTSD and taking forward his diagnosis of BPD without reassessing him. We have found this contributed to failings we have found in the time it took for SLAM to provide appropriate trauma-based treatment. Additionally, we have found SLAM recommended and provided TFP treatment which was not appropriate for his primary reason for seeking help (PTSD).

80. As a result of the failings, we have found Mr R experienced a delay to receiving appropriate therapy for his PTSD. SLAM did not provide appropriate trauma-focused therapy until December 2023, which was over one year after it initially assessed him. This is over six years after the initial referral in 2016.

81. We acknowledge a lack of contemporary records due to the time that has passed. As a result had SLAM assessed Mr R appropriately in 2016, we cannot be sure whether it would have accepted a referral at this point in time. We have found there was a missed opportunity to fully consider his needs and provide a relevant response.

82. Our adviser helped us to understand SLAM had the opportunity and clinical duty to conduct a fresh and comprehensive assessment. Had SLAM done so in 2016, or more thoroughly in 2022, we have found SLAM could have potentially identified and changed Mr R’s BPD diagnosis earlier than it did in June 2023.

83. We have found, the lack of appropriate assessment in 2016 or 2022 also meant SLAM provided TFP rather than more appropriate first-line trauma-focused therapy in 2022. We have found this caused a further delay to Mr R receiving treatment for his PTSD.

84. As above, our adviser explained, NICE guidelines on PTSD show earlier intervention is associated with better outcomes, and untreated PTSD often becomes chronic.

85. Specifically in relation to SLAM’s provision of TFP, our adviser helped us to understand that it is specifically designed for BPD rather than complex PTSD. As an impact, Mr R’s records show a deterioration during treatment, including increased suicidal ideation and a ‘highly activated state’.

86. We note the temporary worsening of symptoms can occur during any form of psychotherapy and therefore we cannot be certain Mr R’s mental health was damaged as a result of the treatment. We could never say for sure that this treatment caused Mr R harm.

87. Additionally, we would never be able to say the Treatment caused Mr R to break a bone in his hand as a direct result of the treatment and failings by SLAM. This is because this may still have happened had Mr R accessed the correct treatment and experienced a temporary worsening of symptoms.

88. Taking the above into account, we have found there was a missed opportunity for Mr R to have earlier treatment for his PTSD symptoms and potentially a better mental health outcome. We acknowledge we could never say for sure he could have had a better mental health outcome, however Mr R is left not knowing. We go on to consider recommendations later in our report.

Combined impact (Oxleas and SLAM)

89. We have found Oxleas’ misdiagnosis meant Mr R missed an opportunity to access appropriate treatment between 2012 and 2016. Additionally, we have found in influenced Mr R’s subsequent treatment and contributed to a delay in him receiving appropriate treatment for PTSD.

90. Additionally, we have found SLAM’s lack of appropriate assessment of Mr R’s mental health in 2016 and 2022 (relying on Mr R’s past diagnosis) delayed a correct diagnosis and correct treatment. We have also found this contributed to him undergoing incorrect treatment.

91. In both Trusts we have concluded there was a missed opportunity for a better mental health outcome for Mr R.

92. We acknowledge the combined impact from Oxleas and then SLAM. We have found the back-to-back failings meant Mr R was left with an incorrect diagnosis and without correct treatment for approximately 11 years. This is an extensive period of time.

93. We have found the length of time involved has only exacerbated Mr R’s mistrust of NHS Trusts and therefore his ability to access appropriate treatment when he needed it. Additionally, this time has been lengthened by the complaints process in which Mr R sought answers to questions he had about the misdiagnosis. This has caused unnecessary distress and anxiety.

94. We cannot say how much Mr R would have benefited from appropriate treatment as this is complex and there are too many factors we cannot be certain of. We acknowledge this means Mr R will never know if his mental health could have improved if the failings had never occurred.

95. Additionally, we cannot say the failings we have found resulted in Mr R accessing private therapy. We can see he started private therapy in 2022, and this ended in 2024. This was whilst he was accessing treatment from SLAM and before he started therapy there. We have found it remained Mr R’s choice to access private therapy at this point in his care.

96. We have considered the individual impact of the failings from each Trust and the cumulative impact. In doing so we have decided the weight of the failings is split equally between both Trusts. This is reflected in our recommendations below.

97. Additionally, we go on to recommend SLAM creates and action plan to address the failings and to prevent them from recurring. We have not recommended the same of Oxleas. This is because a substantial amount of time has passed since the events complained about. In its complaints response Oxleas explained the changes that have occurred since then. In consideration of the above, we do not consider it proportionate to recommend Oxleas creates an action plan.

Recommendations

98. We next considered what the Trusts have already done to put right the impact of the failings we have found.

99. In its complaints response Oxleas stated that it did not give Mr R the chance to decide whether he would have preferred a formal diagnostic process to rule a formal diagnosis of BPD.

100. In considering our recommendations, we have referred to the ‘NHS complaint standards’. These state that where poor service or maladministration has led to injustice or hardship, the organisation responsible should take steps to put things right.

101. As a result of its findings, Oxleas said it would ensure that time is allocated for conversations about diagnosis concerning personality disorder or personality disorder traits and the potential for a formal diagnostic assessment considered with patients. It said it would review the clarity of its communication about diagnosis. This specifically referred to the use of the term ‘traits’ in reference to BPD. We welcome these improvements in communication.

102. We are satisfied Oxleas has made significant changes to prevent the same failings from recurring in line with the ‘NHS complaint standards’. However, Oxleas did not consider a financial remedy as a part of its complaints response. As such we have found there is more Oxleas can do to put right the impact of the failings we have found.

103. In its complaints response SLAM has not acknowledged any failings regarding assessing and treating Mr R’s PTSD in an appropriate and timely manner. It has also not acknowledged failings in providing unnecessary TFP. We have found this is not in line with the ‘NHS complaints standards.’

104. The complaint standards say that public organisations should look for continuous improvement, and should use the lessons learnt from complaints to make sure they do not repeat maladministration or poor service. In line with this, we recommend SLAM creates an action plan to address the impact of the following failings including:

• inappropriate mental health assessments in 2016 and 2022 • delays in the provision of mental health assessments and treatment for PTSD • inappropriate TFP treatment

105. We ask it to do this within three months of the date of our final report (this is our final report).

106. The complaint standards state that public organisations should put things right and, if possible, return the person affected to the position they would have been in if the poor service had not occurred. If that is not possible, they should compensate them appropriately.

107. To decide on a level of financial remedy, we review similar cases where the person has experienced similar injustice, along with our severity of injustice scale. Following this review, we recommend Oxleas and SLAM each pay Mr R £750 in recognition of individual and combined impact of the failings we have described above.

108. We ask Oxleas and SLAM to pay Mr R this sum, within one month of the date of our final report.

1. Mr R complains abouts aspects of care and treatment provided by Oxleas NHS Foundation Trust (Oxleas) and South London and Maudsley NHS Foundation Trust (SLAM).

Oxleas

2. We have found failings in the process Oxleas followed when diagnosing Mr R with a personality disorder. We have found Oxleas did not arrange for a psychiatrist to assess Mr R when it should have or communicate as it should have with Mr R.

3. Additionally, we have found Oxleas inappropriately ended Mr R’s EMDR when it should not have. Eye movement desensitisation and reprocessing therapy is a type of therapy used to treat trauma and other mental health problems.

4. We have not been able to say conclusively that Oxleas incorrectly diagnosed Mr R with BPD. We have found the failings in how it came to a diagnosis and how it communicated this with Mr R meant he understood he had BPD. Borderline personality disorder is a disorder of the mood that affects how a person interacts with others.

5. We cannot say whether this diagnosis was appropriate. As such we have found, Mr R has suffered distress because he will never know if he could have had a different diagnosis, different treatment or whether he missed an opportunity for a better mental health outcome.

6. Additionally, we have found stopping EMDR therapy inappropriately meant Mr R was unable to continue with a therapy that he was engaging with and potentially benefiting from.

7. We have decided we will partly uphold this complaint. We recommend Oxleas pays Mr R £750 in recognition of the impact of the failings on him.

SLAM

8. We have found failings in the care and treatment provided by SLAM. This includes not assessing or treating Mr R’s PTSD when it should have. Post-traumatic stress disorder is a mental health condition caused by stressful, frightening or distressing events.

9. We have also found SLAM inappropriately provided TFP. Transference-focused psychotherapy is a specialised form of therapy specifically designed for people suffering from BPD.

10. We have found the impact of this was Mr R experienced ongoing incorrect treatment for his PTSD. We have also found the actions of SLAM caused him distress and anxiety at a time when he should have been receiving a more appropriate form of treatment. We have found there was a missed opportunity here for Mr R’s mental health to improve.

11. We have decided to partly uphold this complaint. We recommend SLAM completes an action plan to prevent the failings from recurring. We also recommend it pays Mr R £750 in recognition of the impact on him.