Surrey and Borders Partnership NHS Foundation Trust

4. Ms D complains about the care and treatment provided by Trust A and Trust B to her daughter L, between May 2023 when Dr U took on the role of care coordinator, to 7 March 2024, when Trust B withdrew its services.

5. Specifically Ms D complains: • Trust A deliberately withheld information from Service for Complex Autism and Associated Neurodevelopmental Disorders (SCAAND, a tier four mental health service) • Trust A and B failed to discuss the contents of SCAAND’s report with the family or record their views in L’s records • Dr U took around ten months to provide a comprehensive agreed upon care plan • for L • Dr U failed to provide any clinical impressions of L • Trust B’s discharge process and rationale for discharge are unsupported.

6. Ms D says L’s care and treatment was compromised and she missed opportunities to achieve significantly better clinical outcomes, both whilst under the Trusts’ care and during her transition to adult services.

7. She says L’s trust and confidence in NHS services is affected and she and L are concerned about the quality and accuracy of records and their ongoing effect on L’s care. Ms D says this is especially serious given L’s severe communication difficulties.

8. Ms D is seeking a written acknowledgment of failings, apology, service improvements, and a financial remedy in recognition of the distress and lost opportunities.

9. L has a complex history with her mental and physical health, and with her experience of mental health services. In May 2023 Dr U took on the role of coordinating L's care.

10. During this time L also sought support from GP and paediatric services. Her paediatrician made a referral to tier four mental health services SCAAND.

11. On 19 July SCAAND wrote to L’s paediatrician about the referral. It did not accept the referral and asked for it to come from Trust A.

12. On 26 July L’s paediatrician wrote to Trust A to ask it to refer L to SCAAND. It included a summary of the information SCAAND had requested following initial contact with the paediatrician and a copy of its response.

13. Trust A received the letter on 17 August. It sent a referral to SCAAND on 24 August.

14. On 10 October SCAAND advised the referral had been accepted for an initial professionals-only consultation.

15. Trust A met with SCAAND on 30 November 2023.

16. On 1 Feb 2024 the CAMHS service transferred to Trust B as part of a restructure.

17. L’s care was also transferred.

18. On 7 March 2024 Trust B discharged L from its services.

Trust A deliberately withheld information 22. Ms D says the Trust failed to respond to her offer of additional reports to support the referral to SCAAND. She says this meant that essential information was omitted and the referral was not adequate. Specifically: • an updated EP (educational psychologist) report • an updated and complete, agreed care plan referencing L’s support in school or adequate risk and safeguarding concerns • the family’s view of the gaps in L’s support and L’s own preferences or experiences • a full history of L’s 13 years of involvement with the service including L’s diagnosed mental health and neurodevelopmental conditions • views of other clinicians involved in L’s mental health care whilst under CAMHS (such as paediatricians).

23. SCAAND’s referral form says the referrer (in this case Trust A) should attach any relevant information. It lists EP reports as an example of relevant information.

24. Ms D told us she sent emails to Trust A on 13 and 26 October and 29 November 2023 relating to additional evidence.

25. Ms D says without the listed information SCAAND did not have a clear understanding of L’s cognitive level. She says consequently it was prevented from making relevant recommendations and L has missed the opportunity to receive tailored support as she transitioned to adult services.

26. Our review of the records found Ms D offered to provide Trust A with a full EP report on 13 October. We cannot see any direct acknowledgement or response to this from Trust A.

27. On 26 October Ms D again asked Trust A if it needed any additional reports from her ahead of the meeting. Trust A responded to this email but did not comment on the reports.

28. Ms D also says she offered the report on 29 November, we cannot see evidence to support this, but we have seen Trust A sent an email on 16 November which said ‘The SCAAND team have all the recent tutor reports. OT reports, SALT reports and Dr report that you have sent us.’ This refers to the bundle Ms D provided on 24 August 2023.

29. Ms D had a significant amount of communication with Trust A. This was understandable, she had concern for her daughter and wanted help with what was clearly an extremely challenging situation.

30. Equally we can see evidence Trust A was struggling to manage the level of communication and provide adequate and timely responses.

31. It is our view there was an opportunity for Trust A to clarify if it needed to add the documents Ms D was referring to. There was also an opportunity for Ms D to send the document itself to Trust A (rather than offer to), if it was her view it was necessary. We can see she had sent other reports previously.

32. The SCAAND referral criteria suggests EPs and other documents may be relevant but it is not explicit that they must be included in a referral.

33. The referral form suggests the EP report was relevant and the emails from Ms D show she did offer to provide an additional report. It became clear SCAAND explicitly needed an EP report when it was discussed during the consultation on 30 November.

34. We also recognise Trust A’s own investigation identified an updated safety plan would have been useful.

35. We asked our adviser if the referral was in keeping with guidance.

36. Our adviser explained the referral letter was the key document and in their experience this was in keeping with L’s records and what they would expect to see. Our adviser said this is supported by SCAAND’s subsequent action to arrange an appointment.

37. SCAAND’s report shows its clinicians were able to review a range of assessment reports and clinical documentation for L prior to 30 November. It also noted the history of service involvement was summarised by the local clinicians from Trust A present in the consultation.

38. We can see there was a missed opportunity for Trust A to recognise Ms D’s contact and supply that information at the time of referral. Trust A has also recognised it could have provided more information in hindsight. Despite this its referral was in keeping with expectations and the SCAAND criteria.

39. Additionally, we cannot see any evidence Trust A had a conversation or chose to deliberately withhold information from the referral.

40. Taking all these factors into consideration, we can see there was an opportunity to provide a more comprehensive referral. However, we would not go as far as to say the Trust’s actions fell so far short of the expectation that we consider there was a failing in the standard of care provided.

Contents of SCAAND’s report 41. Ms D complains neither Trust A nor Trust B took steps to talk through the contents of SCAAND’s report with the family. She says she was not given the option to clarify the contents and the Trusts did not answer any questions the family had.

42. Ms D says instead the Trusts treated her concerns as a complaint, which meant the family’s comments were not recorded in L’s records.

43. HCPC guidance says clinicians should give service users the information they want or need, in a way they understand.

44. Records show Ms D had clearly wanted to be involved in the clinicians-only referral meeting with SCAAND on 30 November. She then actively sought information from Trust A about the discussion after the meeting.

45. We have also seen SCAAND asked Trust A to talk through the report with the family. It did not specify a timeframe for this.

46. On 7 December Trust A emailed Ms D to confirm the meeting had taken place and it planned to book an appointment in January to discuss the recommendations with her. It explained it was waiting for SCAAND’s report to be finalised and shared.

47. Ms D responded on 11 December and explained she had directly contacted SCAAND, and that she found it deeply distressing that the recommendations could not be shared until the following month. She said she was worried the care L needed could not be provided in the timescale before she transitioned to adult services.

48. Trust A responded on 14 December. It explained it was still awaiting the report and it did not know if it would arrive before Christmas. It said it was in the process of coordinating dates for January amongst the three members of staff who would be at that meeting.

49. Trust A told Ms D in the meantime, L’s OT had agreed to feedback general suggestions as she was due to see Ms D sooner than January.

50. On 18 December Ms D responded to Trust A and explained L’s OT was not expecting to discuss psychological recommendations with her and had not made notes regarding this. She stressed she would like to meet with the relevant mental health professionals regarding this and asked for availability.

51. On 22 December, Trust A acknowledged the response and explained L’s psychologist would be in touch in January.

52. On 3 January 2024 Ms D sent an email explaining her dissatisfaction with L’s care. On 5 January Trust A acknowledged the email. It said it was yet to receive the report but offered an appointment for 17 January. Trust A received SCAAND’s report the following week.

53. The records show staffing availability meant there was delay in initially providing an appointment time for the feedback. However, given the time of year it was reasonable that staff were taking leave over Christmas. Additionally we note the finalised report was not made available to Trust A until a week before the appointment was scheduled.

54. We are not critical of the decision to wait for the full report before discussing its findings, or of the time it took to arrange the appointment. We consider the communication plan was appropriate and for that reason we are satisfied Trust A acted in line with HCPC guidance in its updates to Ms D.

55. Ms D complains when she raised concerns about SCAAND’s report Trust A treated this as a complaint. Consequently her concerns about the report are not logged in L’s records and available for future clinicians. She says this means future clinicians may implement SCAAND recommendations without knowing the harm they may cause L.

56. We recognise Ms D’s frustration and worry about her daughter’s future care.

57. Firstly we considered if was reasonable for the Trusts to address these concerns as a complaint.

58. Ms D was clearly unhappy with the report and sent several emails expressing her concerns. They spanned the transition between Trust A and Trust B. Her emails have been logged in L’s records, but the Trusts responded to her concerns via the Trusts’ complaint processes.

59. NHS complaint standards define a complaint as an expression of dissatisfaction – either spoken or written- that requires a response. Ms D’s correspondence clearly met this criteria.

60. Once a concern is treated as a complaint then NHS complaints standards and record management code say complaints should be kept separate from clinical records.

61. For this reason we are satisfied the Trust has followed this guidance in addressing Ms D’s concerns through a complaint process. We are not critical of the Trusts’ decision to keep complaint records separate, this was in keeping with guidance. This means the information was not directly recorded in L’s records.

Care plan and clinical impressions 62. Ms D complains Dr U took around ten months to provide a comprehensive agreed upon care plan for L. She also says Dr U never shared any clinical impression of L.

63. Records support Dr U informed Ms D she was completing these documents in May 2023. It took Dr U ten months to finalise the care plan and they never completed their clinical impressions prior to L’s discharge in March 2024.

64. Clinical impressions and formulation refers to a theoretical explanation of an individual’s psychological difficulties. They help patients and those involved in their care understand their presentation in a concise way.

65. HCPC guidance says practitioners must listen to service users and carers and take account of their needs and wishes.

66. Additionally the Trust’s CPA policy says developing the care plan will start at the outset of each assessment and it may take time for a clear view to emerge. It says care plans should be reviewed as a minimum every 12 months.

67. Our adviser explained there is no specific timeframe for completing a care plan or clinical impression in the guidance but it forms part of the initial assessment process.

68. In Trust B’s complaint response it said Dr U could not complete a person centred care plan and clinical impression as they could not meet L face to face.

69. Ms D disputes the rationale provided and says a care plan completed on 8 February identified how to engage with L successfully, and a social worker assessment from 19 February demonstrated L could meaningfully contribute to her care planning.

70. We asked our adviser what we would expect to see in this situation. Our adviser explained in their experience in complex cases (such as this case due to multiple reported diagnosis and other difficulties) it can take months or even longer to form effective care plans and clinical impressions.

71. They also highlighted nationally children’s mental health services are extremely overstretched and patients often face long waits for services. This has been formally recognised and commented on in the CQC guide.

72. We have seen there were several care plans in L’s records two of these were noted to have been completed by Dr U.

73. We also recognise Dr U’s comments in the referral to SCAAND specifically say they have been unable to instigate meaningful work (psychological), as it has not been possible to manage L’s complexity.

74. Our adviser explained this does seem to represent a clinical impression, but not a diagnosis or comprehensive formulation, as you may normally see. They explained in their experience in escalating care to SCAAND, Trust A was recognising the difficulties in reaching a sound clinical impression.

75. Good practice guidelines explain developing a psychological formulation, whilst a core skill for a clinical psychologist, is a complex and potentially time consuming process. The main purpose of a formulation is identifying the best way forward and informing the intervention.

76. Taking all of this into consideration we can see a care plan and clinical impressions were key concerns for Ms D. There were opportunities for Dr U to discuss this with her to clarify the difficulties and reassure her of what was happening.

77. We note the referral to SCAAND was not prompted by Trust A, but we are not critical of that. We are satisfied it coincided with a logical point in Dr U’s work that supports their statement they were unable to instigate meaningful work.

78. While there was significant delay and we can see why this caused Ms D frustration and concern about L’s care, we also recognise the complexities of her condition and the demands on the service.

79. We can see there was an opportunity for this to have been handled differently. Despite this we have not seen any evidence the Trusts fell so far short of the guidance and expectations that we would consider it a failing.

Discharge 80. Ms D says Trust B’s discharge process and rationale for discharge are unsupported. She says a care plan and social worker assessment were ignored and clinicians did not make any attempt to meet with L between August 2023 and Trust B’s decision to discharge.

81. On 7 March 2024 the Trust withdrew its service. Trust B’s complaint response says when L was transferred to Trust B, consent had already been removed and the only remaining action for it to complete was a referral, and to share relevant documents with LD services. Ms D told us consent was not withdrawn until two weeks post referral.

82. Trust B says the referral was completed externally (initially thought to be by Ms D but later found out to be by social services). As consent to discuss with other agencies had been withdrawn, there was nothing further for Trust B to do, it said no information or formulation will be shared. It could not complete any further action.

83. Trust B said it would be happy to discuss L with the LD service if she would like this. Trust B said it had no need to extend the timeframe or offer face to face appointments as the referral had been completed.

84. Ms D says Trust B did not consider extending its services to allow to adequately plan a transition before withdrawing.

85. In relation to transitions to LD adult services, Trust B’s transition policy says there may be circumstances where it is in the best interests of the young person to remain involved past the transition date. It says where the young person is newly referred, it may be appropriate for both services to undertake a joint assessment and consider joint work for a period.

86. The guidance also says the process should fully take account of the young person’s views.

87. While the guidance suggests there was room to extend the transition period, Ms D’s withdrawal of consent on L’s behalf limited the action Trust B could take. Additionally, we can see the referral to adult services had been made and consequently the risk to L’s continuing care was not of concern.

88. The Trust’s rationale for discharge was age and consent. L was reaching 18 years of age, which is the usual transfer point from children’s services. She had already been referred to an adult specialist service.

89. From the records it appears that an appointment had already been arranged for this service. Although her transition had not been formally accepted, there were no concern about the continuation of her care provision.

90. Given the restrictions around consent shortly after transfer we are satisfied Trust B respected the views of the family in line with the transition guidance.

91. There was an opportunity to extend the transition period but given the fractured relationship and limitations we have not seen any reason to suggest this was a necessary action. There are no indications of failings in this part of the complaint.

Conclusions 92. We found no failings in Trust A or Trust B’s actions, however we did identify areas where we saw the process could have been better for Ms D and L.

93. We recognise Ms D sees missed opportunities for better outcomes for L and we understand her frustration. We sincerely hope our detailed and thorough consideration reassures Ms D the service was in keeping with relevant standards and guidance and this means L was not substantially disadvantaged in her care.

1. We were sorry to hear about Ms D complaint. We recognise the worry these event has caused her and we appreciate the difficulties she has faced accessing appropriate support for her daughter, L.

2. Whilst we saw there were opportunities to improve on the communication and information sharing regarding L’s care, neither Trust A nor Trust B’s actions fell so far short of expectations that we would say there were failings in the service L received. For this reason, we do not uphold this complaint.

3. We hope our explanation reassures Ms D that her daughter’s care was in keeping with the relevant standards.