Gloucestershire Health and Care NHS Foundation Trust

5. Miss W complains about aspects of the care and treatment her daughter, O, received from Gloucestershire Health and Care NHS Foundation Trust (the Trust) between January 2024 and August 2024. Miss W specifically complains the Trust:

• did not address her daughters school trauma • did not offer appropriate interventions, including formulations sessions, for her daughter and • noted safeguarding issues which weren’t passed on to her daughters’ social worker.

6. Miss W says the impact of the claimed failings has been her daughter’s loss of faith in the CAMHS service, fear of engaging with any professional within a healthcare service, and her education had been disrupted. This included her daughter being unable to complete an entrance exam for a grammar school in summer 2025.

7. Miss W’s personal impact has been paying for a private assessment, to obtain a diagnosis for her daughter.

8. By bringing this complaint to us Miss W seeks financial remedy, for the Trust to reimburse the cost of private treatment, an acknowledgement of how the system should be improved for neurodivergent patients and how these will be put into practice.

9. Miss W also requests an apology and acknowledgement of the extent of impact the failure of this service has had on her, O, and the family.

10. O was referred to the Trust’s Child and Adolescent Mental Health Services (CAMHS) in February 2022 by her GP. The referral request was for anxiety management.

11. A referral assessment took place in February 2022. It was recommended O would benefit from Cognitive Behavioural Therapy (CBT).

12. CBT is a type of talking therapy where a therapist helps you to change how you think and act. It can treat many different mental health problems.

13. In November 2023, the Trust contacted Miss W to offer CBT to O. Miss W said she did not think CBT would be suitable and dramatherapy was arranged as an alternative to CBT.

14. Dramatherapy is a type of psychotherapy that allows the exploration of emotional difficulties through the medium of drama. A drama therapist, who is who is both a clinician and artist, uses a variety of activities to work through different mental health and well-being issues.

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.

Issue 1 – School Trauma

19. Miss W says the Trust failed to address O’s school O during dramatherapy sessions between January and August 2024. She says the Trust had concerns O had experienced school trauma in December 2023 and this was documented in a letter.

20. In the Trust’s response to the complaint, it explained dramatherapy was used to give O a safe space to develop a therapeutic relationship with the practitioner. It had not identified any concerns with the approach and felt trauma factors were considered when providing care and treatment to O.

21. The Health and Care Professionals Councils standards say practitioners should work in partnership with service users and carers, involving them, where appropriate, in decisions about the care, treatment or other services to be provided.’

22. Our adviser told us the Trust took a range of considerations and made reasonable attempts to engage and support O. This included offering CBT, providing dramatherapy and offering formulation sessions with a psychiatrist.

23. Our adviser said trauma is not always explored or worked through in therapy as therapy to address trauma is generally delivered by psychotherapists or psychologists. They also said not all registered mental health professionals have the required knowledge and skills to actively explore and provide therapy for trauma.

24. Having reviewed the records, we can see O attended dramatherapy regularly before deciding to end the sessions. We understand, by that point, she found the sessions frustrating and felt pressured to challenge her thinking. We recognise this would be difficult for anyone, particularly a teenager managing complex conditions.

25. We can see the Trust discussed dramatherapy with Miss W before O’s first session took place. Miss W explained O had engaged well with play therapy in the past and felt a holistic route would be best.

26. In December 2023, O attended her first session and spoke to the drama therapist about her experience in a mainstream school. Following the second session the drama therapist made contact with O’s registered school to understand more about O's experience in education.

27. In further sessions, the drama therapist worked with O to inspire self-empowerment while exploring feelings, thoughts, and her life experiences from the previous week. O was able to identify the therapeutic goals she wanted to work with.

28. The drama therapist later introduced a goal to understand past traumas and work through these creatively. This was discussed with Miss W and it was suggested CBT was integrated into the dramatherapy sessions.

29. CBT was introduced in the next session and discussions about how O’s past experiences impact her intrusive thoughts and future fears were discussed. After the session Miss W contacted the Trust as she was worried about comments O had made after leaving dramatherapy. The drama therapist explained difficult themes were being explored and how these may bring up difficult feelings. As an outcome of the conversation it was agreed the CBT aspect of the sessions would stop and sessions would return to being dramatherapy focused.

30. In further sessions O explored how she felt about her autism and obsessive compulsive disorder (OCD).

31. Autism is a difference in how someone’s brain develops that affects how they see and experience the world. OCD is a mental health condition where a person has obsessive thoughts and compulsive behaviours. These can cause anxiety and lead to repetitive behaviours.

32. We can see the drama therapist explored a specific instance where O shared concerns about working with two new teachers. O later reflected she had begun to use her voice and speak up when the teachers did things she felt were not ok.

33. Our adviser told us O’s needs and risks were varying over the time of the appointments. We have reviewed the records and can see the drama therapist was working with O in a considered approach. They were mindful of the request to provide therapy at a pace suitable for O and explored trauma in sessions where she identified this as a topic for discussion.

34. When O wished to explore other themes in sessions the drama therapist worked with O and the needs she presented with on the day. When Miss W and O expressed concerns about progress steps were taken to consider other therapeutic approaches.

35. Having reviewed all the available evidence, we have seen no indications the Trust failed to address school trauma. The therapy which took place was agreed with Miss W and took place in consideration of O’s needs.

Issue 2 - Interventions and formulation sessions

36. Miss W says the Trust failed to offer appropriate interventions, including offering formulation sessions, for O. Miss W says the Trust should have provided formulations earlier in the therapy journey and realised the extent of O’s issues and had the relevant professionals involved.

37. In the Trust’s response to the complaint, it said formulation clinics were originally set up to address long waiting lists. The Trust said formulation clinics were not something it offered when O reached the top of the waitlist for treatment. It also said formulation clinics took place when a young person was first referred to the service and there was limited information about the young person and their needs.

38. The Trust also explained formulation sessions were not used as a general intervention by the team working with O. However, when O’s treatment plan broke down and engagement with O and Miss W was lost the Trust said it was felt necessary to use the formulation protocol. It said the reason for using formulation at this time was to evaluate O’s care plan.

39. Our adviser told us the Trust took a range of considerations and made reasonable attempts to engage and support O. This included considering her diagnosed conditions and the impact therapy would have on them. The Trust noted O’s diagnosis of Generalised Anxiety Disorder (GAD) and first offered CBT, when she reached the top of the wait list. This was an appropriate evidence-based intervention for someone with GAD.

40. GAD is when a common mental health condition which leads to feeling very anxious about lots of different things. The main symptom of GAD is feelings of stress or worry which affect daily life and are difficult to control.

41. When Miss W said she did not feel CBT was the correct treatment for O the Trust offered dramatherapy. Our adviser told us they had no concern about this intervention (dramatherapy) being offered.

42. The adviser also told us the records show the dramatherapy sessions functioned in part as an ongoing mental health review. They said O’s mental health and risk were actively considered within this work and reference the exploration of OCD related symptoms such as concerns about germs as evidence of this.

43. The adviser also saw when concerns were identified about post-traumatic stress disorder in June 2024 the drama therapist made an appropriate referral to a psychiatrist for further formulation and assessment.

44. The British Association for Behavioural and Cognitive Therapists (BABCP) say practitioners must keep within their scope of practice and only practise in the areas in which they have appropriate education, training and experience. The guidance further says there is a duty for practitioners to refer service users for further treatment if it becomes a task is beyond your own scope of practice.

45. We can see the Trust assessed O in February 2022 and made a referral for CBT at that time. The Trust contacted Miss W in November 2023 and discussed O attending CBT sessions. Miss W said she did not think CBT would be suitable for her daughter. Dramatherapy was arranged as an alternative to CBT.

46. Throughout the sessions we can see the drama therapist was working to support O with how she presented in the sessions. We can further see the drama therapist engaged with Miss W when introducing CBT was seen as a useful step. We can also see when Miss W felt CBT was not suitable for O the drama therapist returned to the previous approach.

47. In January 2024 the drama therapist reached out to O’s social work team. This was to request O and her sibling were assigned the same Social Worker. The therapist told the social work team the continuity for the family would be helpful.

48. In February 2024 we can see the drama therapist made contact with O’s school, which she had recently stopped attending. The drama therapist spoke to the headteacher to discuss O’s experience at the school and the conversation was arranged to inform formulation with dramatherapy sessions.

49. In April 2024 the drama therapist contacted O’s Social Worker to request a check in and asked to be invited to an upcoming Children in Need meeting about O. This was discussed with Miss W and was arranged so the drama therapist could get a holistic view of how all services involved with O could support her.

50. Unfortunately, the drama therapist was unable to attend the meeting but a request for the minutes was made to the Social Worker. The Social Worker was also advised they could contact the Trust if any concerns about O’s mental health were raised during the meeting.

51. Miss W made weekend contact with the Trust’s Crisis Resolution and Home Treatment Team due to her concerns about O in May 2024. The team noted the concerns, told Miss W what actions she could take if she thought immediate support was needed and emailed the team supporting O. This included the drama therapist and duty clinicians.

52. On the next working day, a member of staff contacted Miss W to discuss her concerns and arranged a same day appointment for O. During the appointment the practitioner holding the session introduced an exercise to help O with some of the less distressing thoughts she had.

53. The next day the practitioner attended a Multidisciplinary team (MDT) meeting to discuss how the Trust work with O and to consider if a family care coordinator was needed.

54. The drama therapist met with Miss W and O on 16 May and offered Miss W a 1-1 space to explore how to support young people with OCD through OCD psycho-education. Miss W was advised she could think about it and a booking could be made if she felt it would be helpful.

55. On 23 May, Miss W spoke to the drama therapist about O experiencing a change in coping ability and intrusive thoughts. The drama therapist explained the boundaries of their work and that CBT is the first line intervention. They offered to reintroduce an integrated approach of dramatherapy and CBT.

56. In June 2024 there was a Children in Need meeting attended by the drama therapist, Miss W and O’s social worker. During the meeting a discussion about O’s increased anxiety took place. The drama therapist said they would raise these concerns with the Multidisciplinary team (MDT) or would refer O to a psychiatrist. A medic referral was made the next day and O was placed on the psychiatry waiting list.

57. In July 2024 the drama therapist raised O’s case during a medical referral meeting, and it was decided an MDT meeting with the family would be arranged. The notes show a Consultant Child and Adolescent Psychiatrist would also be invited to attend.

58. At this stage further dramatherapy sessions were scheduled and the Trust were working to see what other support options they had for O. When O said she no longer wanted to attend dramatherapy the drama therapist looked for alternative support and made a referral to a class where O could continue to engage in music.

59. Having reviewed all the available evidence, we have seen no indications the Trust should have offered different interventions or could have provided formulation sessions at an earlier part in the journey.

60. Our observation is through the dramatherapy sessions the Trust were gathering more information about what was going on for O, how she was struggling and how she was presenting.

61. As her emerging deterioration became known and Miss W’s concerns that O had PTSD the Trust put in place measures so further assessments could take place.

Issue 3 - Safeguarding concerns and referral

62. Miss W says safeguarding issues were noted during O’s contact with Trust between January and August 2024 and these were not shared with O’s social worker. Miss W has expressed concern about safeguarding concerns being noted and believes if there were safeguarding issues these should have been shared with the Social Worker.

63. The Trust advised O clinical notes of 13th November 2024 documented safeguarding concerns were provided to CAMHS. The Trust said there was no evidence it saw or spoke to O about this information.

64. The Trust further said following the outcome guidance from Serious Case Reviews the clinicians are demonstrating good practice by being concerned about the well-being of a young person they cannot see or corroborate the information provided with.

65. The Trust confirmed it had consulted with the social worker and were sorry for confusion caused. It advised this would be addressed during supervision with the clinicians involved about communicating clearly with families.

66. Our adviser reviewed records covering the period of complaint and could find no reference in the records of safeguarding concerns which would need to be escalated. Our adviser did see communication and information sharing between the Trust and O’s social care team did take place.

67. The Working Together to Safeguard Children guidance sets out the expectation that safeguarding is a multi-agency responsibility, requiring clear information sharing and joint decision making.

68. We have reviewed the records and can see there were internal discussions within the Trust where safeguarding was noted. We can also see the Trust were communicating with O’s social worker throughout the time she was attending dramatherapy.

69. We can see the Trust explored thoughts about safeguarding, specifically about future discharge, in a team meeting in May 2024. This followed concerns about O’s change in presentation and her struggles with OCD symptoms and intrusive thoughts at that time.

70. We can also see a safeguarding team meeting to discuss O and her family took place on 28 June 2024, with a further meeting taking place on 31 July 2024. In the second meeting a safeguarding note was added to O’s record, and this noted the Trust’s concerns around patterns of past broken down placements and concern of this repeating.

71. We have reviewed the records and can see no evidence the Trust failed to raise safeguarding concerns with O’s social worker. When safeguarding matters were discussed these were internal discussions and did not require further action. For this reason we have not identified any indication of service failure as the Trust acted in line with guidance.

72. We understand Miss W and O will be disappointed with this decision. We hope our reasoning reassures them we investigated the complaint thoroughly. We cannot find any evidence which says the Trust should have done more to address the issues brought to us.

1. We have carefully considered Miss W’s complaint about Gloucestershire Health and Care NHS Foundation Trust (the Trust) on behalf of her daughter, O. We are sorry to hear of O’s experience and the matters Miss W has complained about.

2. We appreciate the time O has spent in treatment has caused emotional distress. We assure Miss W in reaching our decision we have carefully considered the concerns she has raised.

3. Based on the information made available, we have seen no indication that anything went wrong in the care and treatment provided by the Trust.

4. We understand our decision will be disappointing for Miss W and O. We hope our thorough consideration set out below offers some reassurance and will go some way to helping them understand our reasoning.