Sussex Community NHS Foundation Trust

9. Mr A complains about his experiences with his local mental health services when trying to seek support in 2024.

10. Mr A complains that the Surgery incorrectly referred him to the Specialist Perinatal Mental Health Services in January 2024.

11. Mr A complains about the SCFT. He complains that it failed to treat his case as a perinatal referral on two occasions in February 2024, and that he was not seen within the recommended timeframe of the perinatal care pathway for his initial assessment session late March 2024) and initial treatment session (late April 2024). He also complains that in late May 2024, the SCFT misled him to believe he had been discharged from all mental health services.

12. Mr A complains about the SPFT. He complains that the SPFT assessment and treatment service (ATS) incorrectly referred him back to the WSTT in late May 2024, without a clear treatment plan, and that the referral criteria for the specialist perinatal mental health services is unclear.

13. Mr A explains that the delays in him being referred to the most appropriate services have caused a significant and lasting impact on his mental health, as this burden has been weighing on him for almost a year. He tells us this has caused significant distress for his family and has impacted his relationships with his wife and his son. He also says because of the delays in the provision of mental health treatment, he was forced to seek private care at the cost of approximately £3,000, as he felt he was being passed between services without any progress being made and thought he had been discharged due to the poor communication about the services pathways.

14. As an outcome to his complaint, Mr A is seeking the reimbursement of the cost of his private health care fees, as well as a financial remedy which reflects the emotional impact and inconveniences he has faced.

15. Mr A contacted his GP in early December 2023 as he felt his anxiety was worsening as his wife was pregnant and her due date was approaching. The GP agreed to increase his medication vortioxetine (an antidepressant medication) from 10mg to 20mg, prescribed a small quantity of diazepam (medication used to treat anxiety), and planned to follow up with him in ten days. The GP checked in with Mr A in mid-December and reviewed his medication. Mr A reported he was feeling better with the medication increase.

16. In mid-January 2024, Mr A contacted his GP and explained he was having poor sleep due to the newborn baby and could feel his mental health deteriorating. The GP discussed medication and support with Mr A and agreed to look into perinatal mental health support for him.

17. The GP contacted Mr A a few days later to advise that the Sussex specialist perinatal mental health service only provided services to women and signposted new fathers to Time to Talk (provided by the SCFT through WSTT) for new fathers. WSTT is a time-limited psychological therapy service that provides treatment in line with the National Institute for Health and Care Excellence (NICE) guidelines for anxiety and depression, and the NHS Talking Therapies for anxiety and depression manual.

18. The GP also suggested contacting MIND for further support. MIND is a mental health charity which provides information and support to those living with mental health problems.

19. Mr A’s GP spoke to him in his son’s emergency appointment in late January in which it is recorded he reported feeling a bit better. In early February, Mr A reported nightmares and not getting much sleep, and the GP discussed a plan for getting more rest to help his mental health.

20. In mid-February, Mr A self-referred to the WSTT service. The service contacted him in late February to book in an initial telephone assessment. This was booked for late March 2024 and confirmed by letter.

21. On the same day, Mr A submitted an e-consultation form to request an appointment with the GP to discuss his anger and frustration related to postnatal depression and anxiety.

22. Mr A spoke with his GP in mid-March 2024, he explained he had noticed he was getting more frustrated and mentioned concerns about possible diagnoses of bipolar disorder or emotionally unstable personality disorder (EUPD – also known as borderline personality disorder or BPD). Bipolar disorder is a mental health condition characterised by significant mood swings. EUPD is a mental health condition characterised by instability in mood, self-image and interpersonal relationships.

23. The GP encouraged Mr A to explore his feelings with WSTT in his upcoming appointment and planned to review Mr A in two to four weeks to see if he needed a further referral for psychiatric assessment.

24. Mr A had his WSTT assessment in late March 2024. The outcome of this assessment was to offer guided self-help through telephone treatment sessions. The sessions were based on cognitive behavioural therapy (CBT) techniques. CBT is a type of talking therapy and is a common treatment for a range of mental health problems. It teaches coping skills and focuses on how thoughts, beliefs and attitudes affect feelings and actions. Mr A was placed onto the waiting list.

25. A few days after the appointment, WSTT wrote to Mr A’s GP to highlight his level of risk and provide a copy of the risk management plan. It explained that it would not be able to monitor Mr A’s risk whilst on the waiting list for therapy and had told Mr A to book an appointment with his GP to explore further support and monitor risk. On the same day WSTT spoke with Mr A and agreed on video calls to work through guided self-help for behavioural activation and stress management.

26. In mid-April 2024, WSTT spoke with Mr A to arrange his first session for late April 2024 and confirmed this by letter. During the appointment the practitioner assessed Mr A’s risk level and talked through how he was feeling. They decided to make a five-day priority referral to ATS. The practitioner contacted the ATS on their urgent line, and it was agreed they would assess Mr A. The ATS (provided by SPFT) provides a point of entry to secondary adult mental health services and provides a range of medical, psychosocial and psychological evidence-based interventions in line with NICE guidelines and interventions agreed by the SPFT.

27. In late April, WSTT wrote to Mr A’s GP to highlight his level of risk, provide a risk management plan, and to advise that they had decided to refer Mr A to the ATS for an assessment. On the same day, the WSTT practitioner contacted Mr A to advise he would be discharged from the Time to Talk service so that he could be assessed by the ATS. The ATS contacted Mr A the following day to confirm receipt of the referral.

28. Mr A had a telephone appointment with his GP on in late April 2024 and they discussed the referral to the ATS. They also discussed the possibility of an autism assessment as Mr A had discussed this with WSTT. The GP noted they would await correspondence to see if this is something WSTT were planning to do or if they were expecting the GP to do it.

29. On the same day, Mr A wrote to his GP setting out his request for a referral for an autism assessment. Mr A set out the reasoning for his request and explained that his mental health had deteriorated recently. He also provided results of some self-assessments he had undertaken for attention deficit hyperactivity disorder (ADHD) and autism. ADHD is a condition that affects the brain, it can affect an individual’s ability to pay attention to things, their energy levels, and their ability to control their impulses. Autism is also a condition that affects the brain, it can affect how individuals experience and interact with the world.

30. In early May 2024, the ATS wrote to Mr A to offer him an appointment for mid-May 2024. A few days later, the GP sent a referral for an autism assessment to the neurodevelopment team at the SPFT.

31. In mid-May 2024, the ATS wrote to Mr A following his appointment. Following his initial assessment, they developed a care and treatment plan and discharged him from the service. The ATS referred Mr A back to WSTT.

32. In late May 2024, WSTT wrote to the ATS explaining that they had screened the referral and noted emotional regulation work had been requested. WSTT explained it does not offer this treatment, and suggested Mr A could ask his GP to refer him to the Emotional Wellbeing Service (EWS). The letter stated Mr A had also been discharged from WSTT. The EWS provides targeted mental health and holistic support to people who are struggling to access services and have a broader need than any one provider can address.

33. In mid-June 2024, Mr A spoke with one of the mental health practitioners (MHP) at the Practice. He explained the timeline of events and that he was confused and not sure where to turn. They spoke about his mental health and his current level of risk. The MHP noted they had advised Mr A to present to Accident & Emergency (A&E) if his suicidal thoughts escalated and referred him to the EWS.

34. In late June 2024, the SPFT wrote to Mr A to advise he was on the waiting list for an autism assessment.

35. A couple of days later, the EWS had a consultation with the MHP from the Practice to discuss the referral.

36. In late July 2024, the EWS reviewed Mr A and carried out a risk assessment. They agreed to support Mr A whilst he was undergoing assessments with his private provider and deciding on how he wished to proceed with his mental health care and treatment.

37. Mr A had regular appointments with the EWS between July and December 2024. He began CBT with a private provider in January 2025.

The Surgery

41. Mr A complains that the Surgery incorrectly referred him to the specialist perinatal mental health services in January 2024 and says the lack of knowledge and understanding of local services caused a delay in him being referred to the most appropriate service.

42. In response to the complaint, the Surgery explained that the GP contacted the peri-natal services and was informed the service would not be able to see Mr A, as it could only accept referrals for new mothers. At this point, it could then extend support to fathers, supplementary to maternal care. For this reason, the GP advised Mr A to self-refer to the ‘Time to Talk’ service and signposted him to the charity MIND to explore the resources available for new fathers. The Surgery also added that it continued to see Mr A regularly throughout February and March to provide ongoing support whilst he waited for an assessment with Time to Talk.

43. We have reviewed this aspect of the complaint with our GP adviser. NICE G222 recommends clinicians discuss treatment options with people who have a new episode of more severe depression and match their choice of treatment to their clinical needs and preferences (point 1.6.1). Within the guidance is a table which provides options of first-line treatments to discuss with patients. The options listed include increasing medication alone, and a combination of talking therapies and medication.

44. In reviewing Mr A’s medical records and considering his medical history, we understand he had already been diagnosed with depression and anxiety and was prescribed medication to manage this. Following discussion in December 2023, the GP agreed to increase his medication as an initial measure.

45. We can see the GP followed up with Mr A around two weeks after the initial increase in medication to see how he was getting on. When Mr A contacted the GP in January 2024 advising his mental health was deteriorating further, the GP looked into the options available for perinatal support for Mr A and advised him to self-refer to talking therapies. We can see Mr A did this in February 2024, and an initial appointment was booked for the end of March 2024.

46. We consider the GP took appropriate actions to support Mr A with his mental health in line with NICE G222. We have not seen any evidence that the GP made an incorrect referral to the perinatal services. Instead, we can see that the GP enquired about the services available for new fathers, and this led to the recommendation to self-refer to talking therapies.

47. We do not consider the actions of the Surgery contributed to the subsequent delays Mr A faced in being seen by the most appropriate service. We will explore these delays in the following sections of this report.

48. For these reasons, we have not identified a service failure in the actions of the Surgery, and we do not uphold this aspect of the complaint.

SPFT – referral criteria

49. Mr A complains that the referral criteria for the specialist perinatal mental health services is unclear and this led his GP to referring him to this service when it was not suitable for him.

50. In response to the complaint, the Trust apologised Mr A was denied access to perinatal mental health services. It explained that the specialist perinatal mental health service is a commissioned service for women and birthing people due to the specific mental health conditions, risk and needs of this birthing population linked to the pregnancy and the post-natal period.

51. The Trust apologised the referral criteria is unclear and explained that if fathers need mental health treatment or input, the perinatal team would be directing them to their GP for referral to the ATS or to talking therapies through WSTT.

52. Our Principles of Good Administration say public bodies should provide services that are easily accessible to their users. They also say policies and procedures should be clear, and there must be accurate, complete, and understandable information about the service. Where appropriate, public bodies should deal with users in a co-ordinated way with other providers to ensure their needs are met and, if they are unable to help, refer them to any other sources of help.

53. As outlined in the previous section of the report, we have not seen any evidence that Mr A was denied access to perinatal mental health services. From the evidence we have reviewed, we can see Mr A’s GP enquired about the services available and was advised Mr A could self-refer to talking therapies. This is in line with the Trust’s explanation that the service is commissioned for women and birthing people, and that fathers are signposted to alternative services.

54. In our view, this indicates the criteria were sufficiently clear in this case as the service was able to give a clear and appropriate response at the point of enquiry. The information provided to the GP reflected the scope of the service and ensured Mr A was directed to a more appropriate pathway.

55. For this reason, we have not seen any evidence of service failure. The GP appears to have been given correct information at the point of enquiry and was directed to the most appropriate service for Mr A. We consider Mr A’s understanding that he had been referred to this service and rejected appears to be a misunderstanding rather than as a result of unclear referral criteria. We do not uphold this part of the complaint.

SCFT – Handling of the referral and timeframe for appointments

56. Mr A complains that the SCFT failed to treat his case as a perinatal referral on two occasions in February 2024, and that he was not seen within the recommended timeframe of the perinatal care pathway for his initial assessment session (late March 2024) and initial treatment session (late April 2024).

57. In the Trust’s response to the complaint, it explained that Mr A self-referred to Time to Talk in mid to late February 2024 reporting an exacerbation of pre-existing mental health issues following the birth of his son. It acknowledged that the referral should have been treated as a perinatal referral, however it failed to identify this twice. Firstly, when it was initially triaged by the duty therapist, and secondly when an initial assessment appointment was booked by the administration team.

58. The Trust says Mr A was seen for an initial assessment in late March 2024, five weeks after the receipt of the referral, and an initial treatment appointment was held in late April, nine weeks after the referral was received. The Trust has acknowledged this was a breach of the standards set by the perinatal care pathway, and this delayed Mr A’s assessment.

59. The Trust clarified that if the referral had been correctly identified as perinatal, the expected timescale for onward referral would have been six weeks from receipt, rather than the nine weeks Mr A experienced. This means overall, there was a delay of three weeks.

60. There is no dispute regarding what went wrong in relation to this aspect of the complaint which requires the Ombudsman to investigate or resolve any further. What is left for us is to consider the impact this three-week delay had on Mr A.

61. Mr A tells us the delays in him being referred to the most appropriate services have caused a significant and lasting impact on his mental health. He tells us this caused significant distress for his family and has impacted his relationships with his wife and his son.

62. We have considered this with our mental health nurse adviser. From the evidence currently available to us, we can see Mr A experience an increase in symptomology during the time he was waiting for his initial assessment. We have carefully considered if we can attribute this increase in symptomology solely to this delay.

63. Mr A had several influencing factors in his life including his ongoing diagnoses of anxiety and depression, the documented pressure of his new baby, and his concerns that he may have autism and/or ADHD. We consider that these factors would also have added pressure to his situation, making it difficult to attribute this increase solely to the delay.

64. We have also considered what would have happened if the referral had been correctly triaged as perinatal. Whilst it delayed the initial assessment, our current understanding is that the pathway would have been the same with regards to the onward referral to the ATS. This means Mr A would not have received treatment at this point. Therefore, we do not consider this delay had an impact on the pathway the referral followed.

65. Despite this, we recognise the delays at the time of events and learning of the Trust’s errors in its complaint response likely caused Mr A a degree of frustration and worry. We have not seen evidence that this delay alone affected Mr A to such a degree that he was unable to continue with his day-to-day life as normal. However, we acknowledge the inconvenience of the delay and the concern it has caused for Mr A about the pathway of his referrals.

66. We have considered what action the Trust took to address this and whether this is enough to remedy the complaint. The Trust provided an apology for the delay in arranging the initial assessment. The Trust also advised it would be reviewing and strengthening its triage process for identifying perinatal referrals, and recommended refresher training for all staff responsible for processing referrals.

67. We consider the Trust has taken proportionate steps in line with our NHS Complaint Standards to ensure action has been taken from Mr A’s experience to improve the service it provides. We will not be making a recommendation for the Trust to provide an apology, as it has already done this. However, when considering the cumulative impact of this failing with the failings detailed later in our report, we consider the Trust should do more to remedy this complaint by way of a financial remedy. We explain this further in the impact section of our report.

SPFT – incorrect referral

68. Mr A complains the ATS incorrectly referred him back to the WSTT in late May 2024, without a clear treatment plan.

69. In response to Mr A’s complaint, the SPFT acknowledged it should not have referred Mr A back to the WSTT after it had already concluded it was not able to meet his needs. It acknowledged this meant he had been passed from one service to another without a clear treatment plan.

70. The Trust has provided us with a copy of the ATS operational policy. This policy outlines that the ATS should carry out a thorough and comprehensive assessment of need, including mental health and history, physical health, social stressors, medication, family and carer support, review of other services offering support. At the end of the assessment, the assessor should consider how the service and/or other services may offer the most appropriate treatment and support.

71. In reviewing the ATS assessment completed in mid-May 2024 with our mental health adviser, we can see it covered the requirements set out in the SPFT ATS operational policy. There was a thorough assessment of Mr A’s needs including his personal history, wider social stressors and circumstances, current medication and previous mental health interventions accessed. The ATS assessor carried out an assessment of Mr A’s current mental state and completed a thorough risk assessment.

72. The assessor identified what areas Mr A felt he needed help with, specifically, emotional regulation work and considered that a different service would be more appropriate to provide this support.

73. Whilst we consider it was appropriate for the ATS to refer Mr A to another service when it had identified it could not meet his needs, as the Trust has acknowledged, it was a mistake to refer him back to WSTT for emotional regulation work.

74. We understand that at the time of events, only primary care practitioners could refer patients directly into the EWS. Therefore, we consider it would have been more appropriate for the ATS to refer Mr A back to his GP for a referral into the EWS. We consider this was a service failure, and we will consider the impact of this later in this report.

75. With regards to the care and treatment plan developed by the ATS, we can see it clearly lists multiple examples of where Mr A could access help and support in varying forms and advised of the safety net of attending A&E if he felt he could not keep himself safe. Our adviser confirmed this is common practice within mental health services.

76. We consider this is in line with the NMC’s Code which says nurses must act in partnership with those receiving care, helping them to access relevant care, information and support when they need it (point 3.3), it also says they should preserve safety and accurately identify, observe and assess signs of normal or worsening mental health in the person receiving care and make timely referrals to other practitioners when any action, care or treatment is required (points 13.1, 13.2).

77. For this reason, we have not identified a service failure in relation to the care and treatment plan put into place.

SCFT – letter of late May 2024

78. Mr A complains the letter from SCFT led him to believe he had been discharged from all mental health services.

79. The letter was sent from WSTT to the ATS. ATS had re-referred Mr A to WSTT for emotional regulation work. In the letter, WSTT explained it had reviewed the referral and Mr A’s current presentation and advised it did not offer emotional regulation work as part of its service. It recommended Mr A asked his GP to refer him to the EWS and advised he was discharged from WSTT.

80. In response to Mr A’s complaint, the Trust explained the referral had been declined because the service was not appropriate. The responsibility for Mr A’s care therefore remained with the ATS, but the Trust acknowledged this was not made clear to Mr A at the time. The Trust acknowledged the wording in the letter was inaccurate and misleading, as Mr A had not been discharged. Instead, the referral had been declined because the service was not appropriate.

81. As there is no dispute regarding what went wrong in relation to this aspect of the complaint which requires the Ombudsman to investigate further. We consider this was a service failure, and we will consider the impact this letter had on Mr A in the next section of this report.

Impact

82. We will now consider the impact of ATS incorrectly referring Mr A back to WSTT and the impact of the letter from WSTT which implied he had been discharged from all services. We are considering this together as the impact of these two failings is linked.

83. Mr A explains that the delays in him being referred to the most appropriate services have caused a significant and lasting impact on his mental health, as this burden has been weighing on him for almost a year. He tells us this has caused significant distress for his family and has impacted his relationships with his wife and his son.

84. Mr A says because of the delays in the provision of mental health treatment, he was forced to seek private care at the cost of approximately £3,000, as he felt he was being passed between services without any progress being made and thought he had been discharged due to the poor communication about the services pathways.

85. We are only able to recommend the reimbursement of private fees where we are satisfied it was necessary for them to be incurred. By this, we mean if the actions of the organisations involved meant Mr A had no other option but to pursue private care and treatment.

86. We have also considered if Mr A gave the NHS the opportunity to provide the care and treatment required before resorting to private care, including factors such as whether he chased the Trust’s involved to escalate his concerns about delays, and if he gave the NHS the opportunity to provide the care and treatment he required.

87. The letter from ATS in mid-May 2024 indicates that the plan to refer Mr A back to WSTT was agreed during the assessment. The letter also refers to the care and treatment plan agreed between Mr A and the ATS. From this, we can see Mr A was made aware of the plan for accessing support and there are no indications he raised any issue with this further referral.

88. We consider that at this point, Mr A would not have had any cause for concern, as although he had been discharged from the ATS he believed he was being referred to the most appropriate service based upon his needs.

89. As a result of the ATS’ referral back to WSTT, Mr A received the letter from WSTT in late May 2024.

90. We consider the letter sent by WSTT in late May 2024 put the emphasis back on Mr A to ask for help himself, as it advised he had been discharged from WSTT and directed him to contact his GP for a further referral.

91. Our mental health nurse adviser explained that at this time, Mr A’s rating scales were scoring at the severe end for depression and anxiety. He had been asking for help with his mental health since December 2023 and had engaged with both WSTT and the ATS in initial assessments to determine what treatment he could access.

92. Depression often presents as feeling hopeless, unmotivated, and finding it difficult to make decisions (NHS Health A to Z). It is likely this letter was perceived as further rejection, and the suggestion of him finding further support for himself may have felt incredibly difficult.

93. We can see Mr A’s GP was copied into the late May 2024 letter, and so was aware of what was going on. However, we consider given Mr A’s high scores on the rating scales, it would have been more appropriate for the ATS service to write to Mr A’s GP directly to ask them to complete the referral to EWS.

94. Whilst we can see Mr A has a history of seeking support from his GP and other services when needed, this would have ensured that the onus was not on Mr A to self-refer and would have ensured he followed up with the recommendation to seek further help.

95. As Mr A had been discharged from the ATS, and his referral to WSTT had been re-directed, we consider it likely this letter likely triggered feelings of rejection.

96. We can see that Mr A felt strongly enough about being passed between the two services to raise a complaint a few days later in late May 2024. He described his experience as ‘horrendous’ and it is evident he felt he had been left without any access to help. We can also see that in late June 2024 Mr A told the MHP these events had left him confused and unsure of where to turn. This indicates to us that Mr A escalated his concerns about delays through the complaints process and through the services at the Surgery.

97. We can see that Mr A also followed up with his GP and was referred into the EWS in late June 2024. This indicates to us Mr A gave the NHS the opportunity to provide the care and treatment required, before deciding to pursue private care.

98. The EWS completed several sessions with Mr A whilst he was awaiting private treatment related to his ADHD and autism diagnoses.  We can see that whilst Mr A accessed referrals to the NHS pathways for them via his GP, he then chose to pursue the diagnoses through a private provider. The matter of these diagnoses is separate to the complaint we have investigated.

99. In reviewing the medical records from the EWS sessions, we can see Mr A received ongoing support for his mental health. It is documented he spoke with the MHP about either staying with the NHS for mental health treatment or continuing to go down the private route. It is evident Mr A was considering which pathway was best for him at the time, and that he eventually decided to pursue private care and treatment after receiving his diagnoses. Despite the delays, we have not seen any evidence that the NHS was unable to provide the care and treatment he required for his mental health.

100. For this reason, we conclude we have not seen evidence that Mr A had no other option but to pursue private care and treatment and we are not satisfied it was necessary in the circumstances for the private costs to be incurred to obtain this support.

101. We will now consider the cumulative impact of the failings in this case.

102. As outlined in paragraphs 62 to 65, the actions of the SCFT led to a three week delay in Mr A being seen on the perinatal pathway and this contributed to an increase in his symptomology at the time. We recognise that learning of this delay during the local resolution process would have caused further concern for Mr A.

103. We consider the SCFT’s letter of 24 May 2024 likely led to feelings of rejection for Mr A. We can see from his letter of complaint that he felt confused and that he had been left without any access to help. We consider this impact would likely have continued until the point he was able to access the EWS and begin receiving support in June 2024. This was a period of around four weeks.

104. We consider the SPFT caused a four week delay in Mr A being seen by the EWS by referring him back to the WSTT instead of directly asking the GP to complete a referral. We have not seen evidence this error had a significant impact on Mr A’s care and treatment pathway as he was able to approach his GP and access this service.

105. We also recognise that had the ATS (SPFT) asked Mr A’s GP to refer him to the EWS, the impact of the letter from WSTT (SCFT) dated 24 May 2024 could have been avoided.

106. In total, there was a delay of approximately seven weeks caused by the failings in this case. As explained in paragraph 63, Mr A had several influencing factors affecting the way he felt during this period. We consider that these factors would also have added pressure to his situation. This makes it difficult to attribute his full claimed impact solely to the failings we have identified.

107. The medical also records indicate that at the time these events occurred, despite Mr A’s difficulties, he was functioning well and had a wider support network of protective factors which contributed to keeping him safe. For this reason, we are unable to conclude that the failings significantly affected Mr A’s ability to live a relatively normal life during this period.

108. Whilst we cannot say with certainty the failings in this case were the sole cause of how Mr A was feeling at the time, we recognise the failings we have identified likely caused Mr A a degree of distress and uncertainty. We acknowledge it is likely this contributed to the ongoing challenges Mr A was having with his mental health. We also acknowledge this may have been an additional contributory strain on his personal life and relationships.

109. In the next section of our report, we will consider the actions each Trust has taken to put things right for Mr A.

Actions taken by SCFT

110. In response to Mr A’s complaint, the Trust provided an apology for the error in its letter. It has acknowledged that the letter was unclear that the responsibility for his care remained with the ATS at that time, and that it left Mr A feeling as though he had been discharged from all local mental health services.

111. The Trust also explained it had shared the learning from Mr A’s case at its weekly multi-agency hub, attended by all mental health providers in the region, to ensure local healthcare providers are fully aware of WSTT’s service provision and eligibility criteria.

112. Further to this, in our correspondence with the Trust during the investigation, it has confirmed to us that it has shared assurance of learning outcomes with its commissioners. It has also delivered staff training, developed new trauma-informed letter templates, and is currently developing updated referral criteria aligned with national guidance. These criteria will clarify that the provision for complex emotional needs falls within the remit of community mental health teams, not WSTT.

113. We consider the Trust has taken proportionate steps in line with our NHS Complaint Standards to ensure action has been taken from Mr A’s experience to improve the service it provides. We will not be making a recommendation for the Trust to provide an apology, as it has already done this. However, based on the impact the failings had on Mr A, we consider the Trust should do more to remedy this complaint by way of a financial remedy.

Actions taken by SPFT

114. In response to Mr A’s complaint, the Trust apologised the referral back to WSTT left him without access to support and caused him distress. It explained it had spoken to the MHP who completed the assessment and referral, and clarified that in future, any re-referrals to the WSTT need to be agreed with the co-ordinator first to ensure patients do not experience a rejection.

115. Further to this, in our correspondence with the Trust during the investigation, it has advised that since this complaint was received, it has made significant changes to how it manages referrals and communication between services. This has occurred as part of a wider mental health care transformation programme.

116. The Trust explained there are now Neighbour Mental Health Team multi-agency access and team meetings. These meetings bring together professionals from different services to discuss new mental health referrals with the aim of ensuring individuals are directed straight away to the most appropriate support. This is to avoid situations where people are passed between teams or left without any meaningful care or follow-up in the community.

117. We consider the Trust has taken proportionate steps in line with our NHS Complaint Standards to ensure action has been taken from Mr A’s experience to improve the service it provides. We will not be making a recommendation for the Trust to provide an apology, as it has already done this. However, based on the impact the failings had on Mr A, we consider the Trust should do more to remedy this complaint by way of a financial remedy.

1. With regards to Mr A’s complaint about a GP Surgery in the Arun area (the Surgery), we have not found something went wrong in the care provided to him, and we do not uphold this part of the complaint.

2. With regards to Mr A’s complaint about the Sussex Community NHS Foundation Trust (SCFT), we have identified it did not treat his referral as perinatal on two occasions and did not see him within the recommended timeframe for a perinatal referral for assessment and treatment sessions. We consider this was a service failure which caused a three-week delay in Mr A being reviewed by the service. Whilst we do not consider this delay had an impact on the onward pathway the referral followed, we recognise it likely contributed to the increase in symptomology Mr A had in that period.

3. We also identified in May 2024 the Trust sent a misleading letter to Mr A which led him to believe he had been discharged from all mental health services. We consider this was a service failure which likely led to Mr A feeling further rejection from mental health services and added to the ongoing pressures in his life as it put the onus on him to follow up with the recommendation to seek further help.

4. With regards to Mr A’s complaint about the Sussex Community Partnership NHS Foundation Trust (SPFT), we have identified it incorrectly referred him back to the West Sussex Talking Therapies Service (WSTT). We consider this was a service failure which caused a further four week delay to Mr A accessing treatment for his mental health. We consider this four week delay likely contributed to the challenges Mr A was facing with his mental health and his personal life.

5. We found that despite the incorrect referral, an appropriate care and treatment plan was put in place for Mr A which gave him clear pathways of accessing help and support whilst his referral was pending. We also found the referral criteria for the specialist perinatal mental health services were sufficiently clear in this case.

6. When considering recommendations, we have taken account of what the SCFT and SPCT have done to improve services since this complaint. We are satisfied both organisations have taken proportionate steps to implement service improvement in the areas where things went wrong in Mr A’s care.

7. We can see the SCFT and the SPFT provided apologies to Mr A for what went wrong and the impact it had on him. In this case, because of the impact the failings had on Mr A we consider an apology alone is not suitable by itself. For this reason, we will partly uphold Mr A’s complaints about the SCFT and the SPFT and we will be recommending each Trust provides Mr A with a financial remedy. This recommendation is detailed at the end of our report.

8. We will explain the reasons for our decision in this report. Complaints give us valuable insight into the organisations we investigate, so we would like to thank Mr A for sharing his experiences with us.

118. We make recommendations in line with our Principles for Remedy which are reflected in the NHS Complaint Standards. These say organisations should identify instances where things have gone wrong, take responsibility for these and find ways to put things right for those involved. They should learn from complaints to improve services.

119. We expect organisations to take action to compensate people appropriately if they cannot return them to the position they would have been in if the poor service had not occurred. In some cases, a financial remedy will be required. To decide on a level of financial remedy, we review similar cases where the person has experienced a similar injustice, along with our severity of injustice scale.

120. We have identified failings in relation to the way the SCFT triaged Mr A’s referral, the wording of a letter sent by the SCFT in late May 2024, and the onward referral made by the SPFT. We consider this led to a delay in Mr A accessing the mental health support he needed and feelings of frustration and rejection. We consider this likely contributed to Mr A’s poor mental health at the time.

121. With that in mind, we recommend that following this final report the SCFT:

• pays Mr A £240 by 2 September 2026 in recognition of the three week delay in being seen for assessment and treatment sessions with WSTT, which likely contributed to Mr A’s poor mental health at the time. This is also in recognition of the letter dated 24 May 2024 which misled him to believe he had been discharged from all services, leading to feelings of rejection and pressure to find help without support. Whilst we consider the SPFT was the root cause of this letter being sent, we consider the SCFT still bears responsibility for sending the letter and the way it was worded.

122. We recommend also recommend the SPFT:

• pays ​Mr​ A​ £360 by 2 September 2026 in recognition of the four week delay caused by incorrectly referring Mr A back to WSTT instead of asking his GP to refer him to the EWS. We consider the SPFT’s actions led to the SCFT’s letter being sent, which means the impact of that letter could have been avoided had the correct referral been made.

123. The SCFT and SPFT should send us evidence it has completed the recommendations we have made.