Lancashire and South Cumbria NHS Foundation Trust

4. Mr A complains about the mental health treatment the Trust provided to him between February 2022 and February 2024. Specifically: • it failed to appropriately assess his needs and provide appropriate support on 21, 26 October 2022 and 5 December 2022 • it failed to coordinate support and treatment in the community with Mr A’s GP Practice • it failed to support Mr A regarding his court proceedings • in September 2023 it incorrectly withdrew his medication for bipolar disorder (a mental health condition where you have extreme mood changes) without any follow up monitoring.

5. Mr A says the lack of support and treatment compounded his mental health and caused him stress, anxiety and fear. He says he was sectioned under the Mental Health Act 1983 (MHA), which impacted his career, health, personal and financial life. He says he lost faith in the Trust and felt his concerns about his post-traumatic stress disorder (PTSD - a mental health condition that can develop after a person has experienced a traumatic event) were ignored.

6. Mr A is seeking financial compensation as an outcome to his complaint.

7. Mr A is in his fifties. In May 2016, a different NHS Trust diagnosed him with bipolar affective disorder (a mental health condition where you have extreme mood changes). In 2020, his mental health treatment was transferred to the Primary Care Mental Health Team (PCMHT) at the Trust.

11. Before we decide if we should investigate 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.

Mental health support and treatment

12. Mr A complains the Trust failed to address his deteriorating mental health effectively during consultations in October 2022. He says despite his observed decline, the Trust took no preventative action and did not make any adjustments to his treatment. On 5 December 2022, he says the Trust again failed to respond to his worsening condition amid escalating stressors. He complains the Trust did not implement any safeguarding measures despite his vulnerability, repeated triggers, and increased distress, and his clinic report was delayed and inaccurate.

13. Mr A also complains the Trust’s mental health team failed to coordinate support and treatment for him in the community and via his GP. His mother describes a chronology of events of her son trying to seek help and support for a PTSD diagnosis from his GP. She said there was no coordinated approach in care for her son.

14. In its response letters the Trust apologised for Mr A’s experience and said it has taken learning from this complaint.

15. NICE bipolar guidelines recommend assessments for relapse should include a full psychiatric evaluation, risk assessment, and consideration of triggers, symptoms, stressors, comorbidities, medication effects, and recovery goals. A mental health team should develop a care plan collaboratively and share this with the patient and GP.

16. NICE PTSD guidelines recommend assessments should address symptom clusters (e.g., re-experiencing, avoidance, hyperarousal), functional impairment, and physical, psychological, and social needs, including a risk assessment. Shared care responsibilities must be clearly defined on the assessment plan.

17. We note from the Trust records a consultation took place with Mr A on 21 October, by telephone. As the record keeping of this telephone consultation is not clear, we have been unable to form a view on it.

18. The Trust’s consultation with Mr A on 26 October noted his concerns of a lack of contact with his care coordinator over an eight month period and severe stress linked to forthcoming court proceedings. Mr A asked the Trust for support. We note a discussion took place between the Trust and Mr A, exploring his stressors and early warning signs. There is also a reference to considering weekly contact or welfare calls.

19. Whilst we can see the Trust explored some psychological stressors, we have not seen evidence this consultation met all the assessment components, as recommended by NICE bipolar guidelines. Our adviser told us, a structured risk assessment covering the domains in the NICE guidelines was key. We have found an indication the Trust failed to complete a structured assessment for Mr A during this consultation. This is not in line with NICE bipolar guidelines.

20. We note the Trust arranged an urgent meeting on 5 December because its staff expressed concerns that Mr A maybe ‘going into mania.’ The records show some elements of an assessment, in that it discussed Mr A’s stressors, behaviour and medication. However, it did not evidence a full structured risk assessment in line with both NICE guidelines for bipolar and PTSD. For example, it did not include an assessment of Mr A’s risk of self-harm/suicide intent, self-neglect, risks to others and exploitation.

21. Our adviser explained where there is an incomplete structured assessment, the risk to a patient is not assessed or managed. This means care planning and monitoring is unclear. This can cause deterioration of mental health and a risk of relapse due to missed early warning signs, distress and increased anxiety. The Trust should have completed a collaborative care plan approach (CPA) with clear roles, including GP communication with clarity on who was responsible for monitoring Mr A.

22. Our adviser explains without a clear written plan and monitoring agreed with the GP and primary care team, there is risk of discontinuity and harm, where patients effectively fall between gaps due to a lack of coordination. Our adviser is unable to say whether these gaps in coordination directly caused Mr A’s mental health to deteriorate but there was risk factors present, which the Trust should have addressed in its assessment and CPA.

23. From the evidence we have seen there is an indication the Trust’s assessment of Mr A on 5 December was not in line with NICE guidelines for bipolar and PTSD.

24. We now turn to Mr A’s concerns he did not receive coordinated support from his GP.

25. We note Mr A contacted the mental health team, his GP, out of hours service and the Trust’s crisis services multiple times. Mr A had to repeat his medical history several times, and it appears he had difficulties obtaining consistent follow up appointments. The Trust’s records indicate gaps in contact and continuity with a named care coordinator.

26. We can see from Mr A’s records, when he was contacting the Trust’s crisis support lines, it seemed to increase his distress rather than provide him with reassurance.

27. Our adviser explains for a patient with bipolar disorder and trauma/anxiety features, a coordinated care plan (CPA) is appropriate. Mr A required a written, shared plan with agreed monitoring responsibility between the Trust and the GP. This should have included a clear escalation/crisis plan and reliable follow up arrangement, clear medication responsibility and monitoring schedule. Our adviser explains had these measures been in place for Mr A, it may have resulted in reduced distress and fewer repeated crisis contacts.

28. From the evidence, we have seen an indication the Trust’s treatment plan for Mr A was not consistent with the coordination expectations as set out in NICE guidelines for bipolar and PTSD.

Court proceedings

29. Mr A complains the Trust should have supported him during his court proceedings on 12 December, given it had noted he was becoming manic on 5 December. Mr A says without this support he was left with severe anxiety, distress and he was unable to prepare for the hearing. The family also say the treating consultant should have written to the court directly and there was no need for Mr A’s lawyers to request this letter.

30. In its response, the Trust said following a letter from Mr A’s solicitors, requesting medical evidence, it sought legal advice from its own team. It said Mr A’s treating consultant provided the evidence the court had requested.

31. RCP guidelines explain a psychiatrist’s primary role is to provide clinical care. They may provide factual clinical information or reports when properly requested/authorised, and may act as an expert in limited circumstances, but they must follow professional and legal rules. The RCP gives clear guidance as to a psychiatrists’ responsibilities in providing evidence to courts/tribunals, including consent/confidentiality and the treating psychiatrist’s position.

32. GMC disclosure and confidentiality guidelines make it clear that disclosure or reporting to court requires a clear request and clinicians should not send unsolicited letters to the court without consent.

33. On this basis, we consider it was appropriate for Mr A’s solicitors to send a formal request to the Trust for evidence. This is in line with RCP and GMC disclosure and confidentiality guidelines.

34. Despite this, our adviser explains the Trust should have continued to provide Mr A with clinical support.

35. NICE PTSD guidelines state, ‘do not delay or withhold treatment for PTSD solely because of court proceedings or compensation applications. Clinical support should continue.’

36. Our adviser explains as concerns were apparent that Mr A could not navigate the court processes due to his mental state, the Trust should have made a clear care plan and support for engagement. This support may have reduced Mr A’s distress.

37. From the evidence we have seen there is an indication the Trust did not provide appropriate support to Mr A, during his court proceedings. This is not in line with NICE PTSD guidelines.

Medication for bipolar disorder

38. We understand this consultation took place on 18 September 2023.

39. Mr A complains the Trust told him to stop taking medication (Depakote) if he did not think he had bipolar disorder. The family say this led to Mr A’s immediate decline and he was sectioned under the Mental Health Act.

40. In its response, the Trust said during this consultation Mr A informed the doctor he was unhappy with his bipolar disorder diagnosis and with the associated medication of Depakote, as it was causing him adverse side effects. It said it agreed Mr A should reduce the medication dose to 750mg but not to come off this medication and it offered follow up support by its mental health team. It said it offered follow up appointments which Mr A did not attend.

41. Our adviser notes, the Trust’s records for this consultation does not evidence a clear rationale to stop or reduce the medication, evidence of shared decision making with Mr A, a relapse prevention plan or evidence of clear monitoring or follow up arrangements. The Trust’s records refer to the treating doctor to write to Mr A’s GP with their impressions and reduction plan; however, it appears it did not give a copy of this to Mr A.

42. This is not in line with NICE bipolar guidelines and there appears to be a risk of deterioration to Mr A’s mental health.

43. Despite this indication of failing, our adviser is unable to say this was the main reason Mr A was sectioned under the Mental Health Act.

Summary and resolution

44. We are sorry to hear of Mr A’s complaint and understand this was an incredibly difficult time for him and his family.

45. We have identified indications of failings in mental health support and treatment the Trust provided to Mr A during the complaint period. The Trust did not complete appropriate assessments during the consultations dated 26 October and 5 December. It did not provide coordinated community support, and it did not provide a clear care plan and support for engagement to help Mr A navigate court proceedings. It also did not implement a clear plan to support Mr A’s reduction of medication.

46. This is likely to have increased the risk of Mr A’s deterioration. We are sorry to hear of the impact it had on Mr A and his parents.

47. As an outcome to Mr A’s complaint he is seeking a financial remedy.

48. We shared our thinking with the Trust and asked if it was willing to resolve Mr A’s complaint.

49. In its response dated 17 June, the Trust agreed to resolve Mr A’s complaint and pay him a financial remedy of £900 to put this right.

50. We consider this outcome is enough to remedy the impact of what went wrong and is in line with NHS Complaints Standard Framework, which provides guidance on how organisations delivering NHS services in England should handle complaints.

51. We recognise nothing can change the distressing events leading to Mr A’s complaint and the impact it has and continues to have on him and his family. We hope Mr A and his family can take some comfort from our investigation and the action we have asked the Trust to take, to remedy his personal injustice.

52. Complaints give us a valuable insight into the organisations we investigate. We are very grateful for Mr A bringing the complaint to us and are mindful of how difficult this must have been to share with us.

53. This concludes our primary investigation of this complaint, and we thank Mr A for bringing this complaint to us.

1. We have carefully considered Mr A’s complaint about Lancashire and South Cumbria NHS Foundation Trust (the Trust).

2. We have found an indication of failing in the mental health treatment the Trust provided to Mr A during the complaint period. The Trust has agreed to pay £900 to Mr A to resolve his complaint. We agree this is appropriate action to take.

3. We are very sorry to hear about Mr A’s concerns and understand this has been an incredibly difficult and distressing time for him.