Oxleas NHS Foundation Trust

5. Mr D complains about aspects of the care and treatment he received from Oxleas NHS Foundation Trust (the Trust). Specifically, he complains the Trust did not:

• action his MRI referral between June 2023 and January 2025 • action his psychology referral between August 2023 and January 2025 • support the request he made in September 2024 for therapy outside of standard working hours.

6. Mr D says as a result of these failings, his complex PTSD symptoms were exacerbated. The lack of therapy left him feeling abandoned by the Trust, without access to mental health support.

7. As an outcome to his complaint, Mr D seeks an apology from the Trust and service improvements.

8. Mr D has a childhood history of rejection, abandonment and neglect. He suffered from physical and emotional abuse. He has a history of repeating episodes of anxiety and depression which has progressively worsened. He has engaged in long-term private therapy which he reports has been helpful in having someone to talk to, but it did not address his underlying issues.

9. In January 2023, the Trust diagnosed Mr D with complex PTSD, anxiety, depression and pseudo dementia. In June 2023, Mr D was seen by the Trust’s consultant psychiatrist and diagnosed with complex PTSD with repeating depressive episodes. In July 2023, the Trust referred Mr D for an MRI scan and in August 2023, the Trust informed Mr D he would be referred to its psychology department.

10. Mr D did not receive any updates from the Trust about his referrals. He complained to the Trust in August 2024 and received a response in September 2024.

11. Mr D had an appointment with the Trust in September 2024 He was referred for group-based therapy.

12. In November 2024, Mr D raised further concerns with the Trust regarding treatment and therapy. The Trust held a meeting with Mr D, where it discussed the outstanding referrals and the therapy sessions which were yet to begin.

13. In January 2025, Mr D was invited to attend daytime group therapy sessions. Mr D was unhappy with the therapy timings and asked for a referral to the South London and Maudsley (SLaM) Trauma and Dissociation service.

14. Mr D also underwent the MRI in February 2025, where no abnormalities were found.

15. Mr D’s referral to SlaM was actioned in March 2025.

19. Before we decide if we should investigate a complaint in more detail we look at whether there are signs the organisation concerned has got something wrong. We do this by comparing what should have happened with what did happen. If what happened fell far short of what should have happened, we call this a failing. When we see indications of a failing, we next look at whether that failing had a negative impact on the person in question. If we think it did, we will go on to consider what, if anything, the organisation has done to try and put things right.

20. In January 2023, Mr D’s GP referred him to the Trust for help with longstanding anxiety and depression. In June 2023, Mr D attended an appointment with a consultant psychiatrist at the Trust and was diagnosed with complex PTSD and recurring depressive episodes.

21. On 14 July 2023, the Trust made referrals for an MRI scan and involvement from the ADAPT team. The ADAPT team reviewed the referral on 26 July and offered Mr D an outpatient appointment on 21 August 2023. During this appointment, the ADAPT team noted Mr D was still waiting for an MRI scan. They also recorded a referral for psychological therapy should be made. There is no evidence in Mr D’s medical records this psychology referral was actioned at this time.

22. On 5 October 2023, during another ADAPT team review, it was noted Mr D was still waiting for both the MRI scan and a psychology referral. The notes also mentioned Mr D was interested in therapy to help him address past traumatic experiences.

23. In February 2024, Mr D’s GP contacted the Trust to follow up on the MRI referral.

24. On 21 March 2024, Mr D attended an appointment with the ADAPT team and on 25 March he asked for updates about the MRI and psychology referrals. Following this appointment, an ADAPT team doctor chased the MRI referral. The doctor confirmed the referral had been made in July 2023 but noted it had not been followed up for eight months.

25. The Trust stated MRI services are provided by an external organisation, so it had no control over waiting times or responses. However, the Trust acknowledged the delay was lengthy and said it would review its processes for ensuring external referrals are correctly received.

26. On 11 April 2024, during another ADAPT team appointment, Mr D repeated his request for psychological therapy. The Trust confirmed the referral for psychological therapy had not been made on 21 August 2023 as planned. The referral was received and accepted by the psychology service on 18 April 2024, eight months after it was recommended at Mr D’s August 2023 appointment.

27. Mr D attended a psychological assessment on 12 September 2024, where therapy options were discussed. These included Eye Movement Desensitisation and Reprocessing (EMDR) and Mindfulness-Based Cognitive Therapy (MBCT). Mr D agreed to join the next MBCT therapy group. The Trust informed Mr D the MBCT group began in January 2025.

28. On 13 December 2024, the Trust informed Mr D that, according to their records, an MRI referral made in July 2023 had not been followed up. It decided to resend the referral.

29. On 31 December 2024, the Trust sent Mr D a letter inviting him to MBCT therapy sessions scheduled to start in February 2025. The sessions were set to run from 10am to 12pm. Mr D says he reported these timings were unsuitable. He says previous discussions he had with the Trust led him to believe evening sessions would be available.

30. On 2 January 2025, the Trust stated evening sessions were unavailable because facilitators worked during the day and the building used for therapy closed at 5 pm. Mr D declined the daytime sessions.

31. On 21 January 2025, the Trust informed Mr D it was unable to provide evening therapy sessions. It noted Mr D was considering transferring his care to South London and Maudsley NHS Trust (SLaM), which might be able to offer evening sessions. On 24 January 2025, Mr D was discharged from the Trust’s psychology services after declining MBCT due to their timing. He requested his care be transferred to SLaM.

32. Mr D contacted the Trust again on 11 February and 21 February 2025 for updates on the SLaM referral. On 26 February, the Trust attempted to arrange a phone meeting with Mr D to discuss the transfer but was unable to reach him. Mr D emailed the Trust on 27 and 28 February, stating he had tried to return calls but could not get through.

33. On 6 March 2025, Mr D’s GP referred him to SLaM. The Trust also confirmed the referral on the same day and informed Mr D. On 26 March 2025, the Trust confirmed the referral to SLaM had been made.

34. In August 2025, SLaM informed the Trust it had received two referrals for Mr D; one from the Trust in March 2025 and another from his GP in April 2025. Neither referral was accepted because they did not clearly describe Mr D’s PTSD symptoms.

35. The Trust’s complaint response indicated several delays. It acknowledged the MRI referral made in July 2023 was chased only in March 2024, and the psychology referral was not actioned until April 2024, eight months after it had first been recommended. The Trust stated it would review its processes for verifying external referrals to ensure they are correctly received and managed in the future. It also recognised delays to treatment can negatively impact a patient’s mental health.

MRI referral between June 2023 and January 2025

36. GMC guidance states healthcare staff must provide (or arrange) suitable advice, investigation, or treatment promptly when necessary, and refer a patient to another suitably qualified practitioner when doing so is in the patient’s best interests.

37. The NHS waiting times guidance says the maximum waiting time for non-urgent consultant led treatment is 18 weeks from when the hospital or service receives the referral letter.

38. We have seen the MRI was requested to rule out any underlying causes for the symptoms Mr D reported whilst the Trust considered a psychological diagnosis. Our adviser told us the MRI referral was non-urgent.

39. The original referral was made in July 2023, but it was not followed up or acknowledged to be chased up until April 2024, nine months later. Our adviser told us, in line with the NHS waiting times guidance, when Mr D didn’t get treatment within 18 weeks, the Trust as the requestor should have followed.

40. We find an indication of a failing in the Trust not following up on Mr D’s referral. We will discuss the impact of this later in our report.

Action psychology referral between August 2023 and January 2025

41. NHS mental health access standards outline the target for 75% of patients to have a first appointment within six weeks of referral and 95% to have a first appointment within 18 weeks of referral.

42. As stated above, GMC guidance states healthcare staff must provide (or arrange) suitable advice, investigation, or treatment promptly when necessary, and refer a patient to another suitably qualified practitioner when doing so is in the patient’s best interests.

43. Our adviser explains these standards mean the Trust should have followed up on the psychology referral at six weeks and 18 weeks after it initially recommended treatment. We have not seen evidence the Trust did this. This is an indication of a failing.

44. We have seen when Mr D repeated his request for psychological therapy on 11 April 2024, the Trust identified it had not made the referral on 21 August 2023 when it recommended it for Mr D. This is an indication of a failing.

45. We will discuss the impact of these failings later in our report.

Support the request for therapy outside of standard working hours

46. Mr D complains the therapy he was offered did not suit his work schedule. He said during his assessments he specifically requested evening therapy sessions and was told this would be possible. However, he was later offered therapy sessions during working hours, which he says he could not attend due to his work commitments.

47. The Trust said it does not run any groups out of hours. It says it is unable to see patients outside of 9.00am to 5.00pm so it would not have offered this. It accepted this was a limitation of its facilities and clinical provision.

48. The Trust’s policy sets out the psychological ‘services across the three boroughs run from 9.00am to 5.00pm Monday to Friday, all emergency contact outside of these hours is provided via the crisis line, mental health liaison, and/or home treatment team’.

49. We have seen evidence the Trust told Mr D on 2 January 2025 evening sessions were not available. We have not seen any evidence in his records of previous discussions about evening sessions. We therefore cannot verify whether Mr D raised his preference for evening sessions, or whether the Trust assured him this could be accommodated, as there is no documentation of these conversations.

50. We can see the Trust arranged for Mr D to attend its available services as outlined in its Policy. The Trust’s psychological service building operates only during daytime hours, as is standard for most NHS psychology services. Offering evening sessions would pose additional challenges, including risks for therapists working without clinical support outside of hours.

51. The Trust acted in line with its policy, ensuring therapy was offered during its operating hours. It also took appropriate steps by arranging a referral once it became clear Mr D’s needs could not be met within its service timings.

52. We have not been able to establish what conversations took place between Mr D and the Trust about evening therapy sessions, so we cannot make a finding on this part of the complaint. We have not seen any indications of failings in the Trust offering therapy within working hours and arranged for an alternative service when it could not meet Mr D’s needs. For this reason, we will not take any further action on this part of the complaint.

Impact

53. We found the Trust failed to follow up on the MRI referral and failed to make or follow up on Mr D’s psychology referral. This led to a nine-month delay in his MRI referral and an eight-month delay in his psychology referral.

54. Mr D says the delays caused him significant stress and anxiety. He feels he was denied appropriate support and left without guidance for his mental health needs. Mr D described experiencing symptoms of C-PTSD including anger, avoidance, self-critical inner voices and difficulties in relationships. He says these challenges worsened while he waited for therapy and he felt unsupported.

55. We see the delays in accessing treatment likely prolonged Mr D’s his emotional distress and compounded the challenges he was already facing and left him feeling unsupported. Our clinical adviser has explained untreated PTSD symptoms can worsen over time and become more difficult to manage without timely intervention.

56. To resolve his complaint, Mr D asked for an apology from the Trust to acknowledge the impact the delays had on his mental health and for the Trust to make of service improvements.

57. The Trust’s initial complaint response included an apology for the delays and outlined the steps it had taken to improvement its service. It said it had reviewed its processes for verifying referrals to ensure they are appropriately received and managed.

58. The Trust explained letters are now sent with a read-and-receipt confirmation to help track MRI referrals. It stated it expects the radiology team to acknowledge referrals within a few days and to process them within a couple of weeks, depending on urgency. The Trust also confirmed it now follows up if this has not been done, and notes are added to a patient’s record to ensure referrals are monitored.

59. Regarding delays with the psychology referral, the Trust explained staffing challenges had contributed to the issue. It confirmed staffing in the psychology department had since improved. In addition, it had taken learning from Mr D’s complaint and staff are now advised to include the team’s admin email address in their out-of-office messages during leave. This ensures alternative contacts can pick up and act on any correspondence.

60. The Trust said it had introduced a weekly meeting to review administrative processes, including its communication and accountability.

61. Although the Trust apologised for the delays, it did not acknowledge the impact the delays had on Mr D’s mental health. We contacted the Trust to ask if it would provide Mr D with a written apology acknowledging this, and it has agreed to do so.

62. We appreciate Mr D’s patience throughout this process and thank him for raising his concerns with us. We hope he is reassured by the actions the Trust have taken as a result of him raising his complaint.

1. We have carefully considered Mr D’s complaint about Oxleas NHS Foundation Trust. We are sorry to hear of the difficult experiences Mr D has faced while attempting to access support for his mental health.

2. We have found there was a delay in Mr D’s MRI and psychology referrals being actioned by the Trust. The Trust acknowledged this delay, apologised for the failings, and informed Mr D of improvements it had made to prevent the same happening again. However, the Trust failed to acknowledge the impact the delays had on Mr D’s existing mental health conditions. We consider the Trust should do more to recognise the impact the delays had on Mr D.

3. We have not been able to establish what discussions took place between Mr D and the Trust regarding his need for therapy outside of standard working hours. We have seen the Trust acted in line with guidance in offering therapy within its operating hours and then referring Mr D to an alternative provider when it could not meet his needs.

4. We will explain the reasons for our decision below.