Lancashire and South Cumbria NHS Foundation Trust

3. Mr E complains the Trust did not diagnose and treat him appropriately between 6 August, when his GP referred him to its mental health services, and 12 September 2024 when he was discharged.

4. Mr E also complains the Trust discharged him without addressing the trauma and breakdown the psychologist identified between November 2024 and January 2025. Consequently Mr E says he was never given a suitable diagnosis or ongoing treatment plan.

5. Finally, Mr E says his care and treatment at the Trust throughout these periods has been negatively influenced by reference in his medical records to the ongoing use of medical cannabis.

6. Mr E has told us his lack of treatment between August and September 2024 resulted in delays in him getting a psychology referral. He says this could have resulted in an earlier diagnosis and support.

7. Since his February 2025 discharge, Mr E says his mental health has significantly declined. His existing Post Traumatic Stress Disorder (PTSD), linked to childhood abandonment, has worsened due to a feeling of abandonment by the NHS as he feels he is continuously being discharged with no follow up.

8. He also says anxiety attacks have become a daily occurrence, he has difficulty leaving the house, a lack of appetite and self-care which has resulted in significant weight loss. Mr E says his mental health has become so bad he now relies on daily care assistance.

9. He believes decision makers at the Trust have seen the label of “high risk substance user” and his use of medical cannabis, and consequently denied him a suitable diagnosis or treatment.

10. By bringing his complaint to us Mr E for the Trust to:

• provide a formal written apology acknowledging the failings in care • take accountability and make service improvements for any failings identified • provide staff training to improve understanding of trauma, neurodiversity, mental-health crises and the use of medical cannabis • provide financial compensation of £10,000 for the psychological harm, distress, and loss of trust caused by these failings.

13. In August 2024, Mr E experienced a mental health crisis. His GP referred him to the Trust and he was assessed by the Community Mental Health Team (CMHT). CMHT contacted Mr E the same day to arrange an appointment for 31 August 2024.

14. After a deterioration in Mr E’s mental health, the assessment was brought forward and completed on 11 August by the Home Based Treatment Team (HTT) at the Trust. At assessment, Mr E was diagnosed with anxiousness and depression due to childhood trauma.

15. On 22 August 2024, HTT visited Mr E again. The medical notes taken at the time of the appointment indicate Mr E had apologised after his disengagement from HTT. The records show he stated he wasn’t ready for a psychology assessment and felt he should get on with life himself.

16. On 29 August 2024, the Trust issued a discharge warning letter stating he would be discharged in 14 days if he did not reply to it after it had tried to arrange psychology sessions for him.

17. Mr E complained as he says that he attempted contact with the Trust during this time. In resolution of the complaint, the Trust agreed to arrange psychology sessions for him in November 2024. This was to assess and provide a plan for any treatment or interventions he might require.

18. Between November 2024 and January 2025, Mr E attended psychology appointments. Following this, the Trust recommended trauma therapy alongside CMHT support.

19. In a formulation session in January 2025, Mr E raised concerns about the focus on historic trauma. The psychologist said he would be referred back to CMHT for longer term support, but this required his consent and agreement to do so.

20. On 3 February, Mr E met the Trust for his final formulation session where an ADHD referral was made. The Trust explained whilst referrals for a potential diagnosis were usually made by a GP, it would arrange for the referral to ensure continuation of care. CMHT discharged Mr E as no further actions were identified.

21. On 5 February 2025, Mr E raised concerns to the Trust about being directed back to his GP and about long waiting times for ADHD assessment.

22. In May and June 2025, Mr E sought further support via his GP. The Trust’s medical notes show it contacted Mr E over the phone to confirm further diagnostics were not appropriate while he was awaiting an ADHD assessment and there were no additional pathways available to support him.

23. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs of service failings or maladministration which has caused an impact the organisation has not put right.

Mr E complains the Trust did not diagnose and treat him appropriately between 6 August, when his GP referred him to its service and 12 September 2024 when he was discharged.

24. On 6 August 2024, Mr E’s GP referred him to the Trust following a mental health crisis involving property damage, a blackout, and thoughts of selfharm.

25. The GP referral requested CMHT input “ASAP” but stated his presentation did not meet the threshold for crisis services.

26. The Trust processed the referral through its Initial Response Service, booking a triage appointment within four weeks.

27. On 10 August Mr E experienced and reported a deterioration in his mental health. The Trust referred to the Home Treatment Team (HTT) to carry out an initial assessment.

28. Our adviser told us HTT’s offer short term crisis support through a biopsychosocial model of care delivered at home with tasks including rapid assessment, care and crisis planning, practical help and relapse prevention. This occurs most commonly over a period of 2-8 weeks and often includes daily visits, therefore allowing more intensive delivery of care than that of a CMHT.

29. The HTT assessment of Mr E included a risk assessment, clinical assessment, and a plan for daily home visits, medical review, physical health review, and an ADHD questionnaire.

30. The medical notes indicate, due to Mr E’s distress in the appointments, all the information the HTT would have liked to attain was not available.

31. Mr E’s medical records show he declined antidepressants and did not want to discuss trauma.

32. The records show between 14–21 August Mr E disengaged from HTT contact. The records show on 22 August, during an unannounced visit, Mr E apologised for the disengagement saying he did not feel listened to in previous appointments. He confirmed he had started a new job and did not feel at risk.

33. The Trust issued Mr E a discharge warning letter on 29 August as he was no longer in crisis and was not engaging. The letter informed Mr E, if he didn’t contact the Trust by 12 September 2024, it would discharge him.

34. On 12 September 2024, the Trust formally discharged him from HTT after 14 days of nonengagement.

35. Mr E says he received the letter late and complained about this. He explained he felt HTT had neglected his needs. He also stated he did not agree he had been disengaged and explained he had made a number of attempts to telephone HTT.

36. In its complaint response the Trust acknowledged Mr E’s concerns about feeling unheard during his assessment, particularly in relation to his current needs and anxiety. It explained its aim was to work collaboratively, including exploring options such as an ADHD assessment, holistic support, and further psychological sessions to help address his emotional challenges, and support his overall mental health.

37. The Trust apologised for any distress caused. It also admitted errors in the discharge process, including a missed voice message and the late delivery of a discharge letter. It apologised for these mistakes and implemented changes such as sending letters first class to avoid future issues.

38. As part of the resolution to Mr E’s complaint, the Trust arranged psychology sessions to inform it on how to support Mr E going forward. As a result of these sessions the Trust later recommended trauma therapy alongside CMHT involvement.

39. The Trust’s CMHT guidance states an initial face-to-face appointment will be offered within six weeks.

40. The RCP guidance requires HTT to complete a clinical assessment, a risk assessment, and a care plan. Where information cannot be gathered, the guidance requires staff to document this and plan further assessment.

41. Following the assessment, HTT is expected to focus on managing the immediate crisis. Psychological Professions Network guidance describes HTT as a shortterm, intensive service providing rapid assessment, crisis planning, medication monitoring, and practical support.

42. HTT is not expected to provide long term therapy or undertake full diagnostic work. Those responsibilities sit with the CMHT. HTT involvement should end when the acute risk has reduced or when a patient disengages from the service.

43. Where longer term needs are identified, the correct pathway is referral to CMHT, which is responsible for ongoing assessments, diagnosis, and psychological therapy.

44. NICE guidance states, “before treatment ends or your care is transferred to another service, this should be discussed and planned with you and your family or carer (if you agree) and should not happen abruptly”.

45. We have seen the GP’s referral to the Trust indicated Mr E’s presentation did not meet the threshold for crisis services. It was a non-urgent referral. We have seen the Trust acted in line with its CMHS guidance as it booked a triage appointment for 31 August, within four weeks.

46. When Mr E’s mental health deteriorated the Trust’s assessment was appropriately brought forward and completed on 11 August by the HTT.

47. We have seen the Trust acted in line with RCP guidance as the HTT assessment of Mr E included a risk assessment, clinical assessment, and a plan for daily home visits, medical review, physical health review, and an ADHD questionnaire.

48. The HTT acted in line with RCP guidance by arranging daily home visits to continue gathering information and monitoring risk.

49. After consultation with our nursing adviser, we are satisfied the care plan the Trust put in place for Mr E, including daily nursing input, a medical review, a physical health review, and an initial psychology formulation was in line with RCP guidance.

50. Mr E did not attend several planned contacts with HTT after 13 August. We have seen, the medical notes of the unannounced visit on 22 August state he did not feel at risk and did not wish to continue HTT involvement. We can see the Trust acted in line with RCP guidance when it began the discharge process due to his disengagement.

51. Mr E says he called on day 13 of the 14-day discharge timeline and left a voicemail. The Trust sent out its letter on 12 September. In its complaint response on 18 October the Trust acknowledged it had missed his call.

52. Mr E does not feel he should have been discharged as he states he did return calls. In its response, the Trust has acknowledged this was a failing. We find the Trust’s decision to discharge him due to a lack of engagement in the process was not in line with guidance.

53. We have seen, when Mr E raised his complaint about this, the Trust arranged psychological input and continued to explore longer term support options as a resolution to the complaint. The appointments began on 8 November and continued through December 2024, January and February 2025.

54. Mr E received daily nursing input, medical review, physical health review, and access to psychology for initial formulation exactly what HTT is designed to provide. HTT operates over a short period and focuses on crisis stabilisation. Diagnostic work and longterm therapy are CMHT responsibilities. It was therefore appropriate that no formal diagnosis was made during this period.

55. In conclusion, we have seen an indication of a failing in how the Trust dealt with Mr E’s discharge on 12 September given its errors in acknowledging his attempts to telephone it. We will discuss the impact of this later in our report.

56. We have found no indications of failings in the Trust’s treatment of Mr E, or in its lack of diagnosis during this time. The Trust’s actions were consistent with national guidance and the expected functions of HTT and CMHT.

57. We acknowledge this decision may be difficult for Mr E to hear. We understand the issues that he has faced and do not underestimate the difficulties he has faced in managing his mental health.

Mr E complains the Trust discharged him on 3 February 2025 without addressing the trauma and breakdown the psychologist identified between November 2024 and January 2025. Consequently Mr E says he was never given a suitable diagnosis or ongoing treatment plan.

58. Mr E complains the Trust discharged him on 3 February 2025 with the only support offered to him being via his GP and felt he was “slipping through the net” while awaiting an ADHD assessment.

59. When we asked Mr E about this complaint he also expressed frustration his need for a formal diagnosis has not been appropriately addressed by the Trust. He believes this lack of diagnosis has left him in a state of uncertainty and has contributed to his ongoing difficulties.

60. He states past engagements with healthcare professionals have failed to consider the potential presence of an undiagnosed condition and that assumptions have been made about the root causes of his issues. Mr E feels this has resulted in inadequate treatment options.

61. Overall, Mr E expresses hopelessness about his future engagement with health professionals, stating that these repeated experiences have caused him to lose faith in the system.

62. Mr E was engaging with the Trust between November 2024 and January 2025. During this time, the clinical records show the psychologist identified significant trauma related symptoms and recommended trauma therapy alongside support from the CMHT as part of a longer-term treatment plan.

63. The records show the psychologist issued an assessment report on 15 January 2025 setting out a treatment plan, including trauma therapy supported by CMHT and access to a psychiatrist to review Mr E’s diagnosis and any medication needs.

64. After receiving the assessment report, Mr E raised concerns of a lack of trust in the CMHT, stemming from what he perceived as its failure to understand or appropriately address the complexity of his issues during previous interventions. Mr E felt the CMHT discharged him prematurely previously without offering meaningful support and that prior interactions with CMHT professionals had left him feeling dismissed.

65. In email correspondence with the Trust on 24 January, Mr E explained in more depth the struggles he faced in his life, and further issues with how his care had been dealt with over the years. He stated he, “genuinely believe no amount of talking therapy or counselling or whatever can change how I look and see the world and people”.

66. On 28 January, Mr E spoke with the psychologist and confirmed he wished to pursue therapy but felt he was missing a diagnosis required to properly address his issues. It was agreed the next steps would include a psychiatric assessment to review his diagnosis and psychological therapy to address his trauma.

67. On 3 February, Mr E attended a joint meeting with the psychologist and a senior nurse manager at CMHT. The clinical notes record Mr E did not feel in a position to engage in trauma therapy at that time and wished to prioritise an ADHD assessment.

68. During our discussions, Mr E disputed he stated he did not feel in a position to engage in therapy. When we asked him about this, Mr E says he was advised therapy was too invasive, and he did not say that he did not feel ready for trauma therapy. Mr E also says he was denied appropriate treatment, due to his use of medical cannabis.

69. The contemporaneous records from 3 February indicate clinicians told Mr E an ADHD referral was appropriate and this referral concluded its work with Mr E. The records also show Mr E was agreeable to this and thanked the Trust for its support. Following the ADHD referral on 17 February, the CMHT recorded there were no further actions it could take until diagnostic clarification was complete.

70. Mr E says he was told he did not meet the CMHT threshold because he was not at immediate risk. The records show he was discharged because there were no active CMHT interventions to provide while awaiting ADHD assessment and because he stated he was not ready to begin trauma therapy.

71. The Trust’s Engagement procedure requires clinicians to make reasonable attempts to maintain contact, to ensure patients understand their treatment plan, and to assess readiness for trauma therapy.

72. CMHTs are responsible for longer‑term assessment, diagnosis, and formulation of treatment plans, including trauma therapy. The psychologist’s recommendations were therefore appropriately directed towards CMHT as the service responsible for delivering longer term work.

73. The Trust’s CMHT procedure states “discharge is based on the individual completing a recovery focused intervention or no longer benefitting from or being accepting of interventions”.

74. Section 69 of GMC guidelines states that doctors must ensure that formal records of their work, including patient records, are “clear, accurate, contemporaneous and legible”.

75. We have seen evidence the Trust tried to engage Mr E in its services throughout Mr E’s care.

76. We have considered the conflicting accounts from Mr E and the Trust about who decided therapy was not appropriate. Where accounts differ, our findings are made on the balance of probabilities, taking into account the reliability of the evidence available.

77. Mr E first raised his dispute over why trauma therapy was not pursued in April 2025, two months after his discharge, when he received information following his Subject Access Request which he received in April 2025. Allowing time for memories to fade or alter, the contemporaneous notes recorded at the time provide the most reliable evidence of what was discussed. Those notes state that Mr E did not feel ready for trauma therapy.

78. The medical records, made at the time, show multiple occasions where Mr E indicated his belief trauma therapy would not be of benefit to him and he wasn’t ready for it. There are also occasions where he stated CMHT aren’t able to help him, and he had no faith in it. This is in line with the GMC guidelines that require timely, and complete record keeping to ensure continuity.

79. Considering the contemporaneous nature of the medical notes and Mr E’s later recollections, we consider it more likely than not that the Trust did not continue with its recommendation of arranging talking therapy as Mr E told it he was not ready to begin talking therapy.

80. We have seen the Trust offered a psychology assessment, attempted to maintain contact, issued a clear treatment plan, arranged a psychiatric review, and made an ADHD referral in line with its Engagement procedure.

81. Our adviser told us the decision to delay trauma therapy was clinically appropriate because the records show Mr E did not feel ready to begin intensive trauma therapy.

82. The records show at the point of discharge, there were no active CMHT interventions the Trust could provide while awaiting ADHD assessment. The records do not support Mr E’s view he was discharged because he was not at immediate risk. The Trust’s decision to discharge Mr E was in line with the CMHT guidance on trauma therapy.

83. Overall, the evidence shows the Trust acted in line with national guidance and its own procedures. The psychological assessment was completed, the recommended pathway was identified, and the Trust made reasonable attempts to support Mr E. There is no evidence the Trust failed to diagnose or treat him appropriately between November 2024 and February 2025.

84. We understand the emotional impact of feeling as though you are “slipping through the net”, and we do not underestimate how this may have contributed to Mr E’s sense of hopelessness and mistrust in the system. We understand the frustration and uncertainty he has experienced and thank him for the opportunity to investigate his concerns despite these difficulties.

Mr E says his care and treatment at the Trust throughout these periods has been negatively influenced by reference in his medical records to the ongoing use of medical cannabis.

85. Mr E told us he became aware he was listed as a “high risk substance abuser” 15 years ago. He believes his recent treatment options have been affected, resulting in him being denied appropriate medication and treatment. Mr E states: “I've been judged on one thing and that's my self-medicating with cannabis over the years”.

86. Appointment notes completed in August 2024, while Mr E was under the care of HTT, show Mr E stated he used prescribed cannabis which helped him from overthinking and dwelling on his past.

87. This is also referenced in formulation sessions with CMHT in November 2024. The notes state Mr E, “is prescribed medicinal cannabis; he uses this on a daily basis and describes this serves a regulatory function for his emotions”.

88. When we asked our Psychological Counselling adviser about this, they said “Trusts do consider substance use to interfere with therapy and it can be appropriate to delay therapy until substance use is better managed”.

89. Our Nursing adviser explained patients who present to mental health services should be assessed by considering several factors including mental, physical, and social wellbeing and this would also include substance use. Decisions about treatment and interventions are based on these multiple individual patient factors, not just one factor.

90. This is in line with CMHT guidance which highlights any assessments and subsequent care should be decided based on a range of factors and should be a collaborative process with the service user.

91. The Trust’s Engagement procedure explains, it is essential staff working with service users with an identified mental health condition, who are also using alcohol, substances (illegal or otherwise) or both, discuss the nature of this use.

92. It goes on to say, “Knowing this information provides an informed basis for next steps, such as onward referrals to associated local substance user service providers. It also provides staff with opportunities to identify any associated interventions required”.

93. Whilst it is normal and in line with the local guidance to consider drug use when deciding on next steps of a treatment plan, it should not be an overriding factor when deciding on next steps.

94. When we discussed this with our Psychological Counselling adviser, they did not believe there was any reason to think that the use of medical cannabis or being labelled as a historic “high risk substance abuser” changed any outcome.

95. We have seen the care and treatment provided by the Trust was in line with guidance and was clinically appropriate. We have seen the language used in the medical records regarding Mr E’s cannabis use was neutral, and the clinicians did not report any concerns about cannabis use interfering with engagement or potential therapy.

96. We have not seen any evidence the actions of the Trust were based on Mr E’s use of cannabis. For this reason, we will take no further action on this part of his complaint.

97. We recognise how distressing it must have been for Mr E to believe that his past use of medicinal cannabis may have influenced the treatment options available to him. Feeling judged or labelled, particularly when facing mental health challenges, can deeply affect a person’s confidence in seeking care and their sense of being understood. We understand the frustration Mr E must have felt about these concerns.

Impact

98. We found an indication of a failing in how the Trust handled Mr E’s discharge in September 2024, as the voicemail he left was missed. This meant Mr E may not have had a fair opportunity to clarify his intention to continue with HTT involvement before being discharged.

99. Mr E raised his concerns with the Trust on the day of his discharge, 12 September, and the Trust responded on 18 October, five weeks later. In its response, the Trust acknowledged the error, apologised for the distress caused, and implemented service improvements to prevent similar occurrences.

100. The Trust also took corrective action by arranging psychological sessions to restore Mr E’s care to where it would have been prior to the error, ensuring he could continue receiving the support he needed.

101. These actions align with Our Principles of Remedy, which state: "Where maladministration or poor service has led to injustice or hardship, public bodies should try to offer a remedy that returns the complainant to the position they would have been in otherwise."

102. Mr E had disengaged from HTT in the weeks leading up to his discharge, missing several planned contacts and informing staff during an unannounced visit on 22 August that he did not feel at risk and did not wish to continue HTT involvement. He later apologised to the Trust for his lack of engagement. However, the Trust missed a voicemail Mr E left on the day of discharge, which may have allowed him to clarify his position. While this failing understandably caused Mr E frustration, it was a one off communication error rather than it being evidence of a systemic failing in the discharge process.

103. The distress caused by the missed voicemail lasted for five weeks, from 12 September to 18 October 2024. While we recognise the frustration caused by this, it was short-term in nature and did not result in a lasting change to Mr E’s care.

104. Mr E requested £10,000 in financial compensation for the distress caused by the error. However, this amount is disproportionate to the nature and impact of the failings in this case. Compensation at this level is reserved for cases involving severe and long-lasting impacts, such as permanent injury, financial hardship, or prolonged psychological trauma. The evidence does not show that Mr E’s situation meets these criteria.

105. The Trust has taken appropriate steps to address the impact of the failing. It acknowledged the issue, apologised for the distress caused, implemented service improvements, and provided psychological support. These actions have sufficiently remedied the impact of this isolated error and removed much of the detriment caused. Based on this, we do not consider financial compensation necessary to resolve Mr E’s complaint.

106. We understand how upsetting this experience was for Mr E, especially given his broader challenges in managing his mental health. However, the evidence shows that the Trust’s actions adequately addressed the impact of the error and provided a proportionate remedy. For these reasons, we are satisfied that the Trust acted appropriately and no further action, is necessary to resolve this part of Mr E’s complaint.

Conclusion

107. For the reasons outlined above, we will not be taking any further action on Mr E’s complaint about the Trust.

108. We understand this decision may be disappointing for Mr E, especially given the time and effort he has invested. We thank Mr E for bringing his complaint to us and appreciate the opportunity to consider it.

1. We have carefully considered Mr E’s complaint about Lancashire and South Cumbria NHS Foundation Trust (the Trust). We have considered the evidence regarding Mr E’s complaint and having done so we have seen indications of failings in the decision to discharge him. We have not seen that care and treatment has been negatively influenced by any reference to his cannabis use in his records.

2. We are sorry to hear about the circumstances of Mr E’s complaint. We understand the challenges he has faced and his continued struggles in receiving the treatment feels he needs. We recognise the strength of feeling and how important it is to him to receive the treatment.