Humber Teaching Hospitals NHS Foundation Trust

5. Mr D complains about the care he received from the Specialist Psychotherapy Service (SPS) at the Trust in 2023 and 2024. Mr D says the Trust:

• did not refer him to the correct service or provide him with appropriate mental health treatment • mishandled his request for a second opinion • wrongly contacted the safeguarding team without advising him • gave him incorrect information in a meeting in January 2025 concerning Talking Therapies (TT) and Improving Access to Psychological Therapies (IAPT).

6. Mr D says the Trust misinterpreted him, made decisions behind his back and breached his human rights. He says he has not received the right treatment or help from the Trust. He says this has caused him considerable stress and negatively impacted his mental health. He says he feels humiliated and pushed away from NHS services. Finally, he says there has also been a considerable emotional impact on his wife due to supporting him.

7. Mr D is seeking an apology, acknowledgement of failings, service improvements and financial remedy.

8. Mr D has a history of mental health issues, including possible post-traumatic stress disorder (PTSD) and learning disabilities. He was originally referred to the Trust community mental health team (CMHT) in January 2023, before CMHT passed the referral to the Specialist Psychotherapy Services (SPS) team.

9. SPS rejected the referral in April 2023 because they felt he needed assessing by the Community Team for Learning Disabilities (CTLD). In the same month, CTLD rejected the referral because Mr D was able to access mainstream services without assistance. In the letter rejecting the referral, CTLD suggested that Mr D be referred to CMHT. The CMHT team did not identify a need for their involvement and documented that CTLD would be advised to refer Mr [name redacted] back to SPS. The records show this did not happen.

10. In September 2023, Mr D was referred to CMHT again. The referral form noted that the safeguarding team had been contacted for advice regarding disclosures made in Mr D’s risk assessments, to ensure no further action was required. It noted Mr D was not suitable for TT and requested longer term therapy through alternative services.

11. In December 2023, Mr D rang the Trust Mental Health Advice and Support Line and asked for an update on his referral. The call handler contacted SPS, who reviewed the referral in an MDT meeting the following week. They accepted the referral and arranged an initial meeting with Mr D in January 2024.

12. Mr D had meetings with the SPS team in January and February 2024. In the second meeting, SPS advised they did not think psychotherapy was appropriate for him. Mr D asked for a second opinion and for a meeting to be arranged with his wife to discuss further. These meetings took place in March and April 2024.

13. The Trust discussed next steps internally before referring Mr D to CMHT in July 2024. He brought his complaint to the Trust in May 2024 and received a final response in June 2025. He brought his complaint to the ombudsman in September 2025.

The Trust did not refer Mr D to the correct service or provide him with appropriate mental health treatment

17. Mr D was initially referred to CMHT in January 2023. CMHT passed his referral to the SPS team, who rejected it in April 2023 and passed it to CTLD, who also rejected it. CTLD documented that Mr D should have been referred back to SPS, but this did not happen.

18. Mr D was referred to CMHT again in September 2023. He chased the Trust in December 2023 and an initial meeting with the SPS team was arranged for January 2024. SPS advised Mr D it did not think psychotherapy was suitable for him in February 2024 and referred Mr D to CMHT in July 2024 to commence treatment.

19. In its final response, the Trust acknowledged that Mr D’s referral experience had not been handled correctly and apologised for the distress this caused him.

20. NICE guidance NG116 says clinicians should consider cognitive behavioural therapy (CBT) intervention and Eye Movement Desensitization and Reprocessing (EMDR) therapy for adults with possible PTSD.

21. The Trust told us that patients referred with PTSD may be referred to TT services for CBT or EMDR. It said that if a patient’s needs extend beyond that which TT can provide, then they can be referred to CMHT or SPS teams for a further assessment of their needs.

22. Mr D’s initial referral stated that he has a very complex past and is not suitable for other low-level services. It asked CMHT to assess Mr D for underlying conditions such as PTSD and appropriate support. His second referral stated Mr D is not suitable for TT as he has more than three incidents of trauma, and requested he be referred for longer term therapy.

23. Our adviser said the Trust CMHT service attempted to determine a care pathway for Mr D based on his initial referral, which said he was not suitable for TT. They said the Trust CMHT initially concluded that Mr D’s needs went beyond their capacity.

24. Our adviser said the subsequent SPS decision to decline Mr D’s referral and pass him to the learning disability team for assessment was not appropriate. They said that, as the Trust acknowledged in its final response, the service should have consulted with the learning disability team while retaining responsibility for Mr D’s referral. They said this part of Mr D’s referral process was not in line with guidance. They said that each team made appropriate decisions that Mr D was not suitable for their services, but should have communicated better to minimise delays to his referral.

25. Our adviser said Mr D’s re-referral to CMHT in September 2023 resulted in Mr D being reviewed by SPS in January and February 2024, before being referred to a different CMHT service which could meet his needs in July 2024. The records show the clinical view that Mr D would benefit from trauma stabilisation work in the first instance, rather than explorative therapy which could increase distress and be destabilising. Our adviser said this is in line with usual clinical practice, which prioritises safety and stabilisation at the beginning of any trauma treatment to prevent potential re-traumatisation.

26. Our adviser said the Trust’s clinical decision to refer Mr D to a different CMHT service which could meet his needs was in line with relevant guidance, Trust policy and usual clinical practice when treating patients presenting similarly to Mr D.

27. In summary, our adviser said there had been problems with Mr D’s initial referral which were not in line with guidance, but the process around Mr D’s second referral and subsequent review by SPS, before being re-referred to CMHT for trauma stabilisation work, was appropriate and consistent with guidance.

28. Our NHS Complaint Standards say organisations should give meaningful apologies and transparent explanations when things go wrong, which reflect the impact on the people concerned. It says organisations should inform complainants of all learning and improvements relevant to their complaint. In its final response, the Trust said it had tried to ensure Mr D was seen by the correct service and acted with best intentions, but acknowledged it may not have made the right decisions in Mr D’s case. It outlined the improvements it was making to its consultation and referral processes to improve the pathway and avoid similar situations being replicated in the future.

29. We use our severity of injustice scale to calculate appropriate financial remedy when we see indications of failings. The scale defines a level two injustice as causing the person a degree of distress or inconvenience, which had a relatively low impact on them. In these cases, we consider an apology is not suitable by itself.

30. We consider the Trust’s failure to process Mr D’s initial referral correctly caused him avoidable distress and prevented him starting treatment for a period of several months. Although Mr D was a complex patient and it was reasonable that the Trust discussed his referral with several teams to determine who would be responsible for his care, he would likely have begun appropriate treatment through CMHT by the end of 2023 had his initial referral been appropriately processed. Due to the delays Mr D experienced, he began treatment in July 2024, which represents a delay of between six and eight months. There is no indication of any other adverse effects or ongoing wider impact on Mr D beyond the delay, which we would have caused distress for Mr D, contributing to his frustration and disappointment.

31. This places this complaint component in level two on our scale. Based on similar previous cases, we consider an appropriate level of financial remedy would be £350.

32. We contacted the Trust to discuss the complaint. Following our contact the Trust agreed to pay Mr D £350 in financial remedy and to make a further apology for the distress caused to Mr D.

33. We consider this sufficient to resolve this part of the complaint. We will therefore not be looking at this part of the complaint further.

The Trust mishandled Mr D’s request for a second opinion

34. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone wrong.

35. Mr D told us the Trust initially declined his request for a second opinion and did not engage appropriately with his issues of his care and treatment when clinicians spoke to his wife.

36. The records show the Trust SPS told Mr D it did not think psychotherapy was appropriate for him in February 2024. Mr D asked for a second opinion during the meeting, which the SPS agreed to. Mr D also asked that a meeting to be arranged with his wife as part of this process so she could give her perspective on his needs.

37. The SPS met with Mr D’s wife in March and Mr D received a second opinion from different clinicians in April and May 2024.

38. GMC ‘Good medical practice’ says clinicians must request patient’s right to seek a second opinion.

39. Our adviser said Mr D’s second opinion was delivered by another related service to SPS and was therefore appropriate. They said the clinicians reported back to a multi-disciplinary team (MDT) meeting in May 2024 and documented the view that Mr D required therapy but not explorative psychotherapy. They recommended Mr D be referred to CMHT for trauma stabilisation. The referral was actioned in July 2024.

40. Our adviser said the Trust appropriately actioned Mr D’s request for a second opinion and arranged a suitable second assessment for him. They said this process produced a consensus that exploratory therapy would pose risks to Mr D and sought to refer Mr D for treatment through CMHT.

41. We understand Mr D’s concern that the Trust mishandled his request for a second opinion. Having reviewed the evidence, we consider that the Trust arranged a suitable second opinion for Mr D. We will therefore not be looking at this part of the complaint further.

The Trust wrongly contacted the safeguarding team without advising Mr D

42. When the Trust referred Mr D to CMHT in October 2023, it contacted the safeguarding team for advice regarding disclosures made in Mr D’s risk assessments, to ensure no further action was required.

43. The Trust’s internal safeguarding policy says the safeguarding team support Trust staff by giving access to professional guidance when dealing with safeguarding issues or concerns. It says it has an advisory role and does not specifically state whether individuals should be informed about a preliminary consultation. It specifies that individuals should be informed when a formal safeguarding referral is made, unless it is unsafe to do so.

44. Our adviser said the Trust sought advice appropriately and in line with guidance. They said there was no requirement for the Trust to tell Mr D that it had made an initial contact to safeguarding seeking advice. They said the Trust had not made a safeguarding referral but was seeking a discussion on the best procedure to follow given Mr D’s background. Given these circumstances, they said it was appropriate for Trust staff to have sought advice.

45. We understand Mr D’s concern that the Trust contacted the safeguarding team without informing him. Having reviewed the evidence, we are satisfied that the Trust acted in line with guidance when it sought advice from the safeguarding team and did not inform him. We will therefore not be looking at this part of the complaint further.

The Trust gave Mr D incorrect information about his referral in a meeting in January 2025

46. Mr D told us that during a meeting with the Trust in January 2025, it incorrectly told him that TT and IAPT services were not properly trained to treat him and that he should not have been referred to these services.

47. There are some occasions when we decide we should not investigate a complaint made to us. One of these occasions is when an investigation would not be practical, would not reach a satisfactory conclusion and there would be no value in providing that response through an investigation.

48. We acknowledge Mr D’s experience and accept his personal recollection of the meeting. Having reviewed the available evidence, which includes Mr D’s advocate’s notes from the meeting and the Trust’s subsequent follow-up letter after the meeting, we do not think it is likely that we could reach a definitive conclusion on this point.

49. The records do not contain any information about this topic of conversation. Because of the absence of any further evidence, an investigation into this matter would not be practical and could not reach a satisfactory conclusion. We will therefore not be considering this part of the complaint further. We appreciate how Mr D may feel disappointed by the lack of evidence available, and we regret that we are unable to resolve this component of the complaint.

50. We thank Mr D for bringing his complaint to us. We hope our explanation and resolution provides closure for him and explains the care and treatment he received. We wish Mr D the best for the future.

1. We have carefully considered Mr D’s complaint about the care and treatment he received from the Trust in 2023 and 2024.

2. We consider that there were delays in Mr D’s referral process, due to his complex presentation and Trust errors. We considered the Trust needed to do more to recognise the impact of these events on him. We contacted the Trust and asked it to make a financial remedy payment to put this right, which it agreed to. We explain this in more detail below.

3. We consider the Trust handled Mr D’s request for a second opinion and contacted the safeguarding team in line with guidance. We consider that an investigation into the information the Trust gave Mr D during a January 2025 meeting would not be practical and could not reach a satisfactory conclusion.

4. We hope our explanation reassures Mr D and explains the care and treatment he received.