Black Country Healthcare NHS Foundation Trust

7. Miss W, represented by her mother Mrs W, complains the Trust: • did not diagnose her with autism until October 2025, despite carrying out her initial assessment in February 2024 • did not put suitable support in place while she was waiting for the outcome of her assessment.

8. As a result, Miss W says she is significantly distressed, upset and anxious and she has been unable to attend school for over two years. Miss W believes had the Trust told her she had autism sooner, she could have accessed more support.

9. Miss W is seeking an explanation and for us to consider a financial remedy.

10. Miss W experienced anxiety during secondary school, and her attendance decreased at the end of her first year and into her second year, until she stopped attending completely.

11. The Trust accepted Miss W onto its autism pathway, to wait for an assessment, in late 2023.

12. The Trust completed a diagnostic observation (a standardised, interactive assessment to evaluate social communication, play skills, and behaviours) in January 2024. Miss W completed a self-assessment (a screening questionnaire that helps individuals evaluate their own behaviours, communication styles, and sensory experiences) the following month.

13. The Trust wrote to her in May to confirm her case was now waiting to be discussed within the multidisciplinary team (MDT – a team comprised of healthcare professionals with different specialist expertise) to see if the Trust needed to conduct any further assessments or if it could make a diagnosis of autism.

14. In May Miss W also attended sessions with the Trust to help with her anxiety and mental health issues. These sessions with a practitioner were primarily cognitive behavioural therapy (CBT – a type of talking therapy that helps to positively change the way people think and behave) based.

15. Miss W attended five sessions before the Trust discharged her in October. Around that time the Trust also referred Miss W for a psychiatric and medication review, but the team did not accept the referral.

16. The Trust conducted the final parts of Miss W’s autism assessment by discussing the case within its MDT and gathering some further information in late 2025. It gave Miss W her diagnosis in October 2025.

Autism assessment

23. Miss W complains about the length of time she waited for an autism assessment. She says there was a long gap between her initial assessments and the Trust confirming her diagnosis of autism.

24. The Trust says due to the demand on its service there are significant wait times for these assessments. It says this is a national problem that many services across the country are dealing with.

25. The Trust completed the two main assessments with Miss W in early 2024. It then put her case in a queue to be discussed within the MDT to see if any further assessments were needed or if it could make a diagnosis of autism.

26. Our psychiatrist adviser explained it is usual for diagnostic MDTs to happen very soon after the initial parts of the assessment. In Miss W’s case she had her initial assessment in early 2024, which met the three-month timeframe outline in the NICE guidance (CG128). However, the Trust did not revisit this information until around 19 months later.

27. Our psychiatrist adviser explained it is best to analyse information collected during the assessments as soon as possible after it is gathered. We agree with this and can understand the longer the period between the assessment and analysis, the more things that could change in the interim period. This could lead to the assessments needing to be revisited or redone if things had changed significantly.

28. The NICE guidance (CG128) says to avoid repeated information gathering, which supports our view that the assessments should have been analysed within a prompt timeframe to avoid changes in the intervening period needing to be re-assessed.

29. The NICE guidance (CG128) does not give a definitive timescale for diagnostic MDT discussion after the assessment. However, given this guidance sets out a definitive and prompt deadline of three months for the assessment to start after referral, we do not consider an indefinite wait for analysis of that assessment is reasonable. Additionally, this guidance says to discuss the results with the service user and their parents without delay, which supports prompt consideration.

30. We have not seen any evidence the 19-month delay was because the Trust was actively considering Miss W’s assessments and this took a long time. We have found the Trust assessed her promptly to meet the three-month deadline set out in the NICE guidance (CG128) and then put her in a queue for the diagnostic MDT.

31. The Trust should assessed Miss W and then carried out the diagnostic MDT within a prompt timeframe. We consider the explanations above from the guidance supports this approach and, having discussed this with our psychiatrist adviser, this would be in line with the standard NHS practice used by other NHS autism services.

32. This would reduce the likelihood of changes in the interim requiring further information gathering. We can see the Trust did have to speak with Miss W after the initial MDT discussion, before giving her a final diagnosis. This strengthens our view that the assessment and diagnostic MDT should take place closer together.

33. We have considered the impact of the delay between the assessment and the diagnostic discussion had on Miss W.

34. On the overall period of delay, there is a significant demand on autism services across the country, and we must consider this case within the context of wait times for autism diagnosis in the UK.

35. Information from NAS tells us that nine out of ten people are not assessed within the three months outlined in the NICE guidance (NICE CG128) and the average wait time for an autism assessment in England is around 16 months (as of November 2025). We are also aware that the capacity of these services has been under pressure due to a rising demand and this pressure is steadily increasing over time.

36. Miss W’s wait of around 19 months for her diagnosis was too long. This is an area of national concern. The overall delay was due to pressures on the Trust, and we know most autism services in the UK are currently not meeting the timeframes set out by NICE.

37. If the Trust had put Miss W on the waiting list before completing the initial assessments, it is likely the 19 months it took to assess her and consider her within the MDT would have been the same due to service pressures. Although it is likely the Trust would have added her to the waiting list earlier and assessed her after a long initial wait.

38. Once the diagnostic MDT discussed Miss W’s case on 1 October 2025, it did have to gather and consider some further information. However, this was prompt as the Trust confirmed her diagnosis within a month.

39. Miss W told us she has still not been able to access any services to provide mental health support since her diagnosis. Therefore, the few weeks it took to gather further information before her diagnosis did not delay her accessing further support to help her with her anxiety and distress.

40. We found the assessment and diagnostic parts of the assessments should take place close together. However, our view is doing them closer together would not have led to an overall reduction in the time Miss W waited for her autism diagnosis. While the overall time the Trust to diagnose Miss W was too long, it is similar to the average wait times nationally. Therefore, we cannot link an impact specific to the Trust on this.

41. We acknowledge Miss W waited a very long time for her diagnosis. This was clearly a very difficult and stressful period for her.

Support

42. Miss W complains the Trust failed to support her while she was waiting for the outcome of her autism assessment. She says she struggled to benefit from the CBT provided by the Trust, and it discharged her without further support.

43. The Trust explains it provided therapeutic support to Miss W but ended it as she was not engaging. It said the therapeutic intervention it offered involved strategies to manage anxiety, which Miss W was unable to successfully implement.

44. Miss W attended five sessions with a mental health nurse between May and August 2024. During the first session, the practitioner identified Miss W’s anxiety, recording she ‘attended with her hood up and spoke very little… was very anxious today’. Throughout the sessions the practitioner recorded Miss W was anxious and found it difficult to talk to them.

45. The notes, alongside what Miss W told us, reflect she did not cope well with these sessions and, as they went on, she found them increasingly difficult.

46. The NICE guidance (CG170) supports an individual approach, saying therapeutic sessions for young people should be tailored to their individual needs. Examples of this include using structured worksheets, regular breaks, and incorporating the child’s interests into the session.

47. However, after reviewing this case with our nurse adviser, we found very little evidence that the Trust applied these techniques to support Miss W.

48. We cannot see evidence the Trust used visual aids to give Miss W information ahead of sessions on what would happen the structure of the session. Our nurse adviser explained this would be common practice and we can see how this may have helped manage Miss W’s anxiety prior to the session by telling her what to expect.

49. The sessions appear to have revolved around trying to discuss Miss W’s difficulties and there are some references to her trying breathing techniques. The records show a lack of rapport building and making Miss W feeling comfortable within the sessions. The techniques mentioned in the guidance, such as play therapies, might have assisted with Miss W feeling more comfortable.

50. The Trust could have tried a more gradual approach to the sessions. Our nurse adviser explained having shorter sessions in a more familiar environment before gradually increasing Miss W’s exposure to the anxiety inducing sessions could have been helpful.

51. However, the Trust arranged to meet Miss W for a session and booked in regular appointments from the start. The notes reflect she became overwhelmed and over the course of the session would shut down. We have seen little evidence that the practitioner considered a more gradual approach or adapted the structure of these sessions to help Miss W feel comfortable. We have found this is not in line with the gradual approach to sessions outlined in NICE guidance (CG159).

52. Given there is clear documentation of how Miss W was very anxious when attending the sessions, our view is the Trust did not tailor the sessions to her. We have also seen little recorded about what techniques the practitioner tried to work on with Miss W, what the plan for each session was and what goals they worked towards.

53. This is not in line with the individual approach detailed in the NICE guidance (CG170).

54. On 28 August, Mrs W told the practitioner her daughter was extremely upset and anxious at the thought of attending the session, and Miss W said she did not want to attend the sessions anymore. This should have prompted the Trust to think about why Miss W was finding the sessions so difficult and consider what it could do to change this and adapt for her. However, there is no clear record of the Trust doing so.

55. Our nurse adviser said the practitioner could, for example, have discussed Miss W within an MDT meeting to get other opinions or ideas on how they could help or what more they can do. Mrs W contacted the Trust in September to ask whether there were any different ways to engage her daughter going forward. The Trust does not appear to have considered or offered any alternatives. Our view is this is not in line with the individual adaptive approach highlighted within the guidance (CG170).

56. It was especially important for the Trust to try to make this support work as Miss W had a clear unmet mental health need at this time. Mrs W reported on 9 October her daughter was ‘having more meltdowns lately and they feel very lost and unsupported’ and Miss W had not attended school regularly several months.

57. Despite the clear need for help, the Trust discharged Miss W in October 2024, as it felt she was unable to engage. Given our view, that the Trust did not adapt the sessions to Miss W’s needs, we do not find the Trust’s reasoning to be robust. The NICE guidance (CG170) also supports eight to twelve sessions of CBT, therefore, five sessions was insufficient.

58. We have found the Trust’s decision to discharge her at this point was not in line with the guidance (CG170).

59. Just prior to discharge the practitioner referred Miss W to psychiatry to consider medication options for Miss W. This referral was rejected by the Trust as she had ‘not engaged well… not implemented the work recommended, medication is usually an adjuvant (a treatment used alongside therapy to enhance effectiveness)’.

60. We have considered this with the help of our psychiatrist adviser, and we do not find this reasoning to be robust. Miss W’s anxiety was clearly preventing her from engaging effectively, and our view outlined above is the Trust did not do enough to assist her. After this point, Miss W was left without any further support in place while clearly still struggling.

61. In summary the Trust did not provide effective support due to poorly structured sessions and it prematurely discharged Miss W. After discharge, the Trust provided very little ongoing support.

62. We have considered the impact of these failings on Miss W. Our nurse adviser stated that, had the sessions been properly structured, they should have focused on helping Miss W manage her anxiety and addressing the specific difficulties it caused in her daily life. Her records suggest that her anxiety greatly impacted her ability to function on a day-to-day basis. We know these challenges affected Miss W for a long period before the Trust provided the sessions and still remain a concern.

63. We must acknowledge that it is very difficult to determine with certainty whether, or the extent to which, Miss W would have benefitted even had the Trust delivered the sessions as it should have. As we can see throughout the records, Miss W’s anxiety made it difficult for her to engage with new people in unfamiliar settings.

64. Miss W was distressed and anxious prior to these events. This was not caused by the Trust, and we do not know whether different care would have mitigated against this. This was always likely to have remained a significant challenge and was a major contributory factor behind her distress.

65. CBT-based sessions rely on an individual’s engagement and their ability to take on board the techniques positively. While the Trust should have used techniques to adapt to Miss W’s specific needs, the sessions still required her active participation. The records show Miss W found it very difficult to use the techniques attempted in the sessions and did not practice between sessions. For example, on 9 July she told the practitioner she found the breathing techniques and mindfulness (a psychological skill that asks people to focus on the present moment and away from other thoughts) hard and she could not do them.

66. Based on the evidence available, we cannot say for certain that Miss W would have found the sessions and techniques useful had the Trust delivered the sessions differently. We acknowledge that Miss W lost the chance to access care in a way that was better tailored to her needs, though this is difficult for us to quantify.

67. It is particularly difficult for us to say that these provisional failings might have contributed to Miss W not being able to attend school. We can see she was already unable to attend prior to the sessions. We are unable to say the sessions would have had such a marked effect that would have allowed her to attend. We understand that Miss W is now attending school more often, having changed to one specialising in children who face difficulties adapting to mainstream education. This indicates she required a more specialised learning environment, though even with it she is still having difficulties attending full time.

68. Considering all the above, we are unable to robustly say what would have been different had the failings not happened. We acknowledge this was clearly a very difficult period for Miss W.

69. To resolve her complaint, Miss W told us she wanted an explanation about the care she received. We consider our final report outlining our investigation and findings provides this.

70. NHS Complaint Standards state that if it is not possible for the responsible organisation to put things right, then they should compensate the person affected appropriately. We have found failings in some aspects of the care the Trust provided to Miss W. There was a chance of a possible different outcome for Miss W. We must acknowledge the same outcome may very well have resulted even had the potential failing not occurred.

71. In the circumstances, we do not consider it appropriate to make a recommendation for a financial remedy.

72. In closing we hope our comments and considerations given Miss W some answers about the care she received. We know this was a very difficult time for her. We would like to wish her well in the future.