Derbyshire Healthcare NHS Foundation Trust

3. Mr L complains that between March 2024 and July 2025, the Trust:

• incorrectly declined two referrals for long term mental health support by the Community Mental Health Team (CMHT) in May and July 2024 • did not inform him of the clinical decisions following the declined referrals • took too long to issue its complaint response.

4. As a result of the above, Mr L says he experienced a significant deterioration of his mental health, with episodes of self-harm. He has been prescribed with medication to assist his mental health struggles due to the financial strain from seeking private mental health support. The delays in understanding what was happening with his referrals and in receiving complaint correspondence caused him additional stress and frustration.

5. As a result of the above, Mr L seeks a financial remedy.

8. Mr L was referred to the CMHT by Trent Psychological Therapies Service on 20 March 2024 for long-term trauma therapy.

9. He attended an initial assessment with a Homelessness Mental Health Practitioner on 5 April 2024 but was discharged following a multidisciplinary team’s (MDT) decision that his unstable housing situation was a barrier to his engagement with therapy.

10. Mr L raised a complaint on 2 May 2024, expressing dissatisfaction with the CMHT’s decision and its communication, but the complaint was initially sent to the wrong trust.

11. After a second referral, Mr L attended a further appointment on 23 July 2024. He was again discharged following a decision from the MDT on 27 July 2024. He received a discharge letter signposting him to community-based support.

12. On 5 August 2024, Mr L formally submitted his complaint to the Trust. He raised concerns about delays, poor communication and the lack of support.

13. Mr L received the Trust’s response on 10 July 2025, which apologised for delays, acknowledged some shortcomings in its communication, and explained the reasoning behind the clinical decisions.

14. Dissatisfied with the Trust's response, as well as the delays and the Trust’s handling of his complaint, Mr L approached our service on 28 July 2025 to request an independent review.

15. 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 the organisation has not put right. Having done so we have identified signs the Trust’s service has fallen short of expected standards in relation to its discharge processes and complaint handling.

16. Following a self-referral, Mr L was assessed by Trent Psychological Therapies Service (PTS) on 20 March 2024. PTS found Mr L to be unsuitable for short-term therapy due to the complexity of his presentation and referred him to the CMHT for long-term trauma therapy.

17. On 26 March 2024, CMHT contacted Mr L via email, his preferred contact method. It arranged an initial assessment with one of its own Homelessness Mental Health Practitioner, which was scheduled for 5 April 2024.

18. On 5 April 2024, Mr L attended the initial assessment with the Homelessness Mental Health Practitioner. During the assessment, Mr L’s therapy goals were explored, and the CMHT practitioner then sought advice from the MDT on how to proceed.

19. On 16 and 23 April 2024, Mr L contacted CMHT via text message requesting an update on his referral. CMHT responded by text on 23 April, advising that its notes from the initial assessment had been uploaded for review by his GP. However, CMHT did not provide further details on the status of the referral. At this time, no decisions had been made regarding his care.

20. An MDT took place in May 2024 where the CMHT decided it would not offer long-term trauma therapy at that time. The MDT determined Mr L’s unstable housing situation presented a barrier to engagement in trauma therapy. As a result, the CMHT discharged Mr L from its service, concluding stable housing was necessary for therapy to succeed.

21. During discussions, the Trust found Mr L was already in consultation with charities and support networks regarding his housing situation.

22. On 2 May 2024, Mr L raised a formal complaint. He was unhappy with the care and treatment offered by the Trust and believed an agreement for therapy reached during his 5 April 2024 appointment was not followed. Unfortunately, this complaint was sent to the wrong Trust by Mr L.

23. On 3 May 2024, the Trust recorded it attempted to contact Mr L by telephone to inform him of the MDT’s decision. Mr L disputes this call was attempted.

24. No additional attempts were made to get in touch with Mr L. Instead, the decision was communicated to Mr L’s GP in a letter dated 28 May 2024. There is no evidence Mr L received a discharge letter or other written communication about the decision.

25. Mr L contacted CMHT for clarification about the referral outcome in May. However, no one provided him with a full explanation of the MDT decision or information about available support pathways.

26. Mr L has said the lack of communication was ‘beyond traumatic’ as he was left without understanding why therapy had been declined, what other support might be available, or what steps he could take when his mental health was deteriorating.

27. On 23 July 2024, Mr L attended a reassessment appointment with a CMHT practitioner because of a second referral to the service. During the appointment, the practitioner attempted to work with Mr L to identify a treatment goal and offered him 12 weeks of therapy. However, the records show Mr L declined to engage in this discussion because he believed long-term therapy had previously been agreed.

28. On 27 July 2024, the MDT reassessed Mr L’s needs. It concluded in the absence of a defined treatment goal, no further treatment pathway could be offered. The MDT instead recommended signposting Mr L to community-based support services, including Derby City Life Links and Mentell.

29. On 30 July 2024, the Trust recorded it called Mr L to inform him of the MDT decision and discussed available support options. Mr L disputes this call was made. The decision and recommendations were also communicated to Mr L in a discharge letter sent on the same day. The letter thanked Mr L for his time on the phone that day and provided details of alternative community support options.

30. On 5 August 2024, Mr submitted a complaint to the Trust.

31. On 10 July 2025, the Trust issued its response to the complaint Mr L had submitted in August 2024. It apologised for the errors in handling the complaint and acknowledged its communication following the decision to discharge Mr L in May 2024 was below its expected standards.

32. NICE PTSD guidance states practitioners should take safety and stability into account when considering a person’s circumstances during treatment planning. This includes assessing housing situations and how they may impact therapy engagement and outcomes. The guidance also covers the importance of assisting individuals in overcoming barriers that might prevent access to therapy, for example, unstable housing.

33. The GMC's guidance highlights the importance of consulting colleagues or seeking advice from others, where appropriate, as part of providing good clinical care. It states practitioners must ‘consult colleagues or seek advice from supervising clinicians, where appropriate’, to ensure treatment is suitable and based on a thorough assessment of a patient's needs.

34. The NMC Code requires practitioners to work with service users, providing access to appropriate health and social care resources along with clear and relevant information and support.

35. The Trust’s decision in May 2024 not to offer long-term trauma therapy was in line with NICE PTSD guidance. CMHT appropriately considered Mr L’s unstable housing situation as a barrier to successful engagement in therapy.

36. The clinical adviser also noted Mr L was being supported with housing issues by other professionals, so further intervention from CMHT was not necessary. The MDT therefore acted in accordance with GMC and NMC guidance.

37. NICE guidance on patient experience highlights effective discharge planning is an essential practice. Discharge plans should be developed with and shared directly with service users, clearly outlining the next steps and addressing any barriers or concerns.

38. The Trust failed to provide Mr L with a discharge letter or adequate follow-up communication to explain the MDT decision in May 2024.

39. By contrast, communication related to the July 2024 referral showed improvements. The discharge letter issued on 30 July 2024 clearly explained the MDT decision and provided advice on next steps with details of community-based support services.

40. While Mr L disputes whether the recorded phone call on 30 July 2024 occurred, any concern over this was mitigated by the information provided in the discharge letter, which included the decision and his options.

41. On both occasions, the Trust sought input from the MDT to determine the best course of action for Mr L, in line with its obligations under the GMC guidance. This demonstrates a collaborative approach to assessing Mr L’s presentation, ensuring the decision was informed by the expertise of a range of professionals and aligned with NMC and GMC standards of good clinical care.

42. Based on the evidence, the Trust’s clinical decision-making and MDT processes were in line with NICE guidance and the NMC Code. The MDT considered appropriate factors, including Mr L’s circumstances and barriers to therapy engagement. Our adviser said the Trust’s decisions were consistent with professional standards. We have seen no evidence of maladministration in the Trust’s clinical decision making.

43. We have seen an indication of a failing in the Trust not send Mr L a discharge letter following his April 2024 referral. We will discuss the impact of this failing later in our report.

The Trust’s Complaint handling has been poor after it took approximately 10 months to respond.

44. Mr L initially submitted a complaint about his care to a different trust in May 2024. Mr L formally contacted the Trust to submit his complaint on 5 August 2024.

45. Mr L discussed his complaint with the Trust’s Complaints Investigator in September 2024. The Trust issued its formal response on 10 July 2025, approximately 11 months after the complaint was raised.

46. The Trust’s Complaints Policy outlines expectations for how complaints should be addressed to ensure a fair, consistent, and timely process. It states complainants should be kept informed throughout the process and informed of any unnecessary delays, explaining the reason for them. Its aims to deal with even its most complex complaints within 60 working days.

47. Our Principles of Good Complaint Handling set out expectations that complaints should be handled in a timely, transparent, and customer-focused manner. This includes effective communication throughout the complaint process and ensuring any delays are minimised and justified to prevent unnecessary distress for the complainant.

48. The Trust took approximately 11 months to respond to Mr L’s complaint. Based on the Trust’s longest response time of 60 days, we would have expected the Trust’s response by October 2024. Mr L received it in July 2025.

49. The Trust’s complaint policy and our Principles of Good Complaint Handling expect organisations to keep complainants updated throughout the life of their complaint. There is no evidence the Trust provided regular updates explaining the progress of the investigation or the reasons for the delay. It was only within the final response the Trust acknowledged the delay and apologised. For this reason we have identified indications of failings in the Trust’s complaint handling; it took significantly longer than the Trust’s published timeframes to resolve the complaint and it did not keep Mr L informed of the investigation’s progress or provide reasons for the delay or a revised timeframe.

Impact/Resolution

50. We have identified indications of failings in the Trust’s communication of Mr L’s discharge in May 2024. We have also seen indications of failings in the time it took to respond to Mr L’s complaint and in it not updating him throughout the life of his complaint.

51. In its complaint response, the Trust acknowledged its shortcomings in its discharge process and apologised to Mr L. It committed to improving its discharge process to ensure all service users receive detailed discharge plans before being discharged. This action was completed in December 2024. It shows the Trust’s efforts to use its learning from complaints to improve its service.

52. The Trust also acknowledged and apologised for the poor experience Mr L had with its complaint process. The Trust stated its complaints teams were taking action to improve the complaint-handling processes.

53. Mr L told us, following the discharge decision in May 2024, Mr L was left without clear or direct communication about the reasons behind the decision or information on next steps. The Trust failed to provide him with a discharge letter or any follow-up communication explaining the MDT’s decision, leaving him confused and unsupported during a particularly vulnerable time when his mental health was deteriorating. Despite Mr L’s attempts to contact the CMHT in April 2024 for clarification, he was unable to get a clear response, which added to his distress and feelings of abandonment.

54. During this time, Mr L says he felt ignored and helpless, describing the uncertainty as ‘beyond traumatic’. He struggled to understand why his referral for long-term therapy was not being progressed, and without timely communication, his stress and emotional strain increased.

55. By July 2024, when a new referral process was underway it became apparent the previous referral had been discontinued. Whilst we have not seen evidence of the communication that Mr L’s unstable housing situation was the reason for the previous discharge, we have seen Mr L referenced this in his complaint on 5 August 2024. He was therefore aware of the reason for his discharge by this date.

56. Mr L told us he experienced significant frustration because of the excessive delay in the complaints process. He formally submitted his complaint to the Trust on 5 August 2024 but did not receive a formal response until 10 July 2025, nearly 11 months later.

57. Under the Trust’s policy, complaints should be resolved within 60 working days. Based on these timeframes, Mr L could reasonably have expected a response by October 2024, yet he wait for an additional nine months. During this time, there is no evidence the Trust provided him with regular updates or explanations about the progress of his complaint. Mr L said this left him feeling further dismissed and unsupported.

58. We see the combined impact of poor communication following the May 2024 discharge decision and the prolonged complaints handling delay caused Mr L significant distress over an extended period. He endured confusion, distress and feelings of abandonment during a time of heightened vulnerability. The extended complaints process added frustration and disappointment to an already difficult situation.

59. While the emotional toll on Mr L was considerable, we do not consider it appropriate to include the costs he incurred seeking private therapy in our recommendations. We have not identified service failings in the care and treatment he received. However, we do recognise both the distress caused by the lack of communication and clarity about his discharge and the frustration caused by the lengthy complaints handling delay.

60. Taking into account the duration and seriousness of these failings, we assess the severity of injustice as falling within Level 2 of our severity of injustice scale.

61. We have approached the Trust to explore a resolution. We recommend a financial remedy of £500 to reflect the cumulative confusion, distress, and feelings of abandonment caused to Mr L during this time. This remedy acknowledges the emotional impact of the Trust’s poor communication and delays and serves as a commitment to ensuring similar issues are avoided in the future.

62. The Trust have agreed to our proposed resolution.

Conclusion

63. We have seen indications of failings in the Trust’s communication following Mr L’s discharge and in its complaints handling. We are pleased to see the Trust took learning and improved its service as a result of Mr L’s complaint. It has also agreed to pay Mr L £500 for the impact its failings had on him. We hope our thorough consideration of the issues Mr L raised reassures him about the actions of the Trust and goes some way in addressing the distress he experienced.

64. We thank Mr L for bringing his complaint to us and appreciate the opportunity to consider it.