Summary
C complained on behalf of their adult child (A) about the mental health care and treatment that they received. A had previously received talking therapy from Child and Adolescent Mental Health Services (CAMHS) for multiple mental health conditions. A GP referral was made to adult services for attention deficit hyperactivity disorder (ADHD, a condition where the brain works differently to most people). A was assessed twice by a psychiatrist and referred to psychology but this referral was declined. A was referred for group therapy but this was not taken up.
A’s mental health deteriorated significantly. They were privately diagnosed with autism spectrum disorder (ASD, a difference in how the brain develops that affects how people see and experience the world), ADHD-inattentive and avoidant restrictive food intake disorder (ARFID, an eating disorder) but no medication or treatment was offered by the NHS. A's care has since improved ,however, C considers that earlier care was unreasonable. They also complained that the partnership's handling of their complaint was unreasonable.
The partnership apologised for delays in complaints handling, noting that the psychiatrist had left. They acknowledged that several aspects of record keeping and communication were not as effective as they could have been, including: CAMHS record keeping; communication between primary care psychological therapies and secondary care mental health services; communication with the GP; and communication with A. They committed to improving these.
We took independent advice from a consultant psychiatrist. In addition to the failings and improvements identified by the partnership, we found that the mental state examination records, and records of discussion with psychology colleagues were not detailed enough to justify the treatment plan or the complaint response, which claimed that there was no evidence of major mental illness. We also considered that the complaint response had been unreasonably slow and had not responded to all the issues raised. Therefore, we upheld both complaints.
Recommendations
What we asked the organisation to do in this case: Apologise to A for the unreasonable record keeping in regards to A’s mental health examination, medication review, analysis of previous clinical history, consideration of ADHD, consideration of ASD and the rationale for the decision to refer to group therapy. Also apologise to A for unreasonable communication within mental health services and with the GP and patient. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.
Apologise to the family for the unreasonable complaints handling. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.
What we said should change to put things right in future: Record keeping standards and quality assurance processes should be such that all mental health consultations and clinical discussions are reasonably recorded, including rationale for the management plan. This should be the case in both CAMHS and Adult Mental Health Services.
In relation to complaints handling, we recommended: Model Complaints Handling Procedure standards in relation to timeliness and quality should be adhered to. The safety of the patient should be considered.
We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.
Related reading
View Decision Report 202411659 as a PDF (29.72 KB) Updated: June 17, 2026