A joint investigation by the Local Government and Social Care Ombudsman (LGSCO) and the Parliamentary and Health Service Ombudsman (PHSO) has found serious concerns over the way a vulnerable young woman’s situation was handled, after the organisations which should have helped failed multiple times to provide specialist aftercare services.
The investigation found that the young woman trying to overcome severe mental health problems had been put at significant risk of self-harm.
The woman, who lives in the Croydon area, had spent a long time in the care system before she was adopted as an older child. As a young teenager her mental health deteriorated to such an extent she was sectioned under the Mental Health Act.
The Ombudsman report notes that she should have left hospital with a package of aftercare agreed between the London Borough of Croydon, South London and Maudsley NHS Trust and the former NHS South West London Clinical Commissioning Group (now the NHS South West London Integrated Care Board). However, this did not happen.
This ‘Section 117 aftercare’ package is a legal entitlement, which should have helped to ensure she was not readmitted to hospital.
The young woman’s mental health repeatedly deteriorated. Her specific conditions meant she struggled to maintain relationships and led to behaviour which put her at risk of harm or accidental death.
Her parents complained that the Trust failed to provide family therapy as part of their daughter’s section 117 aftercare, making it more difficult for the family to understand and manage the risks.
At one point the Trust insisted the only place the young woman could access treatment was at the hospital in which she witnessed her best friend’s suicide.
The woman has admitted without family support she might not be alive today.
In addition to the lack of support, the investigation found the woman had not been able to access the enhanced Personal Independence Payment (PIP) benefits she was entitled to claim, having a big impact on both her and her family’s finances.
The trust also did not refer the young woman for supported living accommodation away from her parents, as agreed with the Child and Adolescent Mental Health Service (CAMHS) in 2017.
Croydon Council insisted her parents needed to formally make her homeless before this would be offered, which they refused to do.
The investigation by the two Ombudsman services found the parents’ need for support as carers was not met, and there were times when information about their daughter’s health should have been shared with them but was not.
Other areas of fault identified in the report include poor record keeping and failing to hold CPA reviews at least annually.
Michael King, Local Government and Social Care Ombudsman, said: “The young woman in this case tells me she feels she has been cast adrift by the organisations who should have helped her, over many years.
“Despite it having been a legal obligation for nearly 40 years, these organisations are still not getting it right when it comes to working together to provide Section 117 aftercare."
Mr King added: “I am concerned the situation in this case is not unique and is likely to be happening to other people in the area. Indeed, the ICB still has yet to make direct payments available to people to choose their own aftercare services – something which should have been in place from December 2019.
“I hope by publishing this report, that the organisations involved, and those across the country, can revisit their policies and procedures and learn from what has gone wrong.”
Rob Behrens, Parliamentary and Health Service Ombudsman, said: “This young woman underwent a traumatic experience and the failures outlined in this case had a devastating impact on her and on her family. All three organisations failed in their duty of care by not providing the support to which she was entitled. They risked her long-term recovery and placed undue pressure on her parents as her carers.
“I want to see the organisations involved learning from their mistakes and using complaints like this as a driver to improve services in mental health aftercare.”
In this case, the three organisations have agreed to apologise to the young woman.
A Croydon Council spokesperson said: “This woman and her family did not receive the after care they needed and to which they were entitled, and we are sorry for letting them down on this occasion. All the care services involved are currently reviewing how to work together more effectively to make sure we are supporting our clients in the best way we can.”
Between them, the organisations under investigation have agreed to pay the woman a total of £12,750 in recognition of avoidable stress, frustration, increased risk of harm and outrage, as well as missed opportunities to claim PIP benefits.
They will also pay each parent a total of £1,500 in recognition of the injustice they have faced. Croydon will carry out carers’ assessments for the parents.
Together, all three organisations will ensure the young woman has a plan that clearly sets out her section 117 aftercare, and an explanation on how she can request a personal health budget.
The council will review its processes for ensuring carers can have their needs assessed.
The Trust and council will also ensure relevant staff properly understand the law relating to supported accommodation. The Trust will also review a number of its practices, including those around record keeping, working collaboratively and addressing patients’ disclosures of risks to others.
The Trust, council and ICB will work together to ensure the proper processes and record keeping are in place and that everyone to whom they owe a section 117 duty has a care plan in place.
The ICB will take urgent action to ensure its processes around Personal Health Budgets comply with relevant law and guidance.