An unpublished Ombudsman (PHSO) report (2023) stems from a complaint that began in 2019. Also, my final response to NHS Trust’s apology, four and a half years later, in 2024. This fiendish, soul-destroying process would destroy even the most healthy individuals. All identifying names have been removed.
This was a highly distressing and devilishly complex scenario to negotiate, with long-lasting implications that the report did not sufficiently highlight. Nevertheless, I share this abridged version, a real example of injustice and cruel insensitivity. This case was fought in the hope that it would serve as an example. I do not understand why it has not been published on the PHSO website, so I am grateful to ‘Dear Coroner’ for the opportunity to share it.
An NHS Trust Chief Executive, Clinical Commissioning Group (CCG – as they were then called) Chief Executive, PALS complaint managers, an Assistant Quality Manager CCG and a mental health professional (care coordinator/CPN at the time) did their level best to uphold their lies and silence my truth. I should be relieved that after 4 years, the PHSO eventually upheld my complaint. However, I am left with emotional spoils and a final apology from the NHS Trust in 2024 – a letter that lacks any real meaning or relevance. I have kept every piece of evidence, which includes several lever arch files full of correspondence. To this day, I hold this fantastical dream that one day, there might be a future enquiry into the NHS. Society needs to hear and deserves to know what is happening,
PHSO decision – Complaint upheld
Complaint
– her discharge was not carried out under the Care Programme Approach (CPA) in 2019
– the meeting to discuss her discharge should have involved others in her care.
– others (e.g., GP) were not informed when she was discharged.
– a complaint response from the Trust dated 2019 referred to her no longer having mental health problems.
Background
She has been receiving care under the mental health services since 1993. She was dependent on the service and under a CPA.
She was discharged from the service in 2019.
The Trust said she was discharged from a part of the service because her needs were primarily social.
Findings
Issue 1 – discharge not carried out under the Care Programme Approach (CPA) in 2019.
This evidence tells us that her care was complex.
From review of the medical records in 2019, there is a review meeting at 2.30pm which refers to the discharge attendees being the care co-ordinator and complainant.
It says: ‘Significant changes since last review: she has now been discharged from the service, she has agreed to consider what she would like documented on her escalation plan and will send this information to myself via work email, and I will ensure this is documented clearly in her care plan. She has been informed of her discharge from our service. She may make a complaint about being discharged, as she feels rejection when relationships are ending.’
She disputes the content of the medical record and feels the comments made within her record are insulting and minimising.
The medical records do not show that the CPA discharge meeting in 2019 was in accordance with the national CPA policy, NICE guidelines, or the Trust’s own policy. There is also no evidence that any other health care professionals were invited to attend or provide their comments. No assessment of needs took place, and she was not supported.
A CPA review was completed in 2019, but this was with one professional only, which is not a CPA review because no other professionals were involved.
The care coordinator should have conducted a thorough risk assessment before deciding whether to discharge her from the CPA and mental health services. Once an agreement had been made to discharge her, an up-to-date risk assessment should have been completed. This should include a recovery plan outlining the arrangements for any future support. An updated safety plan should have been developed to reflect crisis and contingency arrangements, including who to contact once the care coordinator was no longer involved.
We believe she was not discharged from the service in line with the national CPA policy, NICE guidelines or the Trust’s own policy.
Issue 2 – a complaint response from the Trust in 2019 referred to her no longer having mental health problems. Another letter in 2019 incorrectly stated she had been diagnosed with complex post-traumatic stress disorder (PTSD) and dissociative identity disorder (DID).
The Trust’s letter of 2019 states, ‘It could be seen as a positive step that the team has concluded that you no longer meet this criteria.’
From a review of the complaint file, we can see that a diagnosis of complex post-traumatic stress disorder and DID is mentioned within the complaint response letter dated 2019. Upon review of the medical records, there is no evidence of that diagnosis (cPTSD, DID) mentioned throughout her clinical care.
She says those diagnoses had not taken place at this time. The Trust said it was an assumption that the Trust became aware of the diagnosis in 2017.
We cannot see that those diagnoses are mentioned throughout the clinical records while she was under the trust’s care.
Impact
She says that because of the failings by the Trust she was left highly distressed and vulnerable. She says she was caused additional distress by the failings in how the Trust dealt with her complaint.
We have seen letters from her private counsellor dated 2019 about her symptoms at the time of discharge and her private diagnosis of DID in 2020.
The letters highlight that she was suffering from complex mental health problems at the point of discharge.
She has been receiving care under mental health services since the early 1990s (e.g. with a diagnosis of Borderline Personality Disorder, Anorexia, etc.). Given she was under mental health services for so long, she would have become dependent on its service. Therefore, her discharge planning should have been planned well in advance with her so that it did not come as a surprise.
She said she struggled to understand the decision based on her needs. She was malnourished, severely underweight (anorexia) and vulnerable at the time. Her private counsellor wrote to the service in 2019 expressing her concern, highlighting a risk and asking for the decision to be reversed.
We have found that her discharge was not carried out in accordance with guidance and the Trust’s policy, and she was not supported during the process.
In the complaint response letters dated 2019, the Trust did not accept that anything went wrong during the discharge.
The Trust have not commented upon the impact caused or rectified the complaint. Therefore, the injustice is unremedied.
Below is my final letter in response to NHS Trust apology in 2024 (for which I have never received an acknowledgement for)
“I am writing to acknowledge your letter of apology (2023) and financial remedy. I understand this resulted from accepting the Parliamentary and Health Service Ombudsman’s final report following their investigation.
Although I appreciate the apology, it is disappointing that this has come from someone I have had no prior involvement or communication with throughout this case. This is saddening, considering the report’s gravity and number of faults. Those individuals (Clinicians, Managers, & Executives of the NHS and Clinical Commissioning Group as it was then) know who they are, and it is up to them to have the decency to take ownership of the negligence. They are, in effect, shifting the responsibility and distancing themselves from what they need to be held accountable for.
It is disheartening the NHS Trust believes that providing “the Care Plan Approach is no longer used” as an appropriate response. I regard this as paltry evidence, although true, dismisses the details and avoids acknowledging brutal truths. To “learn about how to improve endings” is, of course, critical. Still, again, this response, including the enclosure of evidence (Endings Toolkit & Clinical Model PowerPoint Slides), fails to acknowledge how fundamentally wrong and harmful The Trust acted. That influential people in positions of authority and power chose to treat me, a mentally and physically unwell individual, with such indignation and disregard, and then on top of that, to repeatedly disprove me from the outset is inexcusable.
The letter of apology does not articulate any understanding of what occurred or its detrimental impact, nor does it mention the lengths I went to to negotiate the subsequent handling of my complaint. This was a real opportunity for the individuals responsible to accept their wrongdoings, demonstrate remorse, and provide me with a genuine explanation for how and why this happened.
I sincerely hope to use my experiences so that individuals who need services provided by the Trust may be considered with kindness, respect, care and compassion. There is much to glean from their vulnerability, valuable insight and willingness to speak out. Ultimately, the formal complaint I made four and a half years ago was only ever about having my experiences believed and my voice heard. I fought to have my truth believed while NHS Trust did everything possible to dodge accountability, minimise and disprove me.”
This is my story as a: Patient
NHS Trust (or Provider): Don’t know/prefer not to say
Timespan: 2019 and ran for 4 1/2 years
Did you complain?: Yes
Did the Trust (or Provider) retaliate?: Yes
Can you share more, maybe share the tactics used?: Sudden and cruel discharge. Disproving. Intimidation. Closed ranks. Denied my truth. Silenced.
Would you recommend PALS as an impartial intermediary?: No
After investigation, did the Trust (or Provider) respond satisfactorily?: No
Did you take your complaint to the Ombudsman (PHSO)?: Yes
Your ethnicity: White British
Have you experienced suicidality due to this?: Thoughts/feelings
Are you autistic?: Formal diagnosis
Are you disabled as defined under the Equality Act 2010?: Yes
