Vulnerable woman put at significant risk of self-harm after systemic failures

The Local Government and Social Care Ombudsman (LGSCO) has reprimanded three organisations after multiple failures in the case of a vulnerable woman trying to overcome severe mental health problems.

The Ombudsman found that she had been put at significant risk of self-harm, after the organisations which should have looked after her failed multiple times to provide specialist aftercare services.

In a joint investigation with the Parliamentary and Health Service Ombudsman (PHSO), the LGSCO said it found “serious concerns” with the way her situation was handled.

The South London woman had spent a long time in the care system before she was adopted, and as a young teenager her mental health deteriorated to such an extent she was sectioned under the Mental Health Act.

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). The ‘Section 117 aftercare’ package, which is a legal entitlement, would have helped to ensure she was not readmitted to hospital. However this did not happen.

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 family struggled to get her the help and support she needed, and the woman has admitted without their support she might not be alive today. 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.

In addition to the lack of support, the woman has not been able to access the enhanced Personal Independence Payment (PIP) benefits she is entitled to claim, and this has had a major impact on both her and her family’s finances.

She was also unable to access supported living accommodation away from her parents, as Croydon Council insisted her parents needed to formally make her homeless before this would be offered. Her parents refused to do this, fearful of the impact it would have on her fragile mental health.

The investigation by the two Ombudsman services also 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.

Michael King, Local Government and Social Care Ombudsman, said the young woman in this case says 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.

“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.”

The role of the Local Government and Social Care Ombudsman and Parliamentary and Health Service Ombudsman is to remedy injustice and share learning from investigations to improve public services. They also have the power to make recommendations to improve processes for the wider public.

The three organisations have agreed to apologise to the young woman and, between them, the 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 too have faced.

The council will also 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 also says it will review its processes for ensuring carers can have their needs assessed.

Rob Behrens, Parliamentary and Health Service Ombudsman, said the 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.”