Trust failed to treat the mental health of a young person with autism

Organisations we investigated: Sussex Partnership NHS Foundation Trust

Date investigation closed: 11 December 2019

The complaint

Complainant G complained that the Child and Adolescent Mental Health Services (CAMHS) at the Trust did not accept the referral from Person E’s GP in a timely manner and then did not provide a diagnosis or treatment for three years. Complainant G also complained that the Trust discharged Person E too soon.

Complainant G complained that the Trust refused to handle the complaint and referred it to another Trust. They also complained about delays in responding to the complaint.

Complainant G said that, as a result, Person E’s condition worsened until it reached crisis point. Complainant G said Person E has missed out on three years of education. They told us of concerns they had for Person E’s future health and the support they need. Additionally, Complainant G told us of the emotional impact on both Person E and the family.

What we found

The Trust did not follow the relevant guidelines when rejecting Person E’s first referral. It should have accepted this referral.

It was not appropriate to wait over 18 months for a diagnosis and treatment, despite Person E not communicating with Trust staff during this time. The Trust should have made more attempts to communicate effectively with Person E, such as email and telephone as non-direct methods of communication. The Trust made no attempt to use other methods of communicating with Person E.

Although Person E did not cooperate with Trust staff, their behaviour should not have prevented the Trust trying other ways to engage them. The Trust should have sought advice from other agencies on how to best engage with Person E. When a member of staff left the Trust, it did not reallocate Person E’s care to another staff member.

The Trust discharged Person E too early from its service, as they continued to need support for their mental health as well as autism. Person E and the family continued to need support on how best to manage Person E’s mental health and wellbeing, which the Trust should have provided. The Trust should have developed a care plan for Person E to outline the support and treatment they needed.

As a result of these failings, the Trust missed the opportunity to help Person E and the family develop the appropriate steps to support her mental health. Person E suffered prolonged mental ill health. Person E and the family were left without the ability to manage Person E’s condition at the time.


Person E’s GP referred them to the Trust. The Trust refused to accept the referral, as Person E did not meet its criteria.

Six months later, Person E’s GP made a second referral. The Trust accepted this referral. Complainant G then reported that Person E was unable to leave the house and would not communicate. The Trust agreed to visit Person E at home. During two home visits, Person E was physically aggressive and would not speak to Trust staff. At a third home visit, Person E spoke to the Trust staff. 

At the fourth home visit, Person E again displayed aggression towards Trust staff. The staff recorded that it had not been possible to assess Person E, but they were suffering severe mood instability and extreme distress over trivial issues. Person E later attended the Trust, but again would not engage in assessments.

The Trust then completed a risk assessment for Person E, noting that family members were restraining them to avoid harm to Person E and others.

Person E was then diagnosed with autistic spectrum disorder. Six months later, the Trust sought to discharge Person E from its service. Person E’s GP then made a further referral to the Trust, which the Trust considered but did not accept. Person E’s GP attempted a further referral to the Trust. The CAMHS service was transferred to another Trust at this time, which continues to care for Person E.

Putting it right

We recommended the Trust acknowledge the failings in Person E’s care and apologise for the impact of this. We recommended that the Trust ensure that CAMHS (which had been taken over by a different Trust) learns the lessons from the failings we identified.

We recommended the Trust pay Person E £1,500 for the impact the lack of treatment had on them. We also recommended the Trust pay Complainant G and the family £500 for the distress they experienced.
The Trust complied with our recommendations.

This case summary is featured in the Ombudsman's Casework Report 2019.