Date of decision: 08 December 2025
Summary
An autistic woman who receives free aftercare under s117 of the Mental Health Act complained that the Council and NHS bodies had failed for years to give her appropriate care and to adapt their assessments to her communication needs. She said the lack of suitable autism‑specific support and refusal to transfer her care to another area left her traumatised, repeatedly overdosing and even trying to get herself imprisoned to obtain help.
The Ombudsman found no fault because professionals repeatedly adjusted their approach, offered a wide range of services and tried to complete a workable aftercare plan despite very significant difficulties in engaging with her.
What happened
An autistic woman eligible for s117 aftercare under the Mental Health Act was detained under s3 in late 2020 and discharged from hospital in January 2021 without a completed s117 plan, because earlier assessments had failed and the stay itself was traumatic; professionals agreed that a detailed assessment should continue in the community to avoid prolonging her detention.
From early 2021, the Trust’s Transforming Care service and the Community Mental Health Team began trying to work with her to develop a care plan and identify support. From Spring 2021, the organisations commissioned 17 hours a week of home‑care support, but she said she could not cope with care worker visits, and this package ended.
In mid 2021, the Transforming Care team offered two visits a week for six to eight weeks to help her understand her autism diagnosis, and professionals also considered whether cleaning support and respite might help; later that year they agreed to fund 10 hours of home support through a different care company, and she emailed her social worker explaining what weekly support she felt was realistic, after which a professional replied and said they could amend the care plan and add hours.
By March 2022, her support consisted of Transforming Care input and 16 hours a week of home care, yet she still could not bring herself to use all of the allocated hours.
A professionals’ meeting recorded that an earlier referral to the ICB’s Out of Area Treatment panel for “specialist autism support” had been refused, and that a referral had then been made to the Trust’s Personality and Complex Team (PACT). In May 2022, staff told her they would not arrange the community Care and Treatment Review (CTR) she wanted, saying the ICB believed it would not produce the outcomes she sought and would cause her distress, but that existing support already aimed to keep her in the community in the least restrictive way; they also said responsibility for her care could not be moved to another area, while the Trust offered to challenge the out‑of‑area refusal, and explore an advocate. The woman was told it remained open to her to work with the CMHT and Transforming Care to ‘explore her strengths and weaknesses’.
Later in May 2022, Transforming Care said that a doctor and a clinical lead would support her instead of a social worker.
By mid 2022, she asked whether a s117 needs assessment had ever been completed, saying her mental health was now worse than before the 2020 admission, and the ICB replied that it had not completed such an assessment because she had not felt able to engage, but they had funded home care in the absence of an assessment.
The woman said that any assessment would have to be adapted: she needed clear, written, specific questions in an accessible font and layout, with plenty of white space and no walls of text.
The questions needed to be specific, not open, preferably with examples of expected answers. The woman said she needed an autism specialist to help her identify her needs, which she said she had needed all along, and hoped would be included in her aftercare.
She said she could not use all her care hours because she did not know what might help. She said, ‘If you expect me to tell you what my needs are, then the answer will be the same as always: I don’t know, that’s why I need someone who understands autism to help me figure out my needs/what might help’.
At the start of July 2022, the ICB said it was happy to meet and go through a s117 assessment at her pace in whatever way suited her, and later that month said it would seek funding for an autism‑specialist advocate. She kept asking for her care to be taken over by another area, which the ICB continued to say was not possible, and she said she did not believe an advocate would help. Towards the end of July 2022, the ICB sent her an amended s117 assessment and asked whether, and how, she wanted to proceed; around the same time, a professionals’ meeting noted another Out of Area Treatment panel referral for “autism specific therapeutic work”, acknowledging there was no autism‑specific service locally and that staff with specialist expertise could not ‘hold the case’ or commit enough time.
In August 2022, she was detained under section 2 of the Mental Health Act, and in early September 2022, a professionals’ meeting recorded an Out of Area panel referral for an advocate, life‑planning, an autism‑specialist therapist to see her weekly, and help with emails.
Mid September, the panel agreed to fund an advocate, life planning and a psychiatrist, though this would take time to put in place, and later that month a CTR took place on the ward, which recommended a joint community–inpatient professionals’ meeting to plan community support and to explore specialist help so she could understand her autism and its impact; it also recommended that the ICB case manager work with her on a structured life plan to identify specialist needs and treatment. In October 2022, the ICB asked whether she wanted them to arrange an out‑of‑area advocate.
In November 2022, Transforming Care emailed to say it had already started a s117 assessment, that she had completed some questions, but this had paused while she was on the ward; they asked whether she was ready for more questions.
Around the same time, the Trust recorded that she was reported to have declined the out‑of‑area advocate, specialist psychiatrist and life‑planning support, but this was later clarified as a misunderstanding regarding life planning.
In December 2022, the ICB told her it had identified two providers willing to undertake an assessment to better understand her needs and asked how best to carry this out, while Transforming Care offered to visit to co‑produce a communication guide for care workers, setting out words or phrases she disliked, tasks she needed help with and preferred task sequences, to form a structured plan for staff.
In mid January 2023, the ICB reminded her that a s117 assessment had been sent previously and partially completed with two staff; it proposed starting afresh to ensure all health needs related to aftercare were captured, offering a paper copy so she could write in each section at her own pace and have the ICB collect and type it up for her to check.
She replied that the assessment still needed more effective adaptation: she could not answer the earlier questions, wanted clear, specific questions with examples, and asked to complete it gradually by email.
The ICB then told her that a potential care provider would visit to ask about what support she wanted, topics she found uncomfortable, issues she needed help with and activities she enjoyed, but she said these topics were too broad and again asked for specific written questions in advance; the ICB responded by agreeing to send the assessment in sections, editing out lengthy paragraphs and offering to pick up sections as she completed them.
She continued to say the assessment format did not meet her needs, and at the end of January 2023, the ICB contacted independent organisations to see if anyone could undertake an independent review of her care.
In early February 2023, another social care provider proposed 14 hours a week of support, but she said she could not cope with what was offered, and the arrangement collapsed on the first day. Also in February, the ICB noted Transforming Care had referred again to the Out of Area panel for an autism‑specific therapist and that an independent review would be done by someone unconnected to the ICB.
Towards the end of February 2023, a provider confirmed it could do the independent review and gave a cost; the ICB sought financial approval and wrote to her, but she asked them to stop the process, believing it would not be truly independent or involve her properly.
In March 2023, the ICB sent another version of the s117 assessment; she provided some responses but still said many questions were too open, so the ICB sought Transforming Care’s advice, and in late May 2023, Transforming Care suggested further changes.
At the end of May 2023, she said the autism advocate arrangement was not working because she could not cope with emailing the advocate; the ICB said it could seek panel approval for another advocate if she had someone in mind, but she remained unconvinced that any advocate could help.
In June 2023, she asked for a trauma therapy referral to PACT; PACT replied that it might have suitable treatment pathways but needed to understand her goals and asked her to see a consultant psychiatrist to clarify needs.
Late June 2023, the ICB sent yet another s117 assessment, including her previous answers and added new questions; she replied that the questions were still too open and that the limited tick‑box options were too restrictive, saying her needs did not fit regular schedules and she could not answer frequency‑based questions, so the form was impossible to complete as drafted.
In mid-July 2023, a community CTR took place, noting the intention to carry out a person‑centred assessment specifying the care and therapy she needed.
In mid August 2023, PACT wrote again after a psychiatrist had reviewed her in clinic; PACT concluded that an out‑of‑area specialist autism service was most likely to help, said it had made a referral to the Out of Area Treatment panel and would advocate strongly for a suitable provider, but could not guarantee the outcome, and all it could do was ‘help the panel understand why the Trust are not best placed right now.’ They thanked the woman for having engaged with PACT and said that it had helped them. They said that it had provided evidence that ‘no local services are best equipped to meet your needs at the moment’.
Towards the end of August 2023, the ICB responded that it had serious concerns about using out‑of‑area providers due to the complexity and risks in her situation. In late September 2023, PACT wrote again saying the panel remained willing to fund a specialist advocate and hoped she could identify someone she could work with, but still felt her needs were best met within the Trust; PACT said it had done its best to advocate for her, acknowledged there was no single service offering the long‑term support she wanted, but suggested social‑care providers could be trained and that PACT could provide a bespoke pathway to help her understand and manage emotions and communicate more confidently, offering weekly sessions alongside her advocate and with Transforming Care’s advice.
In November 2023, in a complaint response, the ICB told her it had made appropriate efforts to support her to complete the s117 assessment paperwork and could not meet all the adjustments she wanted.
In early February 2024, a professionals’ meeting reviewed the support offered by Transforming Care, CMHT and PACT, concluding it would be appropriate to plan discharge because she had not found these services beneficial; PACT and CMHT discharged her in April 2024 on that basis.
In July 2024, the ICB emailed her with the incomplete s117 assessment, noting it had to be finished before sharing with providers and asking whether she wanted to meet in person or via Teams to finalise it; a team manager repeated this offer in October 2024.
What was found
The Ombudsman found that, although a formal section 117 plan was not in place at discharge, this was a pragmatic decision consistent with the Mental Health Act Code of Practice because assessment attempts had failed in hospital and prolonging detention would have been disproportionate; professionals continued assessment work in the community instead.
Throughout 2021–2024, the Council, the ICB and the Trust repeatedly tried to assess her needs, adjusted formats and processes in line with autism‑statutory guidance, involved Transforming Care and other specialists, and offered to proceed slowly and in writing, so their approach met the duty to make reasonable adjustments even if it did not match her preferences.
The Ombudsman accepted that she found broad or open questions impossible and that this made it extremely hard to document the “average” pattern of support needed each week, but concluded that this communication barrier did not stem from fault by the organisations, which still had to record needs and justify resource allocation.
The organisations had explored multiple support options – Transforming Care, CMHT, PACT, life‑planning, specialist advocacy, domiciliary care and possible out‑of‑area provision – and had weighed risks and practicalities when deciding that a fully out‑of‑area treatment package would be unsafe or impractical, which was a merits‑based clinical and commissioning judgement the Ombudsman could not overturn.
There was extensive email contact from her and clear evidence that professionals tried to respond, but the Ombudsman found no fault in the decision to introduce contact restrictions or in their inability to answer every email in the way and timescale she wanted, given pressure on resources.
Overall, the Ombudsman decided there was no maladministration or service failure: the organisations had worked with her over a prolonged period, adapted their assessment and care‑planning approaches and made genuine attempts to provide support, even though the outcome remained unsatisfactory from her point of view.
No compensation was ordered, and no specific training, briefing, learning tool or policy review requirements were made.
Points to note for councils, professionals, people using services and their carers, advocacy groups and members of the public
This was a complaint to the Ombudsman about the Council, the ICB and NHS Trust. The Local Government and Social Care Ombudsman and Health Service Ombudsman have the power jointly to consider complaints about health and social care.
The decision reveals some core legal issues that may have been treated too narrowly: what counts as an assessment of need under s117; how far reasonable adjustments must go for autistic people, and when public bodies may rely on systemic limitations rather than duties. These are not just clinical or process questions but legal ones about statutory powers and duties.
The first issue is whether the repeated s117 “assessment” attempts and drafts met the legal test for an assessment that properly captures needs and their impact, rather than just recording what professionals felt able to offer, and what the woman wanted. The MHA Code of Practice sets out that care planning requires a thorough assessment of the patient’s needs and wishes, and consideration of various points, including specific needs arising from autistic spectrum disorder…
Here, the narrative shows years of partial, abandoned or format‑driven s117 paperwork; at the same time, professionals openly acknowledged the lack of any autism‑specific service locally, that specialists could not “hold the case”, and that out‑of‑area options raised “serious concerns” about complexity and risk, yet the Ombudsman does not interrogate whether the assessment process itself had become skewed by what the system could realistically supply.
The second issue concerns the legal standard for reasonable adjustments and participation for autistic adults who experience substantial difficulty engaging with ordinary processes. The decision refers to the Autism Act 2009 and the Statutory Guidance issued in March 2015.
The Autism Strategy does not necessarily apply to people with s117 rights, because s117 is not listed as a social services function, despite being a duty of a local social services authority. We are not saying that it definitely doesn’t apply, but that it’s a moot point. Of course that Autism Act guidance says organisations should ensure staff working with autistic adults have demonstrable knowledge and skills to use appropriate communication. And of course the Public Sector Equality Duty applies as well regardless, and the Autism strategy Guidance also highlights the duty and importance of making reasonable adjustments to meet individual needs. Section 6.6 of the guidance provides information on good practice in delivering reasonable adjustments effectively.
We wonder whether a Judge would have had been so generous to the authorities. On the one hand, we would have expected a court to have no truck with the stance of the woman that she did not need to appreciate that systems do have limits. A Judge would have been likely to have said that the woman needed to be told the legal truth – the reasons for not making any further adjustments needed to be provided, and then she could have considered her position. Nobody who wants publicly-funded services can keep on refusing to satisfy the authorities of their needs, forever.
The report wholly misses the fact that under the Care Act, a person can be provided with advocacy via a council under s8 – not simply with regard to s67 funded advocacy for the specified statutory processes, but as a service in and of itself.
The whole NHS out-of-area ‘treatment’ requests for better Informed autism-specific advocacy could therefore have been avoided by more legal literacy. She could have been told that that non-statutory form of advocacy could have bought in and maybe moulded to her needs, even if she thought that an advocate in the ordinary sense of the word would have been of no use. But an advocate can be of no use if the person is resistant to answering questions even from that advocate.
Community care law guidance on advance notice, supported self‑assessment, fluctuating needs and specialist involvement all point towards a more assertive expectation that assessors seek and use genuine specialist expertise in autism communication, rather than cycling through internal variations of documentation that the person has already explained she cannot use.
The third issue is the boundary between legitimate merits‑based commissioning judgements and unlawful reliance on systemic gaps to dilute individual aftercare duties. The decision repeatedly notes that there is “no autism‑specific service locally”, that out‑of‑area requests for “autism specific therapeutic work” or specialist autism providers were declined or left in prolonged limbo, and that discharge from Transforming Care, CMHT and PACT was justified because she “had not found these services beneficial”, yet the Ombudsman frames all of this as a “broken system” problem rather than an unlawfully inadequately operating one. The Autism Act guidance specifically says that the duties with regard to social services may still be duties regardless of available resources, as it happens.
Community care law has consistently treated arguments that “there is no local service”, “specialists cannot hold the case”, or “out‑of‑area is too complex” as matters that may justify choosing between several lawful options, but not as reasons to fail to commission what is objectively required to meet assessed needs. It is difficult to justify the investigator’s assumption that, for some reason, the law is different in the context of people with a risk of readmission and s117 status.
Once PACT itself concluded that an out‑of‑area specialist autism service was “most likely to help” and that “no local service is best equipped”, a public law approach would normally expect clear evidence of how the commissioners weighed that expert view, what alternative options were found that could genuinely meet the same needs, and why prolonged delay or eventual discharge remained a proportionate response to ongoing risk of serious self‑harm and re‑detention.
The ICB responded saying that they had concerns due to complexity and risks, but it may have been a cost-based decision made by commissioners, which overrode the views of PACT professionals without a comprehensive rationale.
During the period covered by this complaint, the woman was detained for a second time under the Mental Health Act 1983, s2. Regardless of fault, the failure to ensure proper aftercare for this woman could have had serious implications for her mental health in the future.
The Ombudsman’s acceptance of “risk and practicality” concerns at face value, without testing whether they amounted to a lawful balancing of duties rather than a capitulation to structural shortfall, risks underplaying the enforceable nature of aftercare duties.
But it should not be forgotten that the investigator’s evaluation was as follows.
“The core issue is that the professionals need information which Ms A finds it impossible to provide. In order to agree, plan and commission care for Ms A the organisations need to be able to document an understanding of Ms A’s needs and how any proposed care and support will help her. They need this to allocate an adequate amount of resources to Ms A’s care, which they can transparently justify as appropriate and proportionate. This means that the professionals must get an understanding of the “average” type and amount of support Ms A is likely to need throughout any given week. This, in turn, means trying to understand, from Ms A, what it is that she wants and needs….
Professionals appear to have made proportionate and appropriate attempts to adapt the assessment process. In terms of the requirements of the statutory guidance on autism, it was appropriate to involve the Trust’s Transforming Care team. This meant that staff with knowledge and experience of autism were involved from the outset….
The organisations have not pressed Ms A to complete assessments in set periods and have offered to complete assessments in a piecemeal manner. I have also seen evidence that staff have been encouraging and supportive when Ms A has been able to provide responses via email. In addition, the suggestions of specialist advocates and life planning services appear to have been genuine and well intentioned suggestions. They appear to have been made as ways of helping Ms A to engage in the assessment process and as possible ways to help Ms A better understand and quantify her own needs… Overall, it is disappointing and frustrating for all parties that they do not have a s117 assessment which they are satisfied fairly and fully identifies all of Ms A’s needs. However, this is not due to fault on the part of the organisations…The professionals have used information Ms A has provided to explore a number of avenues of support for her: from Transforming Care, the CMHT, PACT, life planning, specialist advocacy, and domiciliary care. They have also considered funding out of area treatment but determined this would be impractical and unsafe because of the nature and complexity of Ms A’s needs. This is a matter of professional judgement. There is evidence the relevant professionals considered the specific details of Ms A’s case before making their decision. As this is a question of merits, it is not for the Ombudsmen to remake or replace this decision with their own.”
Please use the following link if you want to read the original Local Government and Social Care Ombudsman’s Lincolnshire County Council (24 017 267) report. If you are affected by the issues in this report, please consider asking a free, one-off question, anonymously, at a level of principle, here. Our experts’ response will give you an opinion which may then help you and the broader community, when posted.
Did you enjoy this analysis? Want to stay informed with our weekly Alert Service?
Then do click here to find out how you can receive the latest insights from experts and commentators and stay updated on key judicial decisions, ombudsmen’s reports, and critical law and policy changes, all for just £50 per YEAR and sent straight to your inbox or WhatsApp!