A teenage girl suffering ‘intense emotional meltdowns’ had to wait two years – almost six times the target – for mental health treatment.

England’s Health Ombudsman is urging Government and NHS leaders to prioritise timely treatment of people experiencing poor mental health and support the NHS workforce to deliver this.

The girl from Gateshead was 14 when her GP referred her to mental health services after she began experiencing meltdowns which sometimes involved self-harm. She was also crying a lot, often unhappy, and struggled to concentrate at school so much that she stopped going.

National guidelines state that no one should wait longer than 18 weeks for mental health treatment. In this case, the schoolgirl waited two years for treatment after being referred to Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust’s Children and Young People’s (CYP) services.

The Parliamentary and Health Service Ombudsman (PHSO) investigated the case and found that the Trust failed to provide suitable care in an adequate timeframe. This caused a delay in her mental health beginning to improve.

The Ombudsman published reports in 2018 and 2024 highlighting issues in mental health services including when transferring people with poor mental health out of inpatient and emergency care, and failures in diagnosis that led to poor treatment.

Rebecca Hilsenrath, Parliamentary and Health Service Ombudsman, said:

“Timely treatment is critical for the safety and wellbeing of people experiencing mental illness. The overwhelming majority of professionals in mental health services demonstrate their hard work, commitment and care daily, but they are also working under immense pressure.

 

“Delays in diagnosis and treatment can have a significant impact on patients, as this story shows. In this case, the girl had to wait far too long to be treated and this deeply affected her health, her life, and her family.

 

“We have published two reports highlighting failings in mental health services over the past six years and making recommendations. However, we are still waiting for change. It is clear from our evidence that there are still problems that must be addressed if patients are to receive the care they deserve and need. Urgent action is needed to make sure that mental health professionals can deliver the right care at the right time.

 

“It is important that the new Government looks afresh at the provision of mental health services to avoid this and other failures from occurring in future and to keep people safe.”

The girl, now 18, was referred to CYP in December 2020. She was diagnosed with autism in January 2022.

She then had to wait until December of that year to receive medication for anxiety and sleep problems and was only allocated a care coordinator 27 months after the referral.

No interim support was offered by the Trust during the two years between her being referred and receiving medication.

The girl’s mother, 53, said:

“I can’t put into words how devastating the impact of the delay was on our family. At a crucial time in her life, my daughter was abandoned by the professionals who are supposed to care for her. She couldn’t do all the normal things that teenagers do, she became increasingly isolated and withdrawn, and her intense emotional meltdowns could last for hours.

 

“It was incredibly stressful for us as parents to see her going through this and feel like no one was helping us. I was ringing the crisis team every week, sometimes more than that. No one would tell us where she was on the waiting list or how long it could take to get the help she so badly needed. We just went round in circles. The stress led to me having panic attacks and being prescribed anti-depressants.

 

“I am in awe of what my daughter has been able to achieve despite what she has been through. But it is heartbreaking because she has such potential – she is highly intelligent, articulate, warm, funny – and so much of that has been wasted because she got lost in the system.”

The mother complained to the PHSO who found that earlier intervention could have meant her daughter was able to stay in school, maintain friendships and help her to feel less abandoned.

There were also failings in the way the Trust handled the mother’s complaint which increased the family’s distress as they couldn’t gain answers or updates while they waited for treatment to begin.

The Ombudsman recommended that the Trust apologise to the family and create an action plan to improve services so that future patients don’t have a similar experience. The Trust has complied.

Healthwatch, a body that gathers and champions the views of users of health and social care services to identify improvements, has reported that they are being told about ‘extremely long waits for ADHD and autism services’ in several areas across the country.

Louise Ansari, Chief Executive at Healthwatch England said:

 “This story shared by the Ombudsman makes for difficult reading and is unfortunately reflective of experiences we’ve heard from autistic people across England.

 

“With waiting lists for autism assessments growing, and almost 9 in 10 people waiting over the recommended 13 weeks, we’re incredibly concerned that more people will be feeling the devastating impact of long waits.

 

“Work must be done to ensure people are diagnosed quicker, including through increasing the numbers of specialist staff in the NHS and improving data on autism assessments so long waits can be understood and addressed. And while people wait, they mustn’t be forgotten. More must be done to get people the mental health and other support they need and minimise the impacts on their daily lives while they wait for assessments and further support.”

Read the full case summary.