South London and Maudsley NHS Foundation Trust

5. Mr B complains that during his section on the mental health units governed by the Trust he was subject to sexual abuse, intimidation, and physical abuse. The last occurrence was at Hospital A’s PICU from October/November 2023-January 2024.

6. Mr B states that due to his experience he has sustained trauma following his sections.

7. Mr B is seeking recommendations for improving the services.

8. Mr B’s last inpatient stay under the Trust was at Hospital A’s PICU between October or November 2023 and January 2024 when he was discharged.

9. Mr B complained to the Trust on 10 April 2025 and emailed again on 18 and 27 May 2025. The Trust responded on 24 July 2025. This means local resolution took approximately three and a half months. The Trust’s response referenced the Ombudsman and provided details of an advocacy service.

10. Mr B complained to us on 24 September 2025, and we talked him through the steps to make a complaint to us. He completed an online complaint form and provided evidence to us on the same day.

13. The law says a person needs to make their complaint to us within a year of becoming aware of the problem. We cannot investigate complaints brought to us after one year, unless we consider there is a good reason to do so. We have discussed this with Mr B to understand the reasons why he could not do so. We have also considered the time the organisation has taken to respond to Mr B.

14. We have considered Mr B was aware there was a reason to complain about his care and treatment from the Trust during his last section in October/November 2023 and January 2024. We have taken the later date of January 2024 as the date of knowledge as we can be confident Mr B knew about all the matters he complains about by that date.

15. To be within our time limit, he needed to complain to us by January 2025. Mr B complained to us on 24 September 2025. This means he is eight months outside of our time limit.

16. For cases brought to us outside of our time limit, we consider the reasons the complainant gives us for the delay and the time taken to complete local resolution with the organisation.

17. We understand that on discharge from a mental health ward, there is a period of adjustment. Mr B said he ‘felt lost’ on discharge, he visited friends and hired studio space to make music videos. He was on probation for a harassment charge and explained his goals were to see his children, to be discharged from the community mental health team (CMHT) and to lose the weight gained from mental health medications.

18. Mr B was asked about support he received, particularly from his brother who he had mentioned. He explained his brother was not a carer when he was discharged and he is not his carer now. He said he had no support from his parents and there was no mention of support from friends. Mr B was looking for work when his new Care Co-Ordinator was in place, in October 2025.

19. Mr B stated he was concerned about the impact making the complaint would have if it was made while he was still under CMHT, although he complained approximately one month before he was discharged from the service.

20. Mr B said he was driven to make the complaint having read about a rape that had happened to a transgender individual on one of the wards he has been on. Mr B ‘felt that it [the complaint] needed to be done’ and the behaviour of staff not ‘covered up.’ We can appreciate how difficult making a complaint can be and the impact this can have. We consider Mr B could have raised a complaint before reading about the reported incident.

21. Mr B said when he decided to make the complaint on 24 September 2025, it was ‘easy’ to do as he had been to college, and he was able to submit the online complaint form with evidence the same day.

22. Having considered the time taken for local resolution and Mr B’s reasons for delay, we have not seen good reason to put the time limit aside.

23. We consider Mr B had opportunity to complain much sooner than he did, and we have not seen barriers that prevented him from complaining between him being aware of the matters complained about, in January 2024, and him complaining to us in September 2025, 19 months later.

24. We consider Mr B was aware of the need to raise the issue during his section as he tells us he called the police during his section between Oct/Nov 2023 and Jan 2024, although Mr B could not recall when. Whilst we acknowledge Mr B stated that he did not have support following his discharge from the ward, separate to CMHT, we understand Mr B was able to establish goals following his discharge and work towards these without additional support.

25. We appreciate how distressing these situations are and the strength it takes to make these reports. We consider Mr B was able to contact the police and raise complaints when needed and we do not think that the goals he was working towards explain the eight-month delay in pursuing his complaint after his discharge.

26. For these reasons, we are unable to put the time limit aside and will not be taking further action on Mr B’s complaint. We were very sorry to hear of Mr B’s experience and the difficulties he has faced since the events he complains about. We thank him for sharing the details with us.

1. We have carefully considered Mr B’s complaint about periods of time when he was under a section under the care of the Trust.

2. Mr B’s last inpatient stay was at Hospital A’s Psychiatric Intensive Care Unit (PICU) between October or November 2023 and January 2024 when he was discharged.

3. We appreciate how distressing these situations are and the strength it takes to make these reports. We also appreciate the time and effort spent bringing the complaint to our attention.

4. After considering the relevant information, we have decided the complaint falls outside of our time limit and there is no good reason for us to put our time limit aside to consider it further. In this statement we will explain the reasons for our decision.