Liverpool Universities NHS Foundation Trust

5. Mrs H complains the Trust did not provide adequate care during her attendance or upon her discharge from the Trust’s emergency department (ED) on 18 March 2024. She complains the Trust did not provide food, drink or medication during this attendance. Mrs H also complains that the Trust prevented her from leaving the ED and threatened to call the Police to bring her back.

6. Mrs H told us this has caused her distress, and she no longer has confidence in the Trust’s ED and will avoid attending again, which may put her at greater risk of self-harm. She wants an apology and service improvements.

7. Mrs H attended the Trust’s ED at around 5.49pm on 18 March wanting to be seen by the mental health team (MHT). The Trust’s ED completed a triage at 8.56pm and referred her to be seen by the MHT.

8. Mrs H tried to leave the Trust however returned after staff intervention. She then left the Trust at 12.37am on 19 March. The Trust called the police however they did not do a welfare check as Mrs H was at home with her husband.

Access to food and drink 11. Mrs H complains the Trust failed to provide her with access to food and drink and a waiting area while she was at the Trust’s ED on 18 March.

12. Mrs H arrived at the Trust’s ED at approximately 5.30pm. The Trust triaged Mrs H at 8.56pm.

13. There are no guidelines which indicate a patient should be supplied with food, drinks or blankets while they are attending the ED. Our adviser explained the time that Mrs H attended was outside standard mealtimes and with the ED being busy it is likely that staff did not have sufficient time to consider these needs for all the patients present.

14. Based on the evidence it does not appear that the Trust did anything wrong with how it handled her food and drink requirements while she was in the ED as there are no guidelines to say the Trust should provide food and drinks to patients who are waiting.

15. Mrs H says a nurse offered her a blanket if she would agree to sit in the appropriate area, as she was sat near a crash trolley. She says that no blanket was ever provided. The records indicate that Mrs H asked for a blanket however when she was offered one, she declined it. As we were not present for this interaction, we would not be able to make a decision on which version of events is correct.

16. Mrs H says that at 12am a nurse provided drinks to the patients near the ‘bay’ but did not provide her with a drink. As we were not present for this interaction, we would not be able to make a decision on whether this was a deliberate action by the nurse or if drinks were left in the ‘bay’ area, but she did not get one. As we have explained above there are no guidelines to say the Trust should provide food and drinks for patients waiting.

17. While it is understandable that Mrs H may have been uncomfortable with the lack of food and drink during her wait to be seen, there are no guidelines to say that these must be provided to patients in ED. We cannot say that the Trust did anything wrong.

18. In relation to the actions taken by nurses in the ED regarding providing blankets and drinks it would not be possible for us to make a robust decision as we do not have any impartial evidence to determine whose version of events is correct or what the motivations of staff might have been in the actions they took. Therefore, we will not take any further action on this complaint. We are sorry that we have been unable to add anything further to this matter for Mrs H.

Medication 19. Mrs H complains she missed medication she would have taken at home and the Trust should have provided her with her regular medication while she was present in the ED.

20. There are no guidelines regarding providing patient’s regular medications while they are in the ED.

21. Our adviser explained this would only be done for time critical medications however none of the medications that Mrs H was receiving at the time were time critical and therefore there was no reason to provide her with medication during her admission.

22. Records show that a nurse offered Mrs H some medication to help with her anxiety however she rejected this. It is not clear when this was offered.

23. While it is understandable that Mrs H felt she missed out on her medication while in the ED, there are no guidelines to say that these must be provided to patients in the ED. We cannot say that the Trust did anything wrong. Therefore, we will not take any further action on this complaint.

Waiting area 24. Mrs H says she should have been given a separate area to wait to be seen by the mental health team.

25. RCEM guidelines on emergency departments say that a Psychiatric Liaison Accreditation Network (PLAN) compliant room should be available in every ED for assessing patients presenting with mental health difficulties. This guidance was introduced in October 2025, after the events of the complaint, and does not relate to the waiting areas themselves.

26. These are for mental health assessments and are not designed to be used as waiting rooms. Our adviser explained the only separation of waiting rooms would be between adults and children.

27. Based on the evidence it appears the Trust acted in line with relevant guidelines in how it handled where Mrs H was asked to wait. Therefore, we will not take any further action on this complaint. We hope the information we have provided has provided some reassurance to Mrs H.

Detention 28. Mrs H complains that security guards used violence against her to keep her inside the Trust. She says that two security guards stood over her and asked her to sit on a chair while she waited to be seen. She says that when she tried to leave, as she felt intimidated, the guards stopped her and would not allow her to leave. She says eventually a healthcare assistant (HCA) spoke to her and got her to return to the waiting area.

29. The records show the Trust referred Mrs H to the mental health team at 9.04pm. The records say that Mrs H ‘absconded with security but returned with staff’. Then the records show an ED consultant tried to assess Mrs H however she refused to answer questions around capacity and said she did not want to be seen by the mental health team anymore. The Trust noted Mrs H then left the Hospital at 12.37am. There is no other mention in the records about security guard incidents.

30. Unfortunately, we do not have any independent evidence that the security guards used any force against Mrs H or that they directly prevented her from leaving. It would have been expected that Mrs H would have been seen by the Trust’s mental health team before she was discharged, due to her saying she was suicidal, and it appears the security guards made attempts to get her to stay for this upon her initial attempt to leave.

31. It does appear that no attempt was made to stop her from leaving later that night and she was successful in leaving the ED.

32. As we were not present for the interaction where it appears Mrs H tried to leave the ED before being seen by the MHT, we would not be able to make a decision on which version of events is correct and whether the actions were violent or aggressive.

33. The Trust contacted the Police after Mrs H left the ED and also contacted her husband due to her advising staff she had suicidal thoughts. The rust had a duty of care towards Mrs H as she appeared to be at risk of harm based on what she had told staff.

34. While Mrs H may be upset that the Trust contacted the Police after she left the ED it was acting within the MHA which says that if a vulnerable person leaves without being discharged then the Police should be contacted. While Mrs H was not detained by the Trust it still had reasonable concerns over her safety.

35. Based on the evidence we have we would not be able to make a robust decision on whether the Trust used force or threatened Mrs H when she attempted to leave the ED. It also appears the Trust acted within relevant guidelines when it contacted the Police after she had left. Therefore, we will not take any further action on this complaint. We are sorry that we have been unable to add anything further to this complaint for Mrs H.

Treatment 36. Mrs H complains that the Trust did not provide her with any mental health treatment or with any care plan for after she left the Trust.

37. Mrs H complains that she should not have needed to be triaged before seeing the mental health team. She also says she was left without seeing anyone for over the NHS’s four-hour target.

38. NHS England guidelines (which build on previous RCEM guidelines from 2017) say that patients should usually be triaged within 15 minutes of arrival to the ED.

39. The NHS’ 4-hour target is that at least 95% of patients attending the ED should be admitted, transferred, or discharged within four hours of arrival, though current minimum standards are set at 78%.

40. RCEM guidelines on mental health patients in the ED say that patients should be triaged on arrival to assess their presenting state, level of agitation and the risk of the patient leaving without treatment. It also says that from the time of the referral to the mental health team the patient should aim to be seen within an hour, although this is currently a pilot standard and therefore not an established standard that NHS Trusts are measured against.

41. The records indicate that Mrs H attended the ED at 5.49pm (although Mrs H believes it was 5.30pm). The Trust triaged her at 8.56pm. This is not in line with the NHS and RCEM guidelines as it is far outside the usual 15-minute period.

42. The NHS’s four-hour target is not a guideline but an aim to try and improve service within the NHS.

43. An ED consultant did speak to Mrs H after the referral, although it is not clear when, as the mental health team did not currently have the staffing levels to assess her. It is also recorded that at this time Mrs H was saying that she no longer wished to be seen by the mental health team as she had already been waiting so long.

44. The Trust referred Mrs H to be seen by the mental health team (a part of Mersey Care NHS Foundation Trust (MC Trust)) at 9.05pm. The MC Trust had not seen Mrs H before she left the Trust’s ED over three hours later at 12.37am on 19 March. This wait is again not in line with RCEM guidelines as it was over an hour after the referral. This is however an expectation of the MC Trust which is another local Trust and not the Trust she had attended, and not the Trust itself.

45. Mrs H also complains that she was not provided any follow up care after she left the Trust’s ED.

46. Our adviser explained there is no expectation for the Trust to provide follow up care if a patient leaves without being assessed. As mentioned above the Trust contacted the Police to make sure Mrs H was safe but it did not require any further action by the Trust.

47. Based on the evidence we have seen it appears the Trust did not act in line with NHS or RCEM guidelines by failing to triage Mrs H within 15 minutes of her arrival to the ED. It also had still not yet assessed her three hours after the MHT referral which would be considered outside usual timescales at another local Trust.

48. Mrs H says the Trust’s actions caused her distress and to lose confidence in the Trust. We can see that the Trust’s failure to triage her within 15 minutes of her arrival and the significant time she waited in the ED to be seen by the MHT, would have caused her distress, especially at a time when she was already vulnerable as it could have contributed to her feeling that no one wanted to help her.

49. Mrs H is asking for an apology, for security guards to be retrained, to meet the ED leadership team and for a care plan to be created for her. Out of these outcomes we have explained to Mrs H that the only outcome we could achieve through our processes is asking the Trust to provide her with an apology. As we cannot make a decision regarding the behaviour of the security guards, we would not be able to ask the Trust to retrain them. We are also unable to become involved in Mrs H’s ongoing care so would be unable to ask that a care plan be created or for her to meet the ED team.

50. Our Principles say where something has gone wrong or poor service has led to an injustice or hardship, the organisation responsible should take steps to provide an appropriate and proportionate remedy. This is what Mrs H has said she wants from making this complaint.

51. On 12 May the Trust provided an apology letter for Mrs H that outlines the failings identified, apologises for these failings and explains steps is has taken to improve the service to avoid this happening in the future.

52. As the Trust has demonstrated learning has been taken from this complaint, and has apologised for the failing and impact, we believe the Trust has done enough to address the failings. Based on the above we are satisfied that the agreed actions address what went wrong in Mrs H’s care and provides her with some reassurance following her complaint and has given her the one outcome we are able to achieve through our processes, and consider her complaint resolved.

53. We recognise Mrs H suffered unnecessary distress due to the Trust’s actions. We would also like to thank her for bringing her complaint to us. We hope the agreed actions will provide Mrs H with some reassurance following her complaint and achieves what she is seeking.

1. We have carefully considered Mrs H’s complaint about Liverpool Universities NHS Foundation Trust (the Trust). We were very sorry to hear of the concerns she raised regarding how the Trust handled her triage, not providing her with food or drink, or her medication during her admission and that the Trust used force to prevent her from leaving the emergency department (ED). We can clearly see this has caused her a lot of distress at a time when she was already vulnerable.

2. We have carefully considered all the evidence available from Mrs H and the Trust. It appears the Trust acted in line with relevant guidelines in how it handled her medication during her admission. We are unable to make robust decisions on the Trust’s actions regarding providing Mrs H with food and drink during her admission and also in its actions to prevent her from leaving the emergency department (ED). It does appear that the Trust did not act in line with guidelines in how it handled her triage in the ED. Mrs H explained that this caused her further distress at a time when she was already vulnerable.

3. Based on our findings and the outcomes Mrs H told us she wanted, the Trust has agreed to provide a letter of apology which outlines the actions the Trust has taken to improve based on her complaint. We are satisfied the Trust has agreed to take action to put right what went wrong, and the impact caused which we will explain further below.

4. We hope the agreed actions will provide Mrs H with some reassurance about what happened and achieves the outcomes she told us she was seeking. We hope the explanations below explain how we have fully considered her complaint.