North London NHS Foundation Trust

5. Ms T complains about the care and service she received from the Trust between March 2023 and October 2023. She says when she complained to the Trust after she was discharged about suffering psychological abuse by a member of staff while she was an inpatient, the Trust failed to properly investigate or act on her complaint. She also complains that the Trust did not inform her of the Section she was detained under and did not properly record the details of her section 17 leave.

6. Ms T says the impact of these events have caused her significant anxiety and concern. She states her liberty was restricted without proper justification, which she believes undermined her legal rights as a patient. She also states that the failure to record the name of the staff member who escorted her on leave compromised her safety and affected her ability to seek redress. Ms T feels her concerns have been minimised and does not feel reassured that meaningful improvements will follow.

7. By bringing her complaint to us Ms T is seeking: • verification of whether a safeguarding review was carried out, and if not, whether one should have taken place • confirmation of what internal safeguarding or HR actions the Trust took to ensure patient safety • clarification of the legal section of detention and whether escorted leave was justified and properly communicated • consideration of whether the Trust met required standards for recording escorting staff during leave • assessment of whether the Trust’s complaint responses were consistent and met expected standards • review of whether the Trust’s action plan is sufficiently detailed, accountable, and robust in addressing the issues raised.

8. Ms T was admitted to a ward at the Trust in early March 2023. She was initially admitted as an informal patient under section 5 until mid-March 2023 when she was formally detained under section 2.

9. Ms T’s records show several entries mentioning section 17 leave. On 14 March 2023 her records state she was escorted on leave by “nursing staff”.

10. In mid-April 2023, Ms T was discharged. At the end of October 2023, Ms T complained to the Trust stating she suffered mental abuse from a member of staff while on the ward.

Trust’s response to the allegations Ms T raised

14. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone seriously wrong.

15. Ms T complains that the Trust failed to carry out a safeguarding review after she reported a serious incident, did not produce a suitable action plan after the incident, and did not provide proof the new employer of the named person was notified of the alleged incident.

16. At the end of October 2023, Ms T complained to the Trust stating she suffered mental abuse from a member of staff while on the ward. Ms T stated this member of staff also escorted her on leave on one occasion. She informed the Trust she had reported the alleged abuse to the police in July 2023.

17. In its initial response to Ms T’s complaint, dated 5 February 2024, the Trust state, ‘a safeguarding investigation was undertaken in tandem with this complaint investigation. This involved a meeting including the Director of Nursing and Associate Director of Safeguarding to determine a safeguarding plan’.

18. In its further response to Ms T’s complaint, dated 9 October 2024, the Trust said a Section 42.1 Safeguarding Concern was raised on 25 October 2023 and was closed on the advice of the safeguarding team. The investigation continued under the ‘managing allegations against staff policy’.

19. The Care Act 2014 states a Safeguarding review needs to be considered when an adult at risk suffers significant harm as a result of abuse or neglect. An adult at risk is a person who needs help and support due to illness or disability and because of this is less able to prevent harm or abuse. The review is about learning lessons to make appropriate improvements or changes to prevent similar situations from happening again.

20. The Framework explains that for a section 42 safeguarding review to take place, a three-point criteria must be met. The criteria are that the individual has needs for care and support; that the individual is experiencing, or is at risk of, abuse or neglect; and that, as a result of those needs, the adult at risk is unable to protect themselves from the abuse or neglect, or the risk of it.

21. As Ms T had already been discharged from the Trust at this stage, her circumstances did not meet the third criteria and as a result, a section 42 safeguarding review was not carried out. This means the Trust was not required to conduct a section 42 safeguarding review in relation to the allegations made by Ms T.

22. We can see the Trust acted in line with the Framework when not carrying out a safeguarding review regarding the abuse allegations and can see no indication of failings regarding this aspect of the complaint.

23. Ms T also complains that the Trust did not complete an action plan in relation to an incident where the Trust brought her daughter onto the ward when it shouldn’t have done.

24. After conducting their own investigation of Ms T’s complaint, the Trust found her preference for not having visitors step onto the ward was not adhered to on one occasion when her daughter was brought onto the ward by a member of staff.

25. This was particularly distressing for Ms T as she said some of the alleged mental abuse she suffered from the member of staff was about her daughter. In its complaint response to Ms T, the Trust acknowledged this was very distressing for her and apologised.

26. The Trust created an action plan specific to Ms T’s experience on the ward regarding visitors. This action plan was shared with the wider team during clinical supervision and in a team business meeting. The action plan was specific to the above incident and did not address the alleged abuse as the Trust found no evidence of abuse.

27. Our NHS Complaint Standards say wherever possible, staff explain why things went wrong and identify suitable ways to put things right for people. Staff should give sincere apologies and be clear about how learning will be used to improve its service.

28. We are satisfied the Trust has appropriately acknowledged that Ms T’s preference was not adhered to and apologised for this. It has also explained how it will use this complaint to prevent similar incidents in future. For these reasons, we feel it has done enough, in line with Our NHS Complaint Standards, to put this aspect of the complaint right and produce a suitable action plan. As such we will not take any further action on this aspect of the complaint.

29.  Due to the nature of the allegations made by Ms T against the member of staff, in its complaint response, the Trust said it reported these to the member of staff’s new employer in case there were any future issues.

30. The role carried out by the member of staff on the ward is not one that falls under a statutory professional regulator. As a result, there is no formal register for individuals in this position, and there is no equivalent regulatory body to which concerns about their practice can be formally reported. Considering this, Ms T asked to see evidence the Trust informed the new employer of the allegations.

31. Due to data protection, the Trust said it could not share this information directly with Ms T. We asked the Trust if it would share this with us so we could reassure her on a key part of her complaint.

32. The Trust has now confirmed to us that it did not share this information with the staff member’s new employer. Its reasoning for this is that it found no evidence of the alleged abuse and a police investigation did not lead to any criminal charges. The Trust said therefore its initial response to Ms T should not have given these assurances.

33. Our Principles of Good Administration say that when assessing risk, public bodies should ensure that they operate fairly and reasonably.

34. As the Trust’s investigation did not find any evidence of abuse and the police investigation did not lead to any charges, we consider it is fair, and in line with Our Principles of Good Administration to the staff member involved that the Trust did not share any information with their new employer.

35. We appreciate that it was unhelpful and frustrating that the Trust gave Ms T incorrect assurances. We have not seen an indication of a failing in the Trust not sharing the information with the new employer. We understand this will be disappointing for Ms T to hear.

The Trust did not inform her of which section she was detained under or the legal basis under which she was escorted on leave The Trust did not record the name of the staff member who escorted her on leave The Trust gave inconsistent information in its complaint response

36. Ms T initially went to hospital as a voluntary patient, then was detained under Section 5 whilst she awaited her assessment, then following her assessment was detained under section 2 of the Mental Health Act.

37. Section 5 allows inpatients to be detained temporarily until an assessment has been undertaken.

38. Section 2 allows inpatients to be detained for up to 28 days for assessment of their mental health condition. Two doctors must recommend the detention, and an Approved Mental Health Professional (AMHP) makes the application.

39. Under Section 2 of the Mental Health Act, a person may be admitted to hospital and detained for assessment if they are suffering from a mental disorder that warrants assessment in hospital, and that detention is necessary for the person’s health or safety or to protect others.

40. Under Section 132 of the Mental Health Act, the Trust has a statutory obligation to tell people why they have been detained.

41. We have seen, and our adviser confirmed, that the Trust completed the relevant documentation for the section under which Ms T was detained.

42. In Ms T’s notes, there are documented discussions with her on 9 March 2023 about being under Section 5, during which she refused to have an ECG, stating she had not had two medical assessments while under Section 5. There are also notes from 10 March 2023 where Ms T said she did not want the limitations of being under Section 2, and notes from 28 March where she said she wanted to appeal her Section 2.

43. Ms T is reported as saying she could not clearly remember what happened during her time on the ward as she was unwell. We can see this was a very difficult time for Ms T.

44. We have seen evidence that in line with the Mental Health Act, the Trust did inform Ms T of which section she was under and that she was aware of this at the time. We have not seen any indications of failings for this aspect of the complaint.

45. Ms T was granted Section 17 leave during her time on the ward with the Trust. Section 17 is a leave of absence from hospital. Patients detained under Sections 2 or 3 may be granted temporary leave.

46. Our adviser told us it is the duty of the responsible clinician (RC) to set the terms for leave according to what is appropriate given the patient’s current health and presentation. Whether leave is escorted or not is part of this clinical judgment and a patient would not be informed of a legal basis for escorted or unescorted leave each time.

47. The Trust’s Section 17 Leave policy does not specifically state a requirement for the name of the person escorting somebody on leave must be recorded.

48. As the Trust’s policy does not state that the name of the staff member needs to be included in the records, we cannot say that it was a failing that the Trust did not record this information. Ms T feels not documenting the name of the staff member who escorted her on leave compromised both her safety and her ability to seek redress. Ms T did not report any specific incident during her leave, therefore thankfully we also cannot see this had any impact on Ms T.

49. Ms T told us in its responses to her complaint the Trust gave more than one job title for the staff member the alleged abuse came from. She says this reflects a poor standard of complaint handling.

50. Our NHS Complaint Standards say that organisations should give a clear account of what happened based on established facts.

51. We can see that the Trust provided the job title of the staff member to Ms T in an email in January 2024. The job titles provided in its complaint responses were for other members of staff as requested by Ms T. We have not seen any evidence the Trust gave any other job title for this member of staff at any time.

52. Therefore, we consider the Trust did provide a clear account of what happened and which staff members were involved in her care, in line with Our NHS Complaint Standards. As such, we have seen no indications of failings for this aspect of the complaint.

53. We appreciate that this was a difficult and worrying experience for Ms T. We appreciate our decision may be disappointing for Ms T but would like to thank her for bringing her concerns to our attention.

1. We have carefully considered Ms T’s complaint about North London NHS Foundation Trust (the Trust). We have seen no indication anything went seriously wrong.

2. We can see the events Ms T has complained about caused her a great deal of anxiety and stress that is ongoing today.

3. We have seen that it was appropriate and in line with guidance that the Trust did not carry out a safeguarding review when Ms T reported concerns, and we have seen evidence that the Trust did inform her of which section of the Mental Health Act she was detained under.

4. We have also not seen any indications of failings in the Trust’s omission to record the staff member’s name when recording Section 17 leave. We will therefore not consider this complaint any further.