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Lancashire and South Cumbria NHS Foundation Trust

P-002778 · Statement · Decision date: 10 July 2024 · View Lancashire and South Cumbria NHS Foundation Trust scorecard
Drugs / medication Complaint handling Risk assessment Racial Disproportionality in Stop & Search
Complaint (AI summary)
Mr J complained the Trust did not address reported racial abuse, discharged him knowing self-harm risk, and failed to manage medication and razors, severely impacting his mental health.
Outcome (AI summary)
The complaint was closed as the ombudsman found no indication that anything seriously went wrong with Mr J's care.

Full decision details

The Complaint

3. Mr J complains about the following aspects of his experience with the Trust in January 2022. He says the Trust: • did not address, acknowledge or apologise for the racial abuse he reported in his complaint • discharged him knowing he was going to take an overdose • did not clarify how much medication it prescribed and discharged him with • allowed him to have a razor despite the risk of him self-harming.

4. Mr J says the Trust’s actions had a significant negative impact on his mental health. He took an overdose of the medication he was discharged with. He believes the Trust enabled him to attempt to take his own life and he experienced years of torment following this.

5. He would like the Trust to acknowledge what went wrong, apologise and assure him it will not happen again.

Background

6. We include this brief background to put our decision into context. We have not included all of the information Mr J provided about his experience and what happened after.

7. Mr J was admitted to the Trust on 20 December 2021 after attempting to take his own life. He was detained at the Trust under section 2 of the Mental Health Act. The Trust discharged him on 18 January 2022.

Findings

11. 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 wrong.

Racial abuse 12. Our Complaint Standards say organisations should give fair and accountable responses that set out what happened and whether mistakes were made. Where an organisation has got things wrong, it should give meaningful apologies and identify learning from the complaint.

13. In his complaint, Mr J told the Trust another patient racially abused him on the ward. We do not dispute that such behaviour is unacceptable. The complaint to the Trust was about a lack of support and its response addressed this. We are not critical of it for the lack of an apology because we would not necessarily expect it to apologise for the actions of a patient.

14. The Trust acknowledged Mr J’s clinical records referred to a physical altercation. It said Mr J did not want the incident to be reported to the police at the time, but it had taken action to ensure his safety.

15. Mr J’s records appear to reflect this. They note Mr J had been ‘racially abused then assaulted’ and the Trust wanted to log the incident so it was on the perpetrator’s record. They also reflect information in the Trust’s response about how it considered safeguarding.

16. Based on what we have seen, we have decided the Trust’s actions do not indicate there was a failing. While we cannot change Mr J’s experience, we hope our independent view will reassure him the Trust did act on his concerns.

Discharge 17. Mr J says the Trust gave him a significant amount of medication on discharge, despite his admission being due to an overdose. He says the information in its response is confusing. He disputes the Trust’s account and says he was discharged with one month’s worth of some medication and two months’ worth of others.

18. The Trust has acknowledged Mr J disclosed he was thinking of taking an overdose. It said it decided to give him three days’ supply of medication. It said he emptied the medication he was given out of the box it was in and only took a skin ointment, 24 paracetamol, 12 lorazepam (to treat anxiety) and 6 vortioxetine (antidepressant) with him.

19. This matches what we have seen in Mr J’s records. They say the pharmacy gave the ward three days supply of medication in preparation for Mr J’s discharge. They go on to say when Mr J was handed the medication, he took some with him (as specified in the complaint response) and left the rest with ward staff.

20. Our adviser said the Trust’s records are in line with the NMC guidance on record keeping so we hope our investigation has provided the clarity Mr J is seeking. While we are unable to reconcile Mr J’s account with the information from the Trust, we have not identified any indication of a failing here.

Razor 21. Mr J says the Trust allowed him to have a razor despite the risk of him self-harming. The Trust said it used its Blanket Restrictions Policy to make a clinical decision about this.

22. Section 4.4 of the policy covers restricted items. It says restricted items are items where the access is controlled and may be directed according to policy and individual risk assessment. The policy includes razors as an example of restricted items.

23. Our adviser said there was nothing in Mr J’s risk assessment that would have prompted the Trust consider him a risk to himself with a blade. Our adviser said the Trust’s decision to act in line with its policy was a reasonable approach. We have therefore not identified any indication of a failing in relation to this.

24. Overall, based on the available information and the advice we received, there is no indication of a failing in relation to issues Mr J raised with us. We understand his perspective on the Trust’s actions and we hope it is clear how we reached our conclusions.

Our Decision

1. We have carefully considered Mr J’s complaint about the Trust. We were sorry to hear of his experience and the concerns he has been left with.

2. As we have explained in this statement, we have seen no indication that anything went seriously wrong with Mr J’s care at the Trust. This is why we have decided not to investigate his complaint further.

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