Clinical care
11. To decide if we should conduct a detailed investigation, we first consider if there are reasons not to. These include if an investigation might not be practical or come to a satisfactory conclusion. We have considered this case and think we should not investigate it. On balance, there is not sufficient evidence available to reach a robust view of Mr E’s care.
12. Mr E feels his first discharge on 5 December 2022 was inappropriate. He told us he was discharged from the emergency department (ED) in the middle of the night after telling his wife he would not be home. He says he had no house keys, medication, or suitable clothes. Mr E feels this led to him suffering a second stroke on 8 December.
13. Mr E says Trust staff told him he would be discharged home again on 14 December. Shortly before he left, he says this plan changed and he was asked to stay in hospital so the cardiology team could review him. Mr E told us he needed a cardiac ablation surgery (a procedure that treats irregular heartbeats) and was hoping this would be arranged by the cardiology team during this admission. Mr E’s previous bed had been taken so he was readmitted to a bed in bay four.
14. Mr E says once he was in this bay, he quickly realised there was no hot water in the bathroom. Soon after, he says a patient with the flu was transferred into this bay and he became infected with it as he was not provided with any personal protective equipment (PPE). As he had flu, he had to be quarantined in this bay and could not leave. He says the nursing care at this point became very poor and he spent eight days with no access to clean drinking water, he was barely offered food, he could not bathe and was not offered any alternatives. He also told us that members of the cardiology team did not come to see him as he had the flu.
15. Mr E told us he became emaciated and felt imprisoned on the ward and feels his human rights were breached. Mr E told us he raised his concerns about the care he received and the lack of hot water on many occasions whilst he was a patient on the ward. He says staff repeatedly told him that a maintenance team were aware of the issues with hot water and would attend to fix it. However, this did not happen before his discharge.
16. Following his discharge on 21 December, Mr E told us the cardiology team did not arrange any follow up care. He says he had no other option but to take out a loan for £20,000 to pay for the cardiac ablation surgery he needed privately.
17. During local resolution Mr E requested a copy of his medical records. He says once he received these records, he realised they had been ‘falsified’ and contained lies about his condition at the Trust.
18. We spoke with Mr E on 20 August to discuss his issues. He told us the Trust has ‘lied in his records’. He says it incorrectly said he had been eating and drinking and washing as usual. He says this is ‘completely false’, he was not offered sufficient food and drinks and had no hot water for his entire stay in bay four. Additionally, he says the Trust incorrectly said he was the first person to get flu on the ward (instead of him being exposed to flu from another patient). Finally, he disagrees with the Trust’s records about his discharge and heart condition. He feels the care fell below standard, and it did not accurately record the mistakes it made in his care.
19. It is important to explain our role is to make independent final decisions about NHS complaints in England. We make decisions by weighing up and considering all the available evidence. We then consider the likelihood that something has gone wrong with the service provided.
20. As we are impartial, we must make robust decisions based on facts and evidence. Unfortunately, Mr E believes his medical records are not factual and we are not able to prove or disprove this. He also believes the Trust lied in its responses to his complaint. Regrettably, without further evidence we are not able to reach a view on whether there was anything wrong with the care provided to Mr E as he contests the accuracy of what we would use to come to a decision on this.
21. For this reason, we consider a formal investigation would not be practical for this complaint. We recognise this may cause Mr E further frustration. We are sorry we have not been able to investigate his complaint further or provide him with closure for his concerns.
Complaint handling
22. 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 something has gone wrong.
23. The records show Mr E made a complaint to the Trust in June 2023. He later requested this complaint be withdrawn and submitted his formal complaint on 28 July. Following this, Mr E told us the Trust made an inappropriate decision to issue him an unreasonable behaviour warning. It refused to respond to his emails and ‘banned him’ from its service. He says it also failed to adequately answer his complaint and ‘lied’ in its responses.
24. We asked the Trust to provide us with a timeline of correspondence and its complaint management policy. We reviewed the policy alongside the timeline and its correspondence to Mr E. We have also considered our NHS Complaint Standards (2022).
25. We can see the Trust deemed Mr E’s behaviour to be ‘unreasonable’ as outlined in its complaint management policy. Mr E disagrees with this. The policy explains types of behaviour that may be deemed unreasonable include:
• ‘adopts an excessively ‘scattergun’ approach, for instance, in pursuing a complaint with multiple organisations or individuals • refuses to cooperate with the complaint investigation process, whilst still wishing their complaint to be resolved • makes the same complaint repeatedly, perhaps with minor differences, after the complaint has been investigated • are unwilling to accept documented evidence of treatment given as being factual e.g. drug records, nursing records or deny receipt of an adequate response in spite of correspondence specifically answering their questions • have in the course of addressing a registered complaint, had an excessive number of contacts with the Trust placing unreasonable demands on staff’.
26. On review of the timeline, we can see Mr E contacted the Trust on 37 occasions from 14 July 2023 to 3 January 2024 when he received the Trust’s response. From 3 January to 19 January, Mr E contacted the Trust six times. We can see these emails were sent to multiple staff members. On 19 January, Mr E was issued with an unreasonable behaviour restriction. He was asked not to contact Trust staff at this point.
27. From 19 January to 18 September, Mr E contacted the Trust on 66 occasions. He has provided us with evidence of his correspondence. We can see most of his emails were directed to multiple staff members at the Trust. There is a total of 109 instances where Mr E contacted the Trust between 14 July 2023 to 18 September 2024.
28. The Trust’s unreasonable behaviour policy explains it will issue an unreasonable behaviour warning when a complainant ‘makes the same complaint repeatedly’ and adopts an ‘excessive’ approach when pursuing the complaint. The evidence we have seen indicates Mr E contacted the Trust on multiple occasions about the same issues and sent emails to multiple staff members. Sadly, this level of contact was becoming unreasonable to manage. As such, we consider Trust staff made an appropriate decision, in line with its policy, to issue an unreasonable behaviour warning. We see no indications of failings here.
29. Our complaints standards explain we expect organisations to ‘give open and honest answers’ when addressing complaints. It also explains we expect organisations to give a ‘clear and balanced account’ of what happened. We would expect the organisation to speak to the relevant staff members involved in the complaint and refer to relevant evidence in its response.
30. In this case, we are satisfied the Trust correctly handled Mr E’s complaint. It involved the relevant staff members and considered the relevant available evidence in his medical records. It then reflected its findings openly and honestly in its complaint’s response. We consider these actions are in line with our complaint’s standards. For this reason, we have seen no indications of failings for this part of the complaint.
31. We appreciate how difficult this time has been for Mr E. We want to thank him for taking the time to bring his complaint to us.