NHS in England Closed After Initial Enquiries Search on PHSO website

Sussex Partnership NHS Foundation Trust

P-003140 · Statement · Decision date: 29 November 2024 · View Sussex Partnership NHS Trust scorecard
Drugs / medication Confidentiality, privacy and safeguarding Transfer, discharge and aftercare Pharmacist missed drug contraindications Clinical negligence harms learning
Complaint (AI summary)
The Trust allegedly failed to exercise due care prescribing sertraline to Mr N, did not respond to behaviour changes, and lacked appropriate monitoring.
Outcome (AI summary)
The complaint was closed because it fell outside the ombudsman's time limit, with no grounds to set it aside.

Full decision details

The Complaint

3. Mr N complains the Trust did not exercise due care when prescribing sertraline to him in February 2022 due to his history of psychosis. He specifically complains the Trust: • did not respond appropriately when his father reported changes to his behaviour within two days of taking sertraline • did not appropriately monitor him when it changed the medication or provide a reason the lack of monitoring.

4. Mr N says as a result of the change in medication he attacked two members of the public which resulted in him being detained under the Mental Health Act. He says the Trust endangered him and members of the public by not appropriately monitoring him.

5. Mr N would like financial remedy and for the Trust to admit that an error was made.

Background

6. Mr N was prescribed sertraline in February 2022 by a psychiatrist at the Trust. Sertraline is a medication often used to treat depression.

7. Mr N experienced an episode of psychosis on 2 March 2022. He was detained under the Mental Health Act. The Trust decided to carry out a Serious Incident Investigation.

8. Mr N’s parents emailed the psychiatrist on 6 March 2022 to complain about the medication they had prescribed. A meeting was held with the Trust to discuss the complaint. Mr N’s parents agreed to await the findings of the Serious Incident report before pursing the complaint further.

9. Mr N’s parents wrote to the Trust on 5 December 2022 to dispute the findings of the Serious Incident report and received a response on 30 December 2022.

10. Mr N’s father, Mr T, complained to the Trust about how it prescribed sertraline in April 2024 and received a final response in June 2024.

Findings

12. 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 T to understand the reasons why he could not do so.

13. Mr N is complaining about the Trust’s decision to prescribe him sertraline on 2 March 2022. We consider Mr N and his father knew about the matters complained about on 6 March 2022. This is because we know Mr T raised his concerns about the medication with the Trust on that date. To meet our time limit for looking at a complaint, we would have expected him to bring the complaint to us by March 2023. He brought the complaint to us on 23 July 2024, one year four months later.

14. We asked Mr T why he did not bring the complaint to us sooner. He told us initially the Trust said it would carry out a Serious Incident Investigation. It shared its report on 16 November 2022. Mr T says he contacted the Trust to dispute the investigation findings in December 2022.

15. He told us once he had received a response from the Trust he contacted a solicitor who was representing his son in February 2023. He said the solicitor told him that psychiatrists would not support the view that sertraline caused the change in Mr N’s behaviour which led to the incident on 2 March 2022. At this point he decided he would no longer pursue his concerns.

16. Mr T has told us he then found studies which show a link between sertraline and psychosis. He says this prompted him to make a complaint to the Trust and he did this on 4 April 2024. He received a final response from the Trust on 11 June 2024 which directed him to contact us if he remained dissatisfied.

17. Mr T told us he received a letter from Mr N’s responsible clinician on 28 June 2024 and states this email contained new information that conflicts with previous communications from the Trust. This email prompted Mr T to complain to us in July 2024.

18. Mr T explained he believes the date of awareness should be when they became aware of new information in June 2024. Mr T also expressed that as Mr N has been detained since 2022 the time limit for bringing a complaint should have stopped from then.

19. We recognise Mr T believes the circumstances he has explained should allow for us to investigate the complaint. When we look at whether we should investigate a complaint we look at the first point someone had cause to complain. In this case Mr T had cause to complain on 6 March 2022.

20. We recognise Mr T considers the issue he has brought to us to be different to the one he complained about in 2022, and he has told us he only became aware of this information in June 2024. We consider the central issue of his complaint is how Trust prescribed sertraline to Mr N in 2022.We have not seen that this new information changes that Mr T knew there was cause to complain about this from March 2022.

21. We find Mr T could have brought his complaint to us following the Trust response letter in December 2022. We have not seen that the advice given by Mr N’s solicitors was a barrier to Mr T raising a complaint with us sooner.

22. We recognise that Mr N is unable to bring complaints himself. Mr T has acted as his representative since before the incident in 2022 and has made complaints to the Trust on his behalf. We have not seen that Mr N’s circumstances prevented a complaint being made to us by his father following their dissatisfaction with the Trust’s response in December 2022.

23. Taking into account the evidence we have seen we do not consider we should put our time limit to one side.

24. We do not doubt how significantly this experience has impacted Mr N and recognise how important this complaint is to him. Although our decision may be disappointing, we hope Mr N is assured that we have carefully considered his explanations of delay and have explained our decision clearly.

Our Decision

1. We have carefully considered Mr N’s complaint about Sussex Partnership NHS Foundation Trust (the Trust). We were sorry to hear about the incident in 2022 and the continuing impact this has had on him.

2. We have considered the evidence available, including the significant impact the events had on Mr N. We have decided the complaint falls outside of our time limit and have not seen there are grounds for us to set aside our time limit in this case.

Other Decisions About Sussex Partnership NHS Foundation Trust

P-005136 · 27 Mar 2026
Miss L has raised concerns about the waiting times for an autism assessment and not being prioritised.
Closed After Initial Enquiries
P-004570 · 6 Jan 2026
Miss O complains Sussex Partnership NHS Foundation Trust (the Trust) did not provide her with support or treatment since March …
Closed After Initial Enquiries
P-003744 · 30 Aug 2025
Ms L complains about advice given to her about her daughter’s care by the Trust, and the Trust’s records of …
Closed After Initial Enquiries
P-003700 · 20 Jul 2025
Ms F complains between 7 and 21 December 2023, Dr A discussed E’s needs with a neighbouring service without due …
Closed After Initial Enquiries
P-003572 · 8 May 2025
Mr A complains about care provided to him by Sussex Partnership NHS Foundation Trust (the Trust) from July 2021 to …
Closed After Initial Enquiries
View all decisions for this organisation →