15. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the events complained about had a negative impact which the organisation has not put right.
16. Mr I confirmed when we spoke to him that his wife, Mrs C was allowed to self discharge from hospital, despite not being well enough to leave. Mrs C was found wandering the streets bare foot after nearly 4 hours missing and developed a severe and painful infection in her right foot. Mr I says he has also suffered flashbacks and has had to see a therapist for PTSD.
17. Mr I was dissatisfied with the response he received from the Trust which prompted him to bring the complaint to PHSO.
18. We requested the relevant clinical records from the Trust and it provided these. We then sought some clinical advice from an experienced mental health nurse.
19. NICE guidelines on self-harm, assessment, management and preventing recurrence say clinicians should not rely on the use of ‘risk assessment’ tools and scales to determine who should and should not be discharged’.
20. Similar to risk assessments, capacity assessments can vary, and different clinicians may reach different conclusions. Staff’s primary concern should have been Mrs C’s care and safety, which should have taken precedence regardless of whether she appeared to have capacity at any given moment. She was clearly vulnerable and once her husband had left the hospital, on the basis that he understood she would remain in the hospital’s care, her vulnerability would have increased.
21. Clinical staff should have implemented interventions that safeguarded Mrs C, including assessment under the Mental Health Act 1983 and potential admission to a psychiatric hospital or at the very least continued care and supervision in the hospital.
22. Our principles for remedy say to put things right, organisations should provide an apology and remedial action.
23. We contacted the Trust to ask whether it would be willing to provide Mr I and Mrs C a sincere apology letter which recognises the impact caused as well as financial remedy in the mid-range of level 3 our Severity of Injustice scale. The Trust has agreed to send the apology letter and send them £900 financial remedy.
24. We contacted Mr I by email on 30 September 2025 and by telephone on 6 October 2025 to explain the resolution we agreed with the Trust. We explained we will take no further action, which he accepted.
25. Complaints give us a valuable insight into the organisations we investigate, and we recognise this was a distressing experience for Mr I and Mrs C. We would like to thank them for sharing their experience with us and wish them well.