5. Mr E complains Southern Health NHS Foundation Trust (the Trust) should not have applied to section his daughter, Miss E, in June 2023.
6. He also complains between January and June 2023 the Trust did not communicate with him about Miss E’s presentation when he would visit to take Miss E on leave from hospital.
7. Mr E says the Trust caused distress to him and Miss E.
8. By bringing the complaint they are seeking an apology, acknowledgement of wrong doing and financial payment.
9. Miss E was diagnosed with autism, attention deficit hyperactivity disorder (ADHD) and foetal alcohol spectrum disorder. She also had a learning disability.
10. Miss E was in a hospital setting, deprived of her liberty, whilst the Trust made suitable arrangements for her care in the community.
11. The Trust applied for a section 5 (2) under the mental health act in June 2023. Section 5 (2) allows a doctor to temporarily hold a patient for assessment purposes.
Section 5(2)
15. Mr E is unhappy about the Trust’s decision to apply a section 5(2) to Miss E in June 2023.
16. He says the Trust told him its lawyers advised it had to apply the section but did not provide further explanation as to why. Mr E cannot understand the decision to section Miss E when she was already in hospital. He says this caused unnecessary distress.
17. The Trust says legislation can change and so where there might not be clinical change in a patient, it still needs to review legal frameworks. The Trust explained a separate court case against it had also influenced its reasoning for sectioning Miss E.
18. We are not considering whether the Trust’s decision to section Miss E was right or wrong as we do not have the powers to do this. We can only consider whether the Trust acted in line with the relevant legislation being the mental health act (MHA) 1983.
19. We appreciate it was distressing for Mr E and his daughter to learn the Trust were applying the section.
20. The MHA code of practice (the Code) safeguards patients’ rights, ensures compliance with the law and must be considered by health and social care professionals. The Code is used by patients in hospital and those in the community, their families, carers and advocates. It is there to help make sure that anyone experiencing mental disorder and being treated under MHA gets the right care, treatment and support.
21. Miss E was an informal hospital patient. This means she met the criteria set out in the Code that says the patient must already be in hospital. This includes patients who are in hospital by virtue of a deprivation of liberty which was the case for Miss E.
22. The Trust’s aim was to assess whether it should detain Miss E under MHA. This is also part of the criteria set out in the Code where it says a doctor or approved clinician can use the power if they find an application for detention under MHA should be made.
23. A registered medical practitioner examined Miss E in June 2023. This meets the Code which says doctors and approved clinicians should only use the holding power after having personally examined the patient.
24. We acknowledge the Trust complaint responses relied heavily on a separate court case in its reasoning for sectioning Miss E. We think this caused confusion to Mr and Miss E as whilst the court case may have had similarities it was not relevant to Miss E.
25. The Trust had to meet specific criteria to section Miss E and it should have focussed on whether she did or did not meet these to explain its reasoning.
26. Whilst the Trust could have done better to explain its reasons for applying the section in its complaint response, from the records, we have seen evidence the Trust took proper considerations in its decision making. As above, Miss E met three considerations as set out in the MHA code of practice.
27. We do not uphold this part of the complaint.
Handovers
28. Mr E complains about a lack of communication when he would come to visit and take Miss E out on leave despite asking on several occasions. He said her behaviour could be highly elevated and occasionally violent.
29. Mr E says the Trust did not take the time to talk to him about any risk events or reasons why she may be behaving that way.
30. The Trust acknowledged Mr E did not get consistent handovers meaning he was not aware if there was anything he needed to know before taking Miss E out on leave. The Trust apologised and said it implemented service improvements. Mr E explained lack of communication continued despite this.
31. There is no formal guidance or legislation that obligates NHS staff to provide formal handovers.
32. Our adviser explained it would have been good practice for Trust staff and Mr E to communicate. They said this was arguably both parties’ responsibility.
33. There is very limited information in Miss E’s records related to communications with Mr E when he would visit to take Miss E into the community.
34. Our adviser said it would have been good practice for Trust staff to document any discussions with Mr E prior to and after leave. They said this would include an overview of any key information or concerns from either party and a contingency for if there are difficulties on leave.
35. On 18 January 2024 we asked the Trust to provide any evidence of the steps it took to ensure ongoing handovers were in place for Mr E.
36. The Trust’s head of nursing wrote:
‘The team fully acknowledge that there were times when handover did not take place and apologise for this. The team also acknowledge that good risk management and ensuring that escorted leave is productive and meaningful is supported by whoever is with the patient being aware of any possible issues/concerns. Since this was raised as an issue it was documented in the patient’s record that sufficient handover is to be given either through brief telephone call/email prior to leave or a nurse meeting with him prior to him taking his daughter out. In addition to this a carer’s communication plan was put in place that set out the need for weekly contact with a designated senior member of nursing staff which was the Ward Manager or Clinical Lead depending on who was on duty.’
37. We asked the Trust to explain what steps it took to ensure Trust staff were providing sufficient handovers and acting in line with communication plan. The Trust provided the carer’s communication plan which says ‘staff to give verbal handover about Miss E’s presentation before dad takes her out on leave.’
38. We appreciate the Trust took consideration of Mr E’s concern in writing the above statements. We do not consider we have seen evidence the Trust took initiative to robustly ensure staff took steps to communicate with Mr E outside of simply writing they should.
39. Mr E explained how difficult it was for him ‘always flying blind’ without information about Miss E’s presentation. He said due to his daughter’s conditions Miss E’s presentation was dysregulated most times he took her out. This included physical assault and having a drink thrown at him. Mr E advised Miss E broke his one of his belongings.
40. We are sorry to hear about the frustration Mr E felt having the Trust acknowledge handovers were needed but failing to provide them the majority of the time. We appreciate it was difficult for Mr E to plan where they could go together and who he could take Miss E to visit.
41. The Ombudsman’s Clinical Standard explains we will seek to establish what constituted good clinical care and treatment on the facts of the case by reference to a range of material, including relevant standards or guidance, the accounts of the complainant and the clinician or organisation complained about and any other relevant records and information.
42. We consider consistent, documented communications with Mr E around times of leave was a reasonable expectation. We have not seen evidence the Trust adhered to this. For this reason, we uphold this part of the complaint.
43. Our Principles of Good Administration say:
‘public bodies should do what they say they are going to do. If they make a commitment to do something, they should keep to it, or explain why they cannot’
and
‘public bodies should treat people with sensitivity, bearing in mind their individual needs, and respond flexibly to the circumstances of the case’.
44. Our Principles of Good Administration also say when mistakes happen, we expect public bodies to acknowledge them, apologise, explain what went wrong and put things right quickly and effectively. The Trust has not evidenced it ensured Mr E received consistent handovers as requested and agreed. We do not consider the Trust has fully acted in line with our principles.
1. Mr E has complained to us about the service the Trust provided to him and his daughter, Miss E.
2. In our investigation we found the Trust did not have sufficient processes in place to communicate with Mr E and document this before he took Miss E into the community.
3. We do not consider there were failings in the Trust’s decision making to section Miss E. As we have found failings in parts but not all of the complaint, we partly uphold this complaint.
4. We are recommending the Trust form an action plan demonstrating how it has or will ensure effective communications between staff and parents or carers at times of leave. We are recommending the Trust pay Mr E £120.00 to acknowledge the distress he suffered.
45.We make recommendations in line with our Principles for Remedy which say public bodies should acknowledge failures, apologise, make amends, and use the opportunity to improve their services. The Principles say we aim to ensure the public body puts the complainant back in the position they would have been in had nothing gone wrong. If that is not possible, the public body should compensate them appropriately.
46.Our Principles for Remedy are reflected in the NHS Complaints Standards which say organisations should offer fair remedies to put things right and identify learning and use it to improve services.
What we found
47.Through investigating Mr E ‘s complaint, we found:
• the Trust did not put processes in place to ensure effective communications between staff and parents or carers were in place causing distress.
What the organisation should do
48.Our Principles for Remedy say organisations should acknowledge poor service and take steps to put things right when this leads to an injustice or hardship.
49.Our Principles for Remedy say organisations should compensate people appropriately if they cannot return the person affected to the position they would have been in if the poor service had not occurred.
50. To decide on a level of financial remedy, we review similar cases where the person has experienced a similar injustice, along with our severity of injustice scale.
51. Following this review, we recommend the Trust:
• pay Mr E £120.00 in recognition of the distress he experienced caused by the Trust’s failure to ensure consistent handovers were in place.
• send us evidence it has done this by 28 December 2025.
52.Our Principles for Remedy also say organisations should look for continuous improvement and learn lessons from complaints to make sure poor service is not repeated.
53. We recommend the Trust:
• produces an action plan to address the failings relating to a lack of sufficient processes to ensure staff communicate with parents and care before they take service users on leave • identify the reason(s) for the failing (where possible) • explain the learning taken and set out what it will do differently in the future (or does differently now) • for each action it should state who is/was responsible, timescale for completion, and how it will be/was monitored • share the action plan with us, Mr E and CQC by 20 February 2026.