19. Our SMG outlines the reasons we may not decide to carry out a detailed investigation into a complaint. It includes where the investigation would not be practical and would not reach a satisfactory conclusion, so an investigation would not provide a valuable response. Another reason we may decide not to investigate is if the outcome sought is not achievable.
20. Miss B complains the Trust did not assess the risk patient B posed to others and this failure meant he was not assigned his own security guard. She says, if this happened, then patient B would not have assaulted her father in ED, causing him significant facial injuries.
21. As a result, her father had to be rushed to Royal London Hospital for urgent treatment for his injuries. This caused the family extreme stress and anxiety which they say could have been avoided.
22. The Trust has said in its final response the assault could not have been predicted. This is because the CCTV does not show patient B exhibiting any aggressive behaviour prior to the attack.
23. Similarly, the Trust has explained a member of ED did raise concerns about patient B and this was escalated to the psychiatric liaison team who reassessed patient B. These concerns did not automatically mean the patient should have an enhanced level of security.
24. The Trust also informed us it would not be aware of a patient’s previous criminal history as this does not affect the care the patient would receive. The Trust would only act on the information it has at the time.
25. The Trust apologised for the events complained about and made significant service improvements to ensure this does not happen again.
26. As a result of this complaint the Trust has completed a Serious Incident Report. It identified the following failings:
• lack of clear documentation to be completed within good time between the psychiatric teams and ED, this also include a lack of communication from psychiatric team to ED • psychiatric team to document who they escalate their decision to along with the time.
27. The Trust has explained it made several service improvements as a result of what happened. These include staff learning and training, more security and updates to some internal protocols.
28. It also included the following:
• review of the Service Line Agreement between the Trust and NELFT • NELFT to consider a psychiatric re-assessment for Mental Health patients who are discharged and re-present • adaptation to clinical environment with a view to keeping people safe, for example removal of sharp bins and other dangerous elements.
29. Miss B is complaining the Trust failed to protect her father from an assault by another patient, whilst he was in ED.
30. We have carefully considered if there is anything we could do by investigating further, that the Trust has not done already. We do not think our investigation would add anything further than the Trust did in its Serious Incident Report or come to a different conclusion.
31. We do not believe a further investigation by us would be likely to achieve the outcome Miss B seeks, which is for us to conclude definitively that this attack could have been prevented if the Trust assessed and monitored the risk patient B posed on 1 March 2022.
32. There has been a criminal investigation into the incident. We understand from Miss B that patient B pleaded guilty to GBH (grievous bodily harm) and received a four-year prison sentence.
33. When a finding in a criminal case has been reached that relates to the incident, this also might make it difficult for us to conclude the Trust was responsible for failing to prevent the assault. This is because a court has already accepted patient B was responsible for the assault.
34. We recognise the Trust viewpoint that it’s psychiatric ward should have communicated with ED more clearly. This means, ED could take additional steps to ensure patient B was not a risk to others whilst being allowed to roam freely within the department for a considerable number of hours.
35. Whilst the Trust recognises areas of improvement, we do not think this means it could have predicted such a vicious attack would take place.
36. The Trust itself has already accepted that its communication could have been better. This is documented thoroughly in the serious incident report with a significant amount of service improvements. We are satisfied the Trust has taken Miss B’s complaint seriously and it is reassuring to see the amount of service improvements it has implemented.
37. On this basis, we do not believe it will ever be possible to conclude with certainty the Trust could have predicted and prevented this assault from happening.
38. Miss B explains the impact of the Trust’s failing, is that her elderly and vulnerable father was attacked whilst he lay in bed, and this led to significant facial injuries. As a result of this traumatic event, Miss B did not let her mother visit her husband. Her mother did not have the opportunity to say goodbye to her husband of over 60 years. Other family could not travel back in time to see their father alive.
39. Miss B’s children have also suffered emotionally. They cannot believe someone would choose to attack their grandfather and cause him such injuries.
40. Miss B is seeking service improvements, an apology, and a financial remedy. We have explained to Miss B that the service improvements already implemented by the Trust are significant. If we were to investigate, it is unlikely we would recommend anything in further, even if we upheld the complaint, which is very unlikely.
41. Overall, we would not be able to reach a view on whether this assault definitively could have been prevented. This means it is unlikely we could come to a satisfactory conclusion on this complaint. We do not believe an investigation would reach what Miss B would view as a satisfactory conclusion.
42. We are sorry for any distress this decision causes. We fully recognise the impact this traumatic event has had on Miss B and her family. We thank her for bringing her complaint to us and appreciate how distressing it has been to revisit what happened to her father.