East London NHS Foundation Trust (the Trust)
The behaviour of staff at the Trust
21. Dr G told us that the staff from the Trust were ‘brutal’ and treated her as if she was a child while the patient transport staff were preparing to transport Mr K to the mental health ward. She said they were trying to ‘influence’ her.
22. In its complaint response, the Trust explained that it discussed the case with the staff who were involved with Mr K. It said that the staff had apologised if Dr G was under the impression that they were trying to ‘influence’ her and that they felt they were being supportive to her.
23. We have considered the information provided by Dr G and the information provided by the Trust and feel that we would not be able to reconcile the differing accounts.
24. Although this does not mean that we do not believe Dr G’s account, we do not feel there is sufficient evidence to allow us to make a decision on the balance of probabilities if the staff were ‘brutal’ and treated her as if she was a child or tried to influence her.
25. As there are two conflicting accounts of what happened here, and there is no further evidence we can gather to help us reach a decision, we consider that we would not be able to reach a satisfactory conclusion so there would be no value in taking this forward for further investigation. Therefore, we will not be looking into this matter further.
26. We appreciate the distress that this caused to Dr G and we are sorry from any distress caused by the fact that we are unable to reach a decision on this aspect of her complaint.
Barts Health NHS Foundation Trust (Barts Health)
The decision to section Mr K
27. Dr G told us that she feels the decision to section Mr K was inappropriate. She explained that Barts Health did not respect her opinions and did not consider that Mr K had not slept for three days. She says that because of this Mr K’s medical records were incorrect, and that this led to him being unnecessarily sectioned.
28. We recognise that it will have been difficult for Dr G to see her son experiencing post ictal psychosis. We can understand why the process of him being sectioned will have caused her distress and frustration.
29. Dr G explained that she knew that Mr K’s psychosis was as a result of him not having slept for three days and if the hospital had considered this, there was no need for him to be sectioned, and he could have been discharged home to sleep.
30. Dr G told us that this should have been recorded on Mr K’s medical records, and that this being omitted, contributed to Mr K being unnecessarily sectioned.
31. In its complaint response Barts Health explained that it was known that Mr K was experiencing post ictal psychosis and his behaviour was not something that it felt it could manage in A&E. It said it was appropriate for Mr K to be placed under section.
32. The records show that Barts Health were aware that Mr K had experienced post ictal psychosis previously and understood that Mr K’s symptoms may improve if he was to sleep.
33. The records also say that Mr K was ‘agitated, disturbed, and threatening staff.’ It was also noted that Mr K had been brought to A&E by police after he smashed a window at Dr G’s home.
34. The Mental Health Act explains that two doctors make recommendations, and an approved mental health practitioner considers the circumstances, if possible, taking the views of the nearest relative into account.
35. Our adviser explained that the procedures in the Mental Health Act are required rather than being recommendations. Mr K’s medical records show, in line with the Act, two doctors and a mental health practitioner assessed him when the decision was made to section him.
36. The Mental Health Act says that ‘an application for admission for assessment may be made in respect of a patient on the grounds that – he is suffering from a mental disorder of a nature or degree which warrants the detention of the patient in a hospital for assessment… and he ought to be so detained in the interests of his own health and safety or with a view to the protection of other persons.’
37. Our adviser explained that if a psychiatric condition arises from underlying neurological conditions or another condition (as was the case for Mr K), the Mental Health Act still applies, and cases are assessed using the same procedure. Our adviser told us that Barts Health correctly followed the Mental Health Act in this case.
38. The records show that Barts Health were aware of Dr G’s views that Mr K needed to sleep to improve his symptoms. The record relating to Mr K’s section showed that Barts Health knew that Mr K’s psychosis was likely ‘post ictal’ and that it was important for him to sleep, however concluded that as he was prone to ‘wandering behaviour at night’ and his ‘lack of awareness of risk’ it was still appropriate that he be sectioned.
39. We understand that it will have been frustrating for Dr G to feel that her views were not considered. The records show that Barts Health were aware of the need for Mr K to sleep, however felt that he should still be sectioned regardless of this.
40. We consider that Barts Health appropriately took into account Mr K’s condition, Dr G’s views, his safety, and that of those around him when they accessed him for his section. We consider Barts Health followed the Mental Health Act when deciding to section Mr K and followed the correct process for this. As such, we have not seen any indications of failings, so we will not be considering this issue further.
The transport of Mr K to the mental health ward
41. Dr G explained that the patient transport staff were rude and abusive to both her and Mr K and treated Mr K as if he was an ‘inanimate object.’ She told us that this caused her distress at an already difficult time.
42. We were sorry to hear that Dr G felt distressed by the attitude and behaviour of the patient transport staff who attended to transport her son on 27 February 2025.
43. In its complaint response Barts Health said that its patient transport staff acted appropriately in their treatment of Mr K and Dr G. It said that its patient transport staff take their roles very seriously and they are sorry if this was not exhibited well on this occasion.
44. We have considered the information provided by Dr G and the information provided by Barts Health and feel that we would not be able to reconcile the differing accounts.
45. Although this does not mean that we do not believe Dr G’s account, we do not feel there is sufficient evidence to allow us to make a decision on the balance of probabilities if the patient transport staff were rude and disrespectful or not.
46. As there are two conflicting accounts of what happened here, and there is no further evidence we can gather to help us reach a decision, we consider that we would not be able to reach a satisfactory conclusion so there would be no value in taking this forward for further investigation. Therefore, we will not be looking into this matter further.
47. We understand that this was a distressing experience for Dr G and Mr K and appreciate that she feels that this may have contributed to her son’s death. We understand that it will be distressing for Dr G that we have been unable to reach a decision on this part of her complaint. We apologise for this.
48. We recognise that it will have also been difficult for Dr G to not be able to travel in the patient transport vehicle with Mr K to the hospital when he was sectioned. We acknowledge that this may also have been distressing for Mr K.
49. In Barts Health’s complaint response it explains that the patient transport staff carry out routine risk assessments to decide if it is appropriate for relatives to travel with family members who are under section.
50. It says that in this case it decided that due to the previous agitation between staff and Dr G on the ward there was a worry that this could escalate in the patient transport vehicle. The patient transport staff completed a risk assessment, and made the decision that Dr G should not travel with Mr K. It says that the staff acted appropriately in making this decision.
51. The Mental Health Act explains that ‘relatives may be allowed to travel with the patient, provided a risk assessment has determined it is safe and appropriate for all involved.’ It then continues that ‘this decision rests with the approved mental health practitioner or the person in charge of the transport (e.g paramedic or patient transport staff).’
52. The Act explains that the factors to be considered in a risk assessment include the patients current mental state, their potential for aggression and the safety of the patient, the transport staff, and the relative who is wanting to travel.
53. Our adviser explained that post ictal psychosis is unpredictable and can commonly result in a person becoming volatile. Mr K’s medical records and the information provided to us by Dr G show that Dr G did not believe that Mr K needed to be sectioned and was vocal that she opposed this decision at this time.
54. The records show that, in line with the Mental Health Act, the patient transport staff appropriately completed a risk assessment when it made the decision to not allow Dr G to travel with Mr K. Although the risk assessment does not detail how the decision was made, it shows that the conclusion was ultimately made that no relative would be allowed to travel with Mr K.
55. Our adviser told us that when completing the risk assessment, it was appropriate for the patient transport staff to have considered the previous agitation and that Dr G was actively opposing his section alongside Mr K’s mental state.
56. In line with the Mental Health Act, we have seen that the patient transport staff appropriately conducted a risk assessment and concluded that it was not safe for Dr G to travel with Mr K. We consider this decision was based on appropriate criteria such as Mr K’s mental state, the potential for aggression, and the safety of all involved, and therefore, in line with the Act, it did not allow Dr G to travel with Mr K.
57. We recognise that it will have been distressing for Dr G to not be able to accompany her son to his section. We consider that Barts Health made the correct decision in not allowing Dr G to travel with Mr K.
Treatment on the mental health ward
58. Dr G told us that due to the time that Mr K arrived on the ward, he did not receive his prescribed medication and was not given the opportunity to eat. Dr G explained that this was distressing for both her and Mr K, as being without his medication or food can cause Mr K to experience an increase in regularity of his seizures.
59. In her complaint to Barts Health Dr G complained that Mr K was left isolated in his room and deprived of care the entire time he was there.
60. In its response Barts Health explained that Mr K did receive his medication and ate when he arrived on the ward. It explained that throughout his stay he was observed by staff every 15 minutes and he was reviewed and given his required medication on the evening when he arrived.
61. The NMC Code says to ‘make sure that any treatment, assistance or care for which you are responsible is delivered without undue delay’. It also says to ‘accurately identify, observe and assess signs of normal or worsening physical and mental health in the person receiving care’.
62. The records show that Mr K arrived at the mental health ward late on the evening of 27 February 2023. Shortly after his arrival the staff assessed Mr K’s needs and decided that he would be placed on a ’15-minute observation’, where staff would come every 15 minutes to access his needs.
63. The records also show that Mr K’s required medications were clearly written within his initial treatment plan. The notes show that Mr K had his dose of epilim chrono, a medication used to treat his epilepsy, on the evening after he arrived and his anticonvulsant medication, valproate, the morning after he arrived on the ward.
64. Mr K was on the ward from late evening on 27 February 2023 until 28 February 2023, when he was discharged back to the care of Dr G. The records show that throughout this stay Mr K was monitored every 15 minutes by staff, and received his medication as required.
65. We asked our adviser if there is any evidence to suggest that Mr K was not monitored on the ward and did not receive his prescribed medication. They explained that Mr K’s medication and needs were clearly recorded in his notes. It is recorded throughout that he received his medication and that he took it independently.
66. We recognise that Dr G feels that Mr K was left isolated and deprived of his medication during his stay. The records show that, in line with the NMC Code, Mr K received his medication as was required and was monitored every 15 minutes throughout his stay by staff on the ward.
67. The records also show that Mr K had multiple conversations with staff about his care, and confirmed with them that he was comfortable, and wanted to be left to sleep. The staff did so as per his wishes at the time.
68. We consider Barts Health acted in line with the NMC Code and provided Mr K with his medication when required and observed Mr K regularly for any signs of worsening mental health. As such, we have not seen any indications of failings here.
69. Dr G told us that Mr K was not given food during his stay on the ward, and that this is particularly important for Mr K, as changes in his blood sugar levels can cause an increase in his seizures.
70. In Mr K’s medical records, we can see that Dr G was reassured on multiple occasions that Mr K would be given food whilst on the ward. In its complaint response, Barts Health explained that patients are routinely offered food and water and support with their personal care needs when they are reviewed while on the ward.
71. The NICE nutrition guidance explains that healthcare professionals should ensure that it provides ‘food and fluid of adequate quantity and quality in an environment conducive to eating.’
72. Mr K’s records explain that he was ‘young, fit and well’. It was not identified that he was at risk of malnutrition at any stage throughout his stay on the ward.
73. The Regulations state that where a person is assessed as at risk of malnutrition or needing a specific diet, nutritional and hydration intake should be monitored and recorded to prevent unnecessary dehydration, weight loss or weight gain.
74. Mr K’s medical records do not record the exact food and fluid that he received during his stay and when. In line with the Regulations, as Mr K was not assessed to be at risk of malnutrition, it would not be expected for staff to keep a detailed account of every occasion that he was given food or fluid and how much he consumed.
75. Dr G believes that Mr K was not given food while he was staying on the ward. In its response Barts Health explain that he was well cared for throughout his stay and this included providing him with food.
76. We have considered the information provided by Dr G and the information provided by Barts Health and feel that given the lack of records relating to his nutritional intake, we are unable to make a conclusion on this matter.
77. Although this does not mean that we do not believe Dr G’s account, we do not feel there is sufficient evidence to allow us to make a decision on the balance of probabilities if Mr K had food when he arrived on the ward or not.
78. As there are two conflicting accounts of what happened here, and there is no further evidence we can gather to help us reach a decision, we consider that we would not be able to reach a satisfactory conclusion so there would be no value in taking this forward for further investigation. Therefore, we will not be looking into this matter further.
79. After consideration, we have not seen any indications of failings in the care provided to Mr K. We recognise that it will have been difficult for her to witness Mr K being sectioned and we would like to thank Dr G for taking the time to bring her complaint to us.