13. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone wrong.
14. Mr R told us the Trust unnecessarily instructed the Police to force entry into his property in March 2025. Mr R said the Trust did not make enough attempts to contact him by telephone to check his welfare, before it contacted the Police.
15. Mr R said there was no cause for concern with his welfare in March. He said when the Trust entered his home he was not fully dressed. He said that he has autism and having people in his home made him feel scared and vulnerable. Mr R said he now feels people will enter his home without him knowing in future, and this has caused him significant anxiety.
16. Mr R also told us he wears hearing aids and could not hear the Trust at the door. He further said he had previously told the Trust that his neighbour has a keycode for his door and it should have attempted to obtain this, to avoid calling the Police.
17. Mr R further added that he had to pay £675 for a replacement door. We have received confirmation from a charity organisation that Mr R received a grant for this amount. However, he wishes to pay this money back to the organisation.
18. The Trust said it made multiple attempts to contact Mr R by telephone on the evening before it attended his property. It said it also made several attempts to contact him by telephone during the welfare visit in March.
19. Mr R’s medical records show he attended the Trust’s crisis unit in early March at 3pm. He presented with low mood and suicidal ideation. Mr R had said he was planning on ending his life by taking prescription medication or driving his car into something. Mr R’s medical records note the Trust doctor said he should not drive his car while in crisis. His medical records show the Trust noted Mr R was less willing to engage with the team, after the Trust made this comment.
20. Mr R’s medical records show his treatment plan included daily contact with the crisis team, after his discharge from hospital. The Trust arranged the first call for 6pm on the same date of discharge in March.
21. Mr R’s medical records show the Trust attempted to contact Mr R by telephone several times on that date at 6.08pm, 7.14pm, 7.53pm and 10.25 pm. The Trust also left a voicemail on Mr R’s telephone at 6.08pm. It also sent a text message asking him to call the team back.
22. Mr R’s medical records also show the Trust then attempted to telephone to him at 10am the following day in March, whilst Trust staff were outside his property. His medical records also show Mr R’s neighbour also tried to contact him by telephone, at the same time.
23. The Trust reports that Mr R had switched his telephone off. We have seen evidence in his medical records to show the Trust staff knocked on his front door, knocked on his back door and on his windows. His medical records also note Trust staff spoke through the letterbox in attempt to reach Mr R.
24. Due to Mr R’s presentation in early March and given the Trust could not reach Mr R by telephone or at his property the following day, concern about his health was raised. The Trust said its shift lead agreed to raise welfare concerns with local authorities.
25. The Trust has noted on Mr R’s medical records that on entering his home, he did not wish to receive help or support from the team after it recommended he stop driving, the previous day.
26. In its response, the Trust acknowledged the distress this incident caused Mr R and apologised for this.
27. We have considered the Trust’s Protocol for Assertive Follow Up of Patients Who DNA (Do Not Attend) Planned HBT (Home Based Treatment) Appointments July/Oct 2020. It says patients should receive three call attempts over 24 hours and a text message, if possible, before reviewing individual risk. We can see the Trust attempted to call Mr R four times over two separate days. It also sent a text message, spoke with his neighbour and attended his property. These contact attempts were over a 16-hour timeframe.
28. While the Trust did attempt to contact Mr R within a 24-hour period, it involved the Police after only 16 hours. We understand Mr R did not wish to engage with the Trust after his appointment. We believe it would have been unlikely that he would have answered any contact from the Trust over the remaining eight hours. We consider the Trust made suitable attempts to contact within a 24-hour period, in line with its welfare policy.
29. We understand the stress Mr R has suffered by the forced entry into his property and do not underestimate the anxiety this has caused. We consider in this extremely difficult situation, the Trust took the correct action in confirming Mr R’s welfare.
30. In the NHS Complaint Standards ‘Gives fair and accountable responses’ it says the NHS should ‘fairly reflect the experiences of everyone involved’. We are pleased the Trust has acknowledged Mr R’s distress and apologised for this.
31. We would like to thank Mr R for taking the time to highlight these concerns and hope our review has provided him with reassurance.