University Hospitals Birmingham NHS Foundation Trust

3. Mr A complains about aspects of care provided to his father, Mr S, by the Trust. Specifically, he complains:

• While Mr S was on a ward, he was sexually assaulted by another patient. He says the Trust knew this patient posed a risk to other patients and Mr S, but did nothing to safeguard them • The Trust supplied false and misleading information in its response by saying Mr S made up the allegation and wrongfully said the police stopped investigating due to lack of evidence.

4. As a result of this, Mr A says his father was sexually assaulted leaving him and his family feeling humiliated and angry. Mr A says a hospital should be a place of safety, and the incident left Mr S and his family also feeling stressed, anxious and upset. Mr A says for Mr S to be feeling these emotions in the last months of his life was unforgivable and could have been avoided. Mr A says the Trust blaming Mr S in its response has left him feeling angry and sick.

5. As an outcome to his complaint, Mr A would like and apology, service changes and a financial remedy at a minimum of £1,250.

6. In early December 2024, Mr S had a fall at home. He was taken to the Trust’s Emergency Department via ambulance.

7. The next day, the Trust took a Methicillin-resistant Staphylococcus aureus (MRSA) swab. MRSA is a type of bacteria that is resistant to many antibiotics causing skin infections. If left untreated, it can lead to sepsis and death.

8. On the same day, the Trust transferred Mr S from the Emergency Department to the Acute Medical Unit (AMU). The Trust performed a CT scan which identified a large mass in Mr S’s head.

9. A few days later, Mr S was transferred from the AMU to a ward. Later the same day, Mr S told the Trust after his MRSA swab was taken from his groin, another patient sexually assaulted him. This incident was reported to the police by the Trust.

10. Towards the end of December, two police officers attended the ward after Mr S called them saying he was sexually assaulted while on the AMU. The police discussed the issue with Mr S, Trust staff and Mr S’s present family members. The police concluded they could not continue with the investigation due to a lack of evidence.

11. Two days later, the Trust discharged Mr S.

14. Our Service Model Guidance says there may be occasions when we decide there are other reasons why we should not investigate a complaint made to us. This includes where an investigation would not be practical, or would not reach a satisfactory conclusion, and there would be no value in providing a response through an investigation.

15. We have looked at whether an investigation would be practical. We have done this and consider it is unlikely we could make a robust decision about what is more likely to have happened. This is because what Mr A and the Trust have told us is contradictory, and we think we would be unable to give more weight to either side of the evidence. We have explained why below.

16. Mr A complains while Mr S was on a ward, he was sexually assaulted by another patient. He says the Trust knew this patient posed a risk to other patients and Mr S, but did nothing to safeguard them. We recognise how disturbing and distressing this situation was for Mr S and his family.

17. Mr A also complains the Trust supplied false and misleading information in its response. He says the Trust suggested Mr S made up the allegation and wrongfully said the police stopped investigating due to lack of evidence.

18. The Trust said Mr S had fluctuating capacity. It noted Mr S had told staff that he had been ‘sexually abused by either a patient or a member of staff’. It also noted that when police attended, Mr S told them he had been ‘inappropriately touched by member of staff on AMU… after staff finished doing MRSA swab’. It noted he also told police that he was ‘touched round his groin area… by a patient.’.

19. From Mr S’s account that was documented by the Trust at the time, we can see that it was not clear at the time who Mr S thought had assaulted him. He reported at different times that either a patient or staff member was responsible. Mr A has told us he has a photograph of the patient his father said was responsible.

20. We are sorry to hear of the distress Mr A has experienced. We recognise this would have been distressing for Mr S at an already difficult time. We consider it is unlikely we could make a robust decision about what is more likely to have happened. This is because we have limited evidence, and it is contradictory.

21. From the records taken at the time, we can see two police officers attended the ward. The Trust stated in its response that the police investigated Mr S’s allegations by examining documentation, discussing the issue with nursing staff, Mr S and his family members.

22. From the records taken at the time, the Trust noted Mr S had told the police it was another patient. It seems from the records the police asked the Trust when the MRSA swab had been done, and whether the patient had capacity. The Trust stated in its response, it was probable that, due to Mr S’ confusion, he may have misinterpreted the nursing team performing an MRSA swab in the groin area as someone else assaulting him.

23. We note the Trust has documented at the time of the police visit that the police had decided they could not investigate what is a criminal matter, due to the lack of evidence. The Trust’s response reflects this. We recognise Mr A disagrees with this, and says Mr S asked the police to stop their investigation.

24. We recognise there is a disparity between the Trust’s response and what it noted had happened, with Mr S’s account and Mr A’s view on what happened. We also recognise Mr A is frustrated by the Trust’s views on the assault.

25. We cannot now say that either recollection of why the police decided not to act further was wrong. It is important to emphasise we do not doubt what Mr A has told us, but we have no practical way to investigate what was said, and equally as importantly, what was understood. Given sexual assault is a criminal matter, the police would be best placed to consider this further.

26. As an independent organisation we need to consider Mr A’s and the Trust’s recollections. We think based on the conflicting evidence now available to us, we would be unlikely to be able to reach a robust decision. Therefore, we will not consider this complaint further. We acknowledge our decision may be disappointing for Mr A.

1. We have carefully considered Mr A’s complaint about University Hospitals Birmingham NHS Foundation Trust (the Trust). We acknowledge this period of time would have been extremely distressing for everyone involved.

2. We have considered there is not enough objective evidence for us to come to a robust decision about the issues complained about. We understand our decision may be disappointing.