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Essex Partnership University NHS Foundation Trust

P-004741 · Statement · Decision date: 30 January 2026 · View Essex Partnership University NHS Foundation Trust scorecard
Treatment Confidentiality, privacy and safeguarding Complaint handling
Complaint (AI summary)
Miss R complained about a flawed and delayed safeguarding investigation, failed care plan by a CPN, incorrect medication, failure to instigate a CHC assessment, and slow, insufficient complaint handling.
Outcome (AI summary)
The ombudsman decided not to investigate further as the clinical issues were previously considered. The complaint handling was not deemed proportionate for further investigation under their injustice scale. Complaint closed.

Full decision details

The Complaint

5. Miss R complains about the care and treatment her father, Mr O, received from the Trust. She says:

• the Trust’s safeguarding investigation was flawed, took 22 months to conclude and the Trust failed to communicate the outcome to her • the Trust’s Community Psychiatric Nurse (CPN) failed to implement a care plan for Mr O upon his admission to a care home in March 2022, failed to monitor his needs and failed to communicate his needs to staff • the Trust gave Mr Crowder Zoplicone, a sedative, and failed to perform a medication review in late 2021 • between September and December 2021, the CPN failed to instigate a CHC assessment when Mr O suffered multiple falls in the care home • the complaints process was slow and did not provide sufficient answers to her concerns.

6. Miss R said failings by the CPN meant the nursing home could not provide Mr O with the care he needed which was heartbreaking for her. Miss R said the Trust’s management of the safeguarding investigation left her feeling ignored and caused her stress at an already difficult time. Miss R said the Trust not reviewing the medication it had prescribed caused her father to suffer multiple falls which was distressing for her. Miss R said the trust’s complaint handling did not provide her with answers and has enhanced her grief.

7. By bringing this complaint to us Miss R would like the Trust to improve its service to prevent others suffering as she and Mr O did. Miss R would also like the Trust to acknowledge the failings and the impact these had.

Findings

Clinical Issues

10. Before we decide if we should investigate a complaint, we look at whether there is an organisation that is better placed to deal with the concerns. Some complaints can be looked at by us and by other organisations. We would usually consider that only one investigation should take place.

11. In April 2025 we were contacted by the Joint Working Team which is a team that looks at both health, and local government and social care complaints. It covers the remit of both PHSO and the LGSCO. The Joint Working Team advised it was considering Miss R’s complaint regarding the Trust.

12. We can see the Joint Working Team provided its decision to Miss R in August 2025 (reference number 24 022 531/25 009 073). It determined it had not received Miss R’s complaint within the 12-month time limit, and it had seen no good reason to put the time limit to the side.

13. We have reviewed the decision by Joint Working to determine whether the issues raised to us by Miss R have already been considered. We can see Joint Working considered the safeguarding report and the clinical issues that were raised between the time period from 2021 to 2022, as detailed in paragraph five.

14. We have decided not to investigate the matters Miss R has brought to us because the issues complained about have already been considered. For this reason, we are declining to investigate Miss R’s complaint as it has already been considered, and a decision has been provided. We recognise this decision will be disappointing for Miss R.

15. Miss R has told us of the difficulties she has had with the Trust regarding the care her father received. We would like to take this opportunity to thank Miss R for bringing her complaint to us and hope we have explained the consideration we have given to our decision and clearly outlined the reasons for it.

Complaint Handling

16. As the Ombudsman is a limited resource, we cannot investigate every complaint we receive. We need to use our resources to investigate the most serious cases, alongside cases that will have the biggest impact on improving public services for everyone.

17. Miss R said the Trust’s complaint handling was too slow and the responses did not provide sufficient answers to her concerns. She told us this caused her stress at an already difficult time and enhanced her grief. We acknowledge the time taken by the Trust to respond caused Miss R to feel stress and impacted her ability to grieve.

18. We have considered the emotional impact claimed by Miss R in line with our severity of injustice scale. Levels 1 and 2 deal with distress, worry, frustration and similar emotional impacts. We understand Miss R’s concerns and the distress this caused to her.

19. Level 2 on our scale says it is for instances of poor complaint handling with delays of up to one year or longer. It says we would expect the person to recover once the poor service has ceased. It says we would also reasonably expect any impact to diminish completely in the fullness of time. We do not think we could link the emotional impact on Miss R to a period longer than six months once the Trust had completed local resolution. This complaint would therefore fall on the lower levels of our scale.

20. We have decided to focus on the more serious complaints that people bring to us, where they may have faced a big impact. For example, these cases may be about a potentially avoidable death or where a person has suffered prolonged pain. These types of complaints are where we can often make the biggest difference. This will allow us to provide the right level of service to those people as quickly as possible.

21. We acknowledge how distressing these events were and that this is not the decision Miss R was hoping for. In line with our service model guidance, we do not think it would be proportionate to consider this part of the complaint further. We will therefore not take any further action on this point.

Our Decision

1. We have carefully considered Miss R’s complaint about Essex Partnership University NHS Foundation Trust (the Trust). We were sorry to hear about Miss R’s experience with the Trust, and we recognise Miss R has been through a difficult and distressing time.

2. We have carefully considered Miss R’s complaint about the Trust and have decided not to investigate it further. This is because the clinical issues of Miss R’s complaint have already been considered by our Joint Working Team. As a decision has already been made on these issues, we cannot look at this part of the complaint again.

3. We have also considered the Trust’s complaint handling and the impact Miss R has claimed. Based on our current approach, we do not think it would be proportionate for us to consider her complaint further. We do not consider the impact of the complaint reaches the higher levels of our scale of injustice.

4. In making our decision we do not want to diminish the seriousness of the issues involved and we thank Miss R for bringing her concerns to our attention.

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