26. 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 we have not found any indications that something has gone wrong.
Inappropriate supervision leading to falls and absconding
27. Mr D complains Mr E was not supervised properly while on the medical admission ward, leading to four falls and Mr E absconding. He says Mr E suffered bruising as a result of the four falls.
28. The Trust responded to these concerns in February and May 2025. It says there was no record of Mr E having any falls during his admission and no records of Mr E being bruised. The Trust also explained its policy for recording any patient falls and incidents.
29. The Trust explained the records were not clear as to whether Mr E successfully absconded from the ward, though it is recorded he made attempts on 3 and 4 April 2024. It therefore explored this further with staff on the ward and established Mr E threatened to leave the ward on these occasions but did not leave.
30. Mr D says Mr E did leave and he found him in the hospital entrance, alone, on 2 April 2024. Mr D says he returned Mr E to the ward and staff were grateful to him.
31. Overall, we have two conflicting accounts of Mr E’s care. We have carefully considered these to see if we can reach a view on what likely happened and understand if there was opportunity for Mr E to have absconded without the staff being aware.
32. The Nursing and Midwifery Council (NMC) guidance says to preserve safety, and to ‘accurately identify, observe and assess signs of normal or worsening physical and mental health in the person receiving care’.
33. We can see Mr E was initially risk assessed by the emergency department at the Trust as needing intermittent supervision. The records show Mr E was reassessed when he was moved to the ward and he then received one to one supervision from a HCA. We consider this was in line with the NMC guidance.
34. Our adviser also explains the Trust’s records also show Mr E had a falls management plan in place. This plan detailed actions to minimise the identified risks, including being nursed in an ultra-low bed, being supervised when moving around, using the toilet or repositioning himself.
35. The NICE guidance on falls refers to patients over 50 years old with an underlying condition and says to risk assess them appropriately and intervene on any identified risks.
36. While the NICE guidance is intended for those older than Mr E was at the time of admission, this has still been adhered to when it was identified on admission he was at risk of falling.
37. We therefore consider the Trust acted appropriately to mitigate Mr E’s risk of falling.
38. Overall, on the balance of probabilities, we consider it is unlikely that Mr E had four falls on the ward without this being noted or reported. This is because Mr E was closely monitored and there were regular checks recorded which do not suggest he sustained any injury.
39. We also see evidence to suggest Mr E wished to abscond, but that staff managed this. In the absence of further independent third-party evidence, we consider it is unlikely Mr E absconded without this being noted, as he had one to one supervision from a HCA.
40. We therefore do not see indications of failings in relation to this concern.
Appropriate treatment for Alzheimer's disease
41. Mr D complains the Trust did not appropriately consider Mr E’s Alzheimer’s disease diagnosis while caring for him on the ward. He says this meant the Trust did not ensure his brother received the appropriate care, and he feels this worsened his condition.
42. The NICE guidance on dementia patients says to ‘carry out an assessment that balances their current medical needs with the additional harms they may face in hospital’ and to take into account disorientation and delirium.
43. The NICE guidance on delirium in patients says to facilitate regular visits from family and friends.
44. The Trust’s records show Mr E was admitted to hospital due to his confusion and concerns for his safety. His records show he was admitted with advanced Alzheimer’s disease and that he lacked capacity (capacity is the ability to use and understand information to make a decision).
45. The Trust records show they considered Mr E’s presentation and regularly assessed the level of supervision he needed in line with his disorientation, as explored in our statement above. This was in line with NMC guidance to reassess risk as well as the NICE guidance on patients with dementia to balance medical needs with additional harms faced in hospital.
46. We can see the Trust considered Mr E’s safety through risk assessments and it also took action when he raised concerns about someone using his bank card. The Trust acted on these with referrals to appropriate specialties including the social work team, the elderly psychiatric team and the safeguarding team. This is in line with the NICE guidance on patients with dementia, to take into account medical needs balanced with any additional harms they may face.
47. The Trust records show Mr E’s family and friends had their visiting facilitated by longer visiting hours and letting them carry out some of Mr E’s daily routine, such as bringing his meal deals and scratch cards. This was appropriate in line with the NICE guidance on delirium. Family visits were allowed by the Trust until safeguarding concerns meant intervention was needed by staff to keep Mr E safe and family visiting was limited.
48. We consider the Trust acted appropriately to consider Mr E’s Alzheimer’s diagnosis in multiple ways, in line with standards and guidance. We therefore do not indications of failings in this part of the complaint.
Inappropriate restraint by security
49. Mr D complains security guards from the Trust restrained Mr E while he was on the medical admissions ward, causing him marks and bruising. He feels this caused his brother’s Alzheimer’s disease to progress, as he had his liberty deprived and lacked stimulation.
50. The Trust’s complaint response in May 2025 acknowledges the security guards did engage with both Mr E and Mr D on 5 April 2024. It said the security guards engaged with Mr E due to him setting the fire alarms off to get the ward doors to open so he could leave.
51. The NICE guidelines for patients with dementia say when a patient with dementia is agitated, aggressive, distressed or in psychosis, to ‘explore possible reasons for their distress’ and to ‘check for and address clinical or environmental causes’.
52. The Trust’s records show Mr E was often agitated and trying to leave the ward and was fixated on getting scratch cards. The records also show staff tried to keep Mr E on the ward throughout his stay there without using security guards, using techniques like one to one health care assistant supervision and family visiting while this was still considered an option.
53. These actions are in line with the NICE guidance on dementia, as they show ward staff tried to manage Mr E’s behaviour in a variety of ways before relying on security.
54. We next consider the use of security in the occasion complained about.
55. When considering this aspect of complaint, we also considered Mr E’s mental capacity and vulnerabilities. Mr E has advanced Alzheimer's disease, as detailed in the Trust’s medical records, was described as being confused, and was deemed not to have capacity.
56. The Mental Capacity Act (MCA) says restrictions and restraint are allowed in some cases to be used in a person’s support, but only if they lack capacity and are in that person’s best interests.
57. On the occasion described, Mr E was breaking fire alarms and trying to leave the ward in an agitated state. We consider it was appropriate in this instance for the Trust to use the security guards to keep Mr E on the ward and safe, in line with the MCA.
58. Our adviser explains that due to Mr E’s confused presentation and his admission due to concerns for his safety, it was appropriate to safeguard Mr E with restraint in line with NICE guidance on patients with dementia and the MCA
59. We therefore do not find indications of failings with this part of the complaint. We appreciate Mr D will have found this very distressing to see and recognise Mr E will likely have been distressed and not understood why this was happening to him at the time. We understand how difficult this situation will have been for all involved.
Mr D’s aspects of complaint
60. We have considered some aspects of Mr D’s complaint and have found there is not enough evidence to draw a conclusion on these parts of complaint.
Inappropriate restraint and inaccurate information from the Trust
61. Mr D complains security from the Trust restrained him without reason on 5 April 2024. He also complains the Trust have recorded inaccurate information about him giving Mr E drugs and alcohol while he was on the medical admissions ward, and about him taking Mr E out of the hospital for extended periods of time while he was on the ward.
62. Mr D says this has caused the Trust, the local council and the care home where Mr E was discharged to, to restrict Mr D’s access to Mr E, his finances and his information. Mr D says this in turn has caused him to drink more alcohol to cope.
63. The Trust’s records say security restrained Mr D when he was found giving Mr E drugs and alcohol on the ward and was asked to leave. This was at the same time the records describe security engaging with Mr E who was trying to abscond from the ward on 5 April 2024, as described earlier in this statement.
64. The Trust’s records also say Mr D took Mr E off the medical admissions ward on 5 April 2024 for four hours, ‘depriving Mr E of medical attention’ during this time.
65. We therefore have conflicting accounts of what happened during this period of time. There is not further evidence to support either account.
66. We have carefully considered both accounts to see if we can reach a view on what likely happened on these occasions. Sadly, in the absence of any further third-party evidence, we are unlikely to be able to say which account is accurate.
67. We are therefore unlikely to be able to find failings on the part of the Trust that then supports the impact Mr D has told us about, and the outcome he is seeking.
68. This is not to detract from the clear distress Mr D feels around these events and any personal impact he feels around these events.
Updating family when Mr E moved ward
69. Mr D complains he was not notified of Mr E’s move to a different ward on the evening of 5 April 2024. Mr D explains the lack of notification caused him distress and concern.
70. The Trust addressed this concern in its complaint response dated February 2025, acknowledging there is a failing in this area, and it should have contacted Mr D.
71. Our ‘Complaints standards’ say organisations should acknowledge any failings and impact, then provide an appropriate remedy to these and take on board any learning.
72. The Trust’s response apologises for the lack of communication and acknowledges the distress this will have caused Mr D.
73. The response also outlines what should have happened and acknowledges the Trust fell short of expected standards of communication. It then goes on to explain staff have been reminded of the importance of notifying patients next of kin immediately when patients are transferred to other wards.
74. We consider the Trust’s actions are in line with our ‘Complaints standards’, as it offered remedy in the form of apology, explanation and improvements. We consider this appropriately addresses the impact of upset described by Mr D and we do not consider it needs to take any further action on this part of the complaint.
Conclusion
75. We thank Mr D for bringing his complaint to us. While this may not be the outcome he was hoping for, we hope it is clear how we have balanced our decision impartially and in line with standards and guidance.