Events in early November 2024
14. Mr Z complains the Trust refused to dialyse him in early November 2024. He says that whilst he had a dialysis line in his neck, four security guards removed him from his chair and told him he had been discharged.
15. Within its February 2025 complaint response, the Trust explained that the curtains or screens are usually kept open during dialysis sessions for safety reasons. It says this is in line with its standard practice.
16. Furthermore, the Trust states that on the day in question, it was reported that Mr Z threw a tray containing some dialysis implements onto the floor. It says he acted in a manner that staff and other patients nearby felt to be threatening. The Trust explained it has a zero-tolerance policy regarding violent, aggressive and abusive behaviour towards its staff and so security were requested to attend.
17. The Trust said the nurse in charge explained the situation to the security team leader when they arrived in the dialysis unit. It said the nurse in charge informed security that a decision to discharge Mr Z without receiving his dialysis treatment had been made. The Trust said that based on the information provided by the nurse in charge, security had the authority to remove Mr Z from its premises in line with the Criminal Justice and Immigration Act 2008 (the Act).
18. The Trust explained the security team is specifically trained on how to restrain people within the NHS environment. It says the fact that Mr Z had a dialysis line in place would not stop or prevent security from carrying out their responsibilities. The Trust said that its security team asked Mr Z to leave of his own accord on several occasions, but he refused to do so.
19. It said security then made the decision to physically remove Mr Z from the premises, which required him to be restrained. The Trust also said the restraint was carried our using the minimal required reasonable, justifiable, proportionate and necessary force for the minimum time required.
20. We can see from Mr Z’s initial complaint letter that he stated he pulled the screen around him in bay 9 upon arrival to the dialysis unit in early November 2024. He said a nurse informed him that he would not be dialysed if the screen was drawn. Mr Z said the tray with the dialysis implements on fell to the floor. He confirmed he got frustrated and slammed his hand on the table in front of him but states this was enough for the nurse to call for security.
21. The Trust’s incident report confirmed Mr Z drew the curtain around bay 9 and closed this area. It also said a nurse approached him and informed him that it is a risk to have the curtains around whilst on dialysis. It said Mr Z demanded to be put in a side room for privacy if he could not have the curtain drawn but he was informed side rooms are for clinically indicated patients. The report also said Mr Z was asked to agree to this before being connected, as previous sessions had been very challenging for other staff and patients.
22. The report continues that a health care assistant made the nurse aware that Mr Z had thrown the tray on the floor and was banging his hand on the table whilst shouting in an aggressive manner. It stated the nurse became scared of his behaviour and observed that other patients were also scared. It said the nurse attempted to reassure Mr Z, but he continued banging his hand on the table and shouting aggressively and so security were requested. Furthermore, the report documented that security tried escorting Mr Z out, but he said he was going to call the police. It confirmed security then managed to removed Mr Z from the dialysis unit.
23. UKKA Guidance uses the acronym STOP, which stands for the principles to enable patients and healthcare professional to maintain safety and reduce the risk of needle or catheter dislodgment. The S in STOP stands for safety and the O stands for observation.
24. Under the safety element of UKKA Guidance, it lists several factors that can increase the risk of venous needle dislodgement. One such factor is poor or reduced visibility of the access. Under the observation section is states that needle sites should always be visible so early recognition and prompt action are taken should there be a needle dislodgment.
25. Whilst we understand Mr Z’s request for privacy during his dialysis sessions, we consider the Trust has acted in line with UKKA Guidance when it refused to provide dialysis to Mr Z. This is because keeping the curtains drawn during a dialysis session presents the Trust with a potentially unsafe situation as the needle site would not be visible. It was therefore required to act to try and prevent any incidents from occurring.
26. Regarding the matter of security being called to the dialysis ward on the day in question, we have two conflicting accounts of what happened. We have Mr Z’s recollection of the events, and the Trust’s version of events as explained in its complaint response and the incident report form.
27. Without any further independent evidence to support either account, we do not think we can say, even on the balance of probabilities, what happened. As a result, we do not think an investigation would be practical and would not reach a satisfactory conclusion on this part of Mr Z’s complaint.
28. This is not to say we do not believe Mr Z’s account of events. However, we cannot give more weight to one account over the other when the evidence for both accounts is balanced. We will take no further action here.
29. We acknowledge the events of early November 2024 caused Mr Z stress and trauma. Our decision regarding this element of his complaint is in no way meant to diminish this for him.
Lost bodycam footage
30. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the event complained about had a negative effect which the organisation has not put right. Having done so we have found the Trust has already done enough to put right the impact of these events.
31. Mr Z complains the Trust lost the security bodycam footage from the events in early November 2024.
32. Within its complaint response, the Trust explained that due to a technical fault, the security team no longer have any bodycam footage of the events in early November 2024. It said this technical fault occurred whilst the security team were uploading the footage to a secure online vault, which is part of the security team’s process. It explained by the time the footage was uploaded, the retention period of 30 days had passed and so the footage was automatically deleted.
33. The Trust explained the technical fault has since been fixed and so will not reoccur. Furthermore, it stated it has changed its retention process and so all footage is now retained for 60 days.
34. At the time of the events, the Trust’s security policy stipulated the retention period for all CCTV footage was 30 days. It detailed that after this time; the recording would be overwritten unless any footage was specially required for an investigation.
35. The section of the security policy regarding body worn cameras (BWCs) stated that data should be held directly on the device. Furthermore, it stated that any incidents should be deleted from the device at the end of a shift, unless the footage is required as part of an investigation. If it was required, the footage should be downloaded from the device onto a PC held in the security department with appropriate software installed.
36. The evidence shows a complaints officer contacted the contract security manager to request any CCTV and security footage from the early November 2024 events be saved for consideration upon receipt of Mr Z’s complaint.
37. We can see the contract security manager responded in mid-January 2025 explaining the situation regarding the loss of the BWC footage due to a technical fault.
38. We are satisfied that the Trust was following its security policy correctly as it was attempting to save the bodycam footage. However, due to an issue outside of its control, it was unable to save the footage within the 30-day timescale, which resulted in it being deleted.
39. Our Principles for Remedy state that good practice regarding remedies includes seeking continuous improvements. This means organisations should use the lessons learned from complaints to ensure that maladministration or poor service is not repeated. As set out in paragraph 33, we think the Trust has done this.
40. We note that Mr Z is seeking a financial remedy. We have considered this alongside out Guidance on Financial Remedy. This says a case will be at level one on our severity of injustice scale where the annoyance or inconvenience typically arises from a one-off incidence of service failure. The effect on the person will be of short duration and there are no other adverse effects from the failing. We usually consider an apology, and no financial remedy is an appropriate remedy in these cases.
41. We do not consider that in this instance, a financial remedy is required. This is because we think the frustration Mr Z has experienced has occurred as a result of a one-off incident. We think the impact of this has been of a short duration, which we would expect someone to deal with without the need for external support. We have seen no indication this has affected Mr Z’s day to day functioning, or his ability to live a normal life. As such, we think the injustice Mr Z has experienced falls into level one on our scale, and a financial remedy is not appropriate.
42. It is our view that the Trust has taken appropriate and reasonable steps to rectify this matter. It has confirmed that it has had the technical fault fixed and has amended its retention policy to try and prevent this situation from occurring again in future.
43. With all the above in mind, we have decided not to take this element of Mr Z’s complaint further. We acknowledge that Mr Z is disappointed with the Trust’s response and has lost faith in it. It is not our intention to dimmish this for him with our decision.
Refused to respond further
44. 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 seen any indications that something has gone wrong.
45. Mr Z complains the Trust has refused to respond to his further complaint letter.
46. The Trust’s February 2025 complaint response details that it had finished investigating Mr Z’s complaint and that if he remained unhappy, he could contact our service.
47. The Trust’s complaint policy states that if a person remains unhappy after it has investigated and responded to their complaint, they may suggest the person meet the appropriate staff in person to discuss the complaint. It also states it may make further enquiries and write to the person again.
48. Furthermore, the Trust’s complaint policy details that if it can still not settle the complaint, the person can refer it to our service.
49. We can see that Mr Z complained to the Trust through an advocacy service in midNovember 2024.
50. As detailed above, the Trust responded to Mr Z’s complaint in February 2025. We can see the Trust responded to each of the points Mr Z raised within his complaint. Furthermore, we can see the Trust stated it had finished its investigation and advised Mr Z that if he remains unhappy, he can refer his complaint to us.
51. Mr Z then sent a further letter of complaint to the Trust via the advocacy service in early March 2025. In this letter he raised further questions regarding the events of early November 2024 and raised concerns regarding the chair he received his dialysis in being broken.
52. We recognise that it can be frustrating for people to not get all the answers they are seeking.
53. We feel it important to explain that when an organisation feels it can do no more to resolve a complaint or has nothing further to add, it should make the person complaining aware of their right to escalate their complaint to us. This is part of the NHS Complaint Standards.
54. With the above being said, we are satisfied the Trust has followed its own complaints policy and the NHS Complaint Standards. It has provided a final response to the complaint and then directed Mr Z to our service as the next step for escalation.
55. As we have been unable to identify any potential failings in the way the Trust has handled Mr Z’s complaint, we have decided not to take this element of his complaint any further.
Chair issues
56. Mr Z complains the Trust has failed to move him from bay 9 or replace the broken dialysis chair in the bay, although it advised him it would.
57. Within its complaint response, the Trust said it has accommodated several location changes for Mr Z within the dialysis unit. It said Mr Z requested to be moved from a bed to a chair and requested he be given an end of row bay, which resulted him being placed in bay 9.
58. We contacted the Trust on 22 December 2025 forwarding the photographs and the video that Mr Z provided of the dialysis chair in bay 9. We also forwarded the explanation of the issue Mr Z provided to us. We asked the Trust if it could inspect the chair to identify if any repairs or a replacement were required.
59. The Trust responded on 6 January 2026 stating that it had inspected the chair in question and found that it is not broken. It explained it has an adjustable mechanism to allow the repositioning of a patient’s arm for both comfort and ease of cleaning. Furthermore, the Trust stated it had examined other chairs within the dialysis unit, and they have the same design.
60. We acknowledge there is no fault with the chair in bay 9 and so does not require fixing or replacing.
61. Regarding the matter of moving Mr Z from bay 9 to bay 11, which Mr Z has requested, we contacted the Trust again on 23 January 2026 to enquire if it could accommodate this move.
62. The Trust responded on 2 February 2026 reiterating that it has previously, on several occasions, accommodated all of Mr Z’s requests to move. It explained that bed and chair allocations must balance patient preferences which clinical need and service capacity. It noted this includes multiple daily dialysis slots by factoring in transport timing for other patients who dialyse in the same bed/chair on different slots. The Trust therefore stated that it could explore this matter further and assess the associated risks, but it could not guarantee that a move would take place.
63. Section 4 of our Administration Principles states that organisations should ensure decision and actions are proportionate, appropriate and fair.
64. We can see the Trust has moved Mr Z on several different occasions previously. We consider this demonstrates it has tried to make his experience on the dialysis unit more comfortable for him. However, due to several contributing factors, it is unable to guarantee any moves at present.
65. We consider the Trust’s explanation on this matter to be proportionate, appropriate and fair as whilst it must consider Mr Z’s needs, it must also consider the needs of other patients. Furthermore, there is no evidence to indicate a move is clinically required.
66. We acknowledge that Mr Z has explained that his experience of receiving dialysis in bay 9 is unpleasant for him. We do not wish to minimise or diminish this for him. With the above in mind, we have decided not to progress this element of Mr Z’s complaint further.
67. We would like to thank Mr Z for providing us with the opportunity to consider his concerns regarding the Trust.