Misuse of Violence and Aggression Policy
17. On 27 February 2024, the Trust gave Mr B a verbal warning for recording an interaction with a staff member who found his behaviour threatening. The Trust subsequently retracted the verbal warning as it was not used in line with its Violence and Aggression Policy.
18. Mr B complains the Trust gave him a verbal warning because he was advocating for his son; he says this was a misuse of its Violence and Aggression Policy. He says he recorded the interaction with the staff member so that he could remember what was discussed in a stressful situation, pertaining to his son’s missing prescription. Mr B said he would like the incident report to be removed from the Trust’s records.
19. The Trust explained its staff complete an incident report in line with its Violence and Aggression Policy if they feel that the behaviour of a patient or visitor is inappropriate. It acknowledged that even though the staff member had felt that Mr B’s behaviour was challenging, it was understandably a distressing and frustrating time for Mr B and its Violence and Aggression Policy was not the right policy to use. It also acknowledged Mr B has the right to record his interactions with staff if he notifies them. The Trust said the Policy was applied incorrectly as Mr B was not sent anything in writing as a follow-up to the warning.
20. We can see the Trust informed Mr B that it still holds the incident report within its reporting system as it cannot delete an incident report once it has been logged. It acknowledged Mr B had concerns about the accuracy of the report but said the report reflected the lived experience of the staff member. The Trust explained it had added a note to the report, making it clear that the warning issued to Mr B was retracted and the matter was closed.
21. The Trust also confirmed there was no verbal or written warning against Mr B on file and that further training would be provided to its management teams to ensure its Violence and Aggression Policy is better understood and used correctly in future.
22. We recognise how stressful it would have been for Mr B when the Trust used its Violence and Aggression policy against him, especially during a particularly stressful time. We appreciate that this would have caused considerable distress to Mr B at the time, and thereafter until the Trust rescinded this.
23. Our Complaint Standards state that organisations should be open and honest when things have gone wrong and give meaningful and sincere apologies and explanations that openly reflect the impact on the people concerned. They also say that organisations should identify what learning can be taken from a complaint and be clear about how the learning will be used to improve services and support staff.
24. In its complaint response, the Trust has acknowledged and apologised to Mr B for incorrectly applying its Violence and Aggression Policy against him. It also recognised that Mr B had the right to record his interaction with staff once he had notified them.
25. The Trust has explained what improvements it will make to minimise the risk of this happening again and added a note to its system to make clear that the warning should not have been given. We consider this shows that the Trust has been honest when things have gone wrong, provided an apology, and identified what learning can be taken to improve its services.
26. As such, it is our view that the Trust’s response to this aspect of Mr B’s complaint is in line with our Complaint Standards, and that it has already remedied the impact caused. Therefore, we will not take any further action in relation to this aspect of the complaint.
Care at risk because of complaint
27. Mr B complains K’s care was at risk because he complained the Trust had lost K’s medication Buccal Midazolam (an emergency sedative medication used to stop prolonged epileptic seizures). He says his son’s care was at risk because he tried to advocate for him.
28. Our Complaint Standards state that people should be able to complain without fear that it will affect their care. It also says organisations should actively reassure people who use their services that their care will not be compromised if they make a complaint.
29. We can see K was admitted to hospital on 16 February 2024 and was discharged on 21 February. Mr B’s interaction with staff, which gave rise to his verbal warning, occurred on 19 February 2024 and Mr B complained on 27 February.
30. Mr B told the Trust that since making his formal complaint, he had been informed that his access to the hospital would be removed. The Trust reassured Mr B that it did not intend to restrict his access, and it said it did not want to add to Mr B’s challenges.
31. We note the contents of an internal email in the complaint file where a staff member wrote of their negative interaction with Mr B and the impact on them. The staff member said K might be at risk because people do not want to care for him due to Mr B’s behaviour.
32. We understand Mr B’s concerns with the comments he had read and the distress this would have caused him and his family. The Trust explained that the internal email was from a member of staff to the senior team, this did not impact K’s treatment, and the email was not recorded as an incident on its incident reporting system.
33. There is no reference to Mr B’s complaint within K’s clinical or nursing notes and all interactions are reported factually. Our adviser said that there is no evidence from the records that K’s care was impacted due to the complaint.
34. In line with Our Complaint Standards, we have not seen any evidence in the medical notes to suggest K’s care and treatment was adversely affected because Mr B had submitted a formal complaint and note that he was reassured that his access to hospital would not be affected.
35. Mr B explains that he continues to be dissatisfied with K’s care and treatment and has cited issues with the gastroenterology support K is receiving. Mr B has raised a further complaint about this matter, which is not within the scope of this investigation. We have not seen any indication of a failing for this aspect of Mr B’s complaint.
Lost emergency-controlled medication
36. Mr B complains the Trust lost K’s emergency-controlled medication Buccal Midazolam. He says the nurses could not locate K’s medication for 72hours and as a result, K lost the opportunity to be transferred to another hospital for treatment.
37. This aspect of Mr B’s complaint centres on the delay in providing a discharge prescription of Buccal Midazolam for K, for use in the event of a seizure outside of the hospital setting.
38. The NMC code says clinicians should take all steps to keep medicines stored securely. The Trust’s Controlled Drugs Policy also says all controlled drugs must be stored in a locked controlled drugs cabinet.
39. The Trust acknowledged it had misplaced K’s medication and due process had not been followed regarding the storage of K’s medication. The Trust explained that on arrival to the ward, Buccal Midazolam should be handed to nurses to be locked in the controlled drug cupboard, in line with its Controlled Drugs Policy. It explained that in the event K requires the medication, it should be provided from its own stock. The Trust said it has disseminated this information to staff to prevent any future issues.
40. Mr B was understandably concerned that the discharge prescription for K’s emergency-controlled medication was missing. Buccal Midazolam was essential for K during his seizures and according to our adviser is a ‘rescue medication’ to be used during emergencies. The Trust did not act in line with the NMC code or its Controlled Drugs Policy when it did not store K’s medication properly. This is an indication of a failing.
41. Having seen an indication of a failing, we next looked at whether this had a negative impact on K, and, if so, whether the Trust has put things right.
42. We can see that the Trust had its own supply of Buccal Midazolam and according to the notes, K’s parents were administering his regular anti-seizure medication. Our adviser said the anti-seizure medication, designed to prevent seizures happening, are the most important and there were no reported issues with the supply of this medication.
43. K’s medication that was misplaced was needed for if he was discharged home to be used if he had a seizure in an out of hospital setting. Our adviser said, as K was being transferred to another hospital and was not being discharged, there was no impact caused by misplacing the discharge prescription for Buccal Midazolam.
44. As such, we have not seen any evidence that K’s care and treatment in hospital was adversely impacted because the Trust could not locate medication required during K’s discharge from hospital, or that his transfer to another hospital was delayed.
45. Taking into account all the evidence, we cannot investigate this matter further as we cannot determine that the indicated failing had an impact on K.
46. We are sorry to hear of the distressing circumstances of K’s admission. We hope our decision provides Mr B with assurance about what happened with his son’s care.