Patient in mental hospital was not adequately assessed in A&E

What happened

Mr D, who was in his thirties, lived in a high-secure psychiatric hospital. Staff were concerned about a knee injury and other signs of a worsening physical illness. They took him to A&E at the nearby general hospital, where he was seen by a nurse and a doctor. He was diagnosed with soft tissue injury and discharged. Staff at the high-secure hospital continued to be concerned by Mr D's condition and later that evening, took him back to A&E. This time he was admitted to intensive care, but died three weeks later of a serious infection.

The patient's aunt, Mrs E, complained to the Trust in summer 2011, saying that she was concerned that failures might have contributed to her nephew's death. At first, the Trust refused to respond to her complaint, because it did not have permission from Mr D's next of kin. The Trust eventually responded to her complaint in summer 2013.

What we found

The Trust failed to assess Mr D when he first presented to A&E. Although we did not find that this failure contributed to Mr D's death, it caused distress to him and his family. Although Mr D was given appropriate care and treatment when he returned, the Trust failed to take action to address the earlier mistake.

Furthermore, there was maladministration in the Trust's handling of Mrs E's complaint. It was unreasonable to insist that Mr D's next of kin needed to give permission to investigate the complaint. Even after the Trust accepted this was wrong, there was an unreasonable delay in responding to Mrs E.

Putting it right

The Trust agreed to acknowledge and apologise to Mrs E for the poor service her nephew received and for failing to take reasonable action when the problem became apparent. It also agreed either to explain to Mrs E the service improvements that had taken place since the events or to prepare an action plan to stop the failings happening again.

The Trust also agreed to pay Mrs E £500 for the poor handling of her complaint.