Ms J has a borderline personality disorder, which means she sometimes has little physical or mental awareness. During a therapy session at Avon and Wiltshire Mental Health Partnership NHS Trust (the Trust), Ms J became distressed. She went into a nearby room and lay down on the floor under her coat. Later, a clinician called in two security guards to remove her and one of them allegedly kicked Ms J.

Ms J complained to the Trust that she had been assaulted, saying that after the incident her ‘levels of distress were massive’ and she had thought of harming herself.

The Trust took nearly a year to respond formally to Ms J’s complaint. Our investigation uncovered serious flaws in the Trust’s two investigations into the incident. Neither was independent or thorough. The Trust did not take statements from all the key witnesses, nor seek advice about the wisdom of calling in security guards given Ms J’s condition. The Trust’s formal response to Ms J lacked authority because it was not signed by the chief executive or nominated deputy, as required by the Trust’s own policy, and made no mention of any potential learning for the Trust. The Trust’s response did not give proper respect to Ms J’s account of events. She felt bewildered and frustrated: ‘It was bad enough being kicked by the security guard. It has now all been made even worse by a very unsatisfactory complaints process’.

In line with our recommendations, the Trust apologised to Ms J for the considerable distress and inconvenience they had caused her, and paid her compensation of £250. They also agreed that their executive board would consider our investigation report, and that they would commission an independent review into their complaint handling function.