Please quote Ref: 3446
17th October 2024
Private & Confidential
Mrs Mervelee Nembhard-Myers-Tomlinson
Via email: rattynem56@live.co.uk
Dear Mrs Nembhard-Myers-Tomlinson,
Patient Complaints
King’s College Hospital
Denmark Hill
SE5 9RS
020 3299 3209
kch-tr.complaints@nhs.net
http://www.kch.nhs.uk
Thank you for your email of 9th April 2024, regarding the treatment your husband, Mr
Arnold Tomlinson, received under the care of the Byron Ward team at King’s College
Hospital. I would like to offer you and your family my deepest condolences at what I
imagine is still an extraordinarily difficult time with the sad loss of your husband.
While we appreciate feedback from our patients and their relatives, I must address
the language used in your correspondence. It is important for us to maintain a
respectful and constructive dialogue that fosters understanding and resolution, and I
believe that the tone of your complaint did not align with this principle.
I hope I can reassure you that your complaint has been investigated fully.
Your complaint was shared with Dr Dan Wilson, Clinical Director, and Ms Felicia
Kwaku, Head of Nursing, who are responsible for monitoring the quality of care
within the Acute Specialty Medicine Care Group. Matron Yamu Njie, Patricia Ikhena,
Ward Leader Byron Ward, Dr Ambika Irving, Byron Ward Consultant, and the
Security Team at King’s College Hospital have investigated your concerns, and it is
with this information that I am responding to you. I have addressed your concerns in
line with how you have raised them.
Your husband was admitted on 9th March 2024, with generalised weakness,
hypothermia, and confusion. On reviewing Mr Tomlinson in the Emergency
Department (ED), it was noted he was confused and therefore not able to provide a
good clinical history. He was transferred to Annie Zunz Ward and later moved to
Byron Ward on 10th March 2024.
During a visit whilst on Byron Ward you found Mr Tomlinson sliding out of bed and
were alarmed that the nurse did not seem to notice. I am very sorry for the distress
caused; this is not the practice we expect from our staff. Staff are expected to
regularly check on patients especially those unable to independently manage their
activities of daily living. This would include repositioning the patient, checking their
toileting needs, and offering drinks. My sincere apologies that this did not happen on
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this occasion. This has been discussed at daily handovers on the ward since your
complaint, to reiterate to staff the need for regular checks on patients who need
additional support. I am sorry that you felt the situation required you to video events
on Byron Ward. Family and carers should have confidence that our staffs are
providing appropriate, patient-centred care at all times which should include
adequate supervision. I apologise if you felt that this was not the case in this
instance.

You mentioned that the nurse looking after Mr Tomlinson became abusive to you
when you started filming him. I am sorry that you felt the nurse responded
inappropriately. As part of the investigation, the nurse was interviewed, and CCTV
was reviewed. During the interview with the nurse, he explained that he felt
uncomfortable being filmed hence requested for you to stop filming and delete the
video. No combative behaviour was evident on the part of the nurse. The nurse
went on to explain that he was concerned that your recording might breach the
privacy and dignity of other patients on the ward. It is appropriate for our staff to
advocate for other patients. Since he felt uneasy, he reported the issue to Betty, the
Nurse in Charge. Recording our staff without their consent constitutes a breach of
our policies regarding privacy and recording in our facility. We take the privacy and
rights of our employees very seriously, and such actions are not permissible. We
kindly ask that you refrain from recording any staff members in the future and
respect their privacy.

Betty arrived at Mr Tomlinson’s bedside to ensure he was more comfortable and
made an attempt to diffuse the situation. Unfortunately, this led to an altercation
between you and Betty. Other nursing staff reported that you were raising your voice,
and they were concerned about the other patients in the room. Speaking with Nurse
Betty, she explained that she was unable to de-escalate the situation. Nurse Betty
does not recall shouting at you, but does remember asking you to calm down. You
asked her to leave the room. In order to respect your request, she did so but, for the
safety of her staff and patients, she had to contact Security to ask for their support.
The care group is undertaking a review of incidents where staff escalate to Security
in order to diffuse situations. They have identified that the escalation process for
these situations needs to be clearer and shared with our staff. The staff directly
involved on this occasion have been reminded that this could have been handled
differently. A call to more senior nursing staff on duty would have been more
appropriate before involving security staff. I apologise that this was not considered
at the time as it may have resolved things sooner.

Encounter with Security

You raised concerns about the security staff’s response when they assisted you to
leave the hospital premises. I am sorry that you felt you were manhandled. However,
after carefully reviewing the footage captured by the body-worn video cameras
(BWVCs) worn by our security staff, it is evident that they maintained a high level of
professionalism throughout the incident. Despite facing personal and derogatory
remarks from you, including racist comments directed towards them and accusations
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of being a paedophile, the security staff remained composed and focused on their
responsibilities.

The footage clearly depicts the security staff calmly explaining to you the reasons for
their intervention and subsequent request for you to leave, which was initiated at the
request of the nursing staff due to their concerns regarding your behaviour. After
initially walking off the ward, you stopped, so two security staff briefly assisted you to
move forward by holding your arms. When you refused to cooperate, they promptly
released their hold upon reaching the lift lobby, allowing you to proceed unaided into
the lift.

Additionally, the security staff can be heard confirming with nursing staff, prior to you
leaving, that your departure would not impact the patient’s care, ensuring that the
situation was handled with consideration for all involved parties. Furthermore, when
you were in the lift lobby, you mentioned leaving your coat in the patient’s room, the
security staff promptly retrieved it from the nursing staff and returned it to you without
any indication of interference or theft.

We are sorry that you felt discriminated against or harassed, the security staff aimed
to ensure your safety, the safety of your husband, and the ward staff.

It has been reported that you used inappropriate language, including racist slurs,
which is completely unacceptable.

We are committed to maintaining a respectful and inclusive environment for our
employees, patients, and their relatives. Such language not only violates our policies
but also undermines the values we stand for as an organisation. We ask that you
refrain from using any form of discriminatory language in the future.

Discharge arrangements

Mr Tomlinson was first seen by the consultant Dr Irving on Byron Ward on 14th
March and you were contacted by her later that day. You confirmed that you wanted
Mr Tomlinson to come home for end-of-life care and so this remained the plan from
the ward team. The occupational therapy team spoke to you again on 18th March to
confirm your understanding of the plan for discharge. On 20th March, the team were
told the existing package of care had been cancelled on Mr Tomlinson’s admission
to King’s and so the team sent a new request for care to Southwark Social Services.
This was for two carers to come four times per day, which is the maximum support
social services can offer.

On 22nd March the ward staff received a call from your husband’s social worker to
say she had spoken with you. The social worker asked the ward team to contact you
as she was worried that you seemed overwhelmed by the situation and the
discharge plans. Dr Irving called you later that day to go through your concerns and
you expressed that the equipment that had been ordered had not yet arrived, but
that also you were not happy for your husband to remain at home on his own in case
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you needed to go out to attend appointments. Dr Irving suggested a care home as
an alternate place of care in this case and you agreed this may be more suitable for
you. A decision was therefore made for Mr Tomlinson to be fast-tracked (an urgent
request for a place to be found) to a nursing home the following week; both you and
Trevor (Mr Tomlinson’s son) were in agreement.

The paperwork for the Fast Track was sent on 26th March. The ward were asked to
provide some more information before the funding was approved. This was sorted
out by Dr Irving. The fast-track paperwork was approved on 28th March. The team
awaited feedback about which nursing homes had availability.

On 3rd April, Mr Tomlinson deteriorated, and it was felt he was in the last days of his
life. Tower Bridge care home was due to assess him that day. Trevor was updated
that Mr Tomlinson may not be well enough to transfer, and the chaplain was
contacted. On 4th April the clinical team contacted you and explained that Mr
Tomlinson was likely approaching the last days of his life. It was explained that
Tower Bridge care home had felt Mr Tomlinson was too unwell for transfer and that
he was at high risk of deteriorating, perhaps dying, in transport if he was moved at
that point. You understood this and acknowledged that Mr Tomlinson was likely “no
longer aware of his surroundings” and would not have wanted to die in transport. It
was agreed that if your husband remained stable, then the team could always restart
discussions with the care home with a view to discharging him there if he stabilised.
You were happy with this plan and said you were due to visit later that day.

Mr Tomlinson did not become more stable and sadly passed away at 06:30hrs on 8th
April.

The nurses tried to reach you several times by telephone finally contacting you at
10:29hrs to inform you of Mr Tomlinson’s passing; you said you would come to the
ward as soon as possible.

Later that morning at 11:58hrs the ward manager tried contacting you but there was
no answer on any of your known contact numbers. Mr Tomlinson’s son was at his
father’s bedside, and he advised the team of other contact details. Three alternative
numbers were provided and tried but they either reached voicemail or failed to
connect.

In most circumstances, deceased patients are moved off the ward after a short
interval. You did not want Mr Tomlinson to move from the ward to the chapel of rest
until you could say goodbye. Once you arrived you were able to spend some time
with your husband.

Palliative Care input

The palliative care team are not routinely involved in all fast-track discharges and do
not always see all patients approaching the end of their lives. Your husband’s
Advance Care Plan had been updated by the consultant on the ward and there was
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a plan for a referral to community palliative care on discharge. However, when he
deteriorated on the 3rd/4th April, a referral was sent to the inpatient palliative care
team. They undertook a remote review when they triaged the referral. They noted
that his end-of-life symptoms were being well managed by the team on Byron Ward
and they did not have any other input at that stage. They were happy with the
ongoing plans to support Mr Tomlinson for end-of-life care in the hospital at that
point. They would likely have reviewed your husband on Monday 8th April; however,
he died in the early hours of that day.

We are sorry that we were not able to support your late husband’s return home for
end-of-life care. All efforts were made to allow this to happen with the correct
equipment, care package, and support. We also appreciate that caring for someone
at home even with lots of support can be very stressful and we fully understand the
need for you to ask for a change of plan. The Byron Ward team worked with you
and Mr Tomlinson’s son, Trevor (who both hold LPA for health and finances) and
you both agreed that the plan should change to transferring him to a nursing home
for end-of-life care. The team were not aware at any stage that you wished for this
plan to revert back to a discharge home.

We would like to thank you for taking the time to highlight your concerns. We aim to
give our patients the best possible treatment and we are sorry your experience has
not been entirely positive. Please be assured that we take your concerns seriously
and will continue to monitor the quality of the care that we provide at King’s College
Hospital.

If you are not happy with how we have dealt with your complaint and would like to
take the matter further, you can contact the Parliamentary and Health Service
Ombudsman. The Ombudsman makes final decisions on complaints that have not
been resolved by the NHS, government departments, and some other public
organisations. Their service is free for everyone. There is a time limit for making your
complaint to the Ombudsman so you should do this as soon as possible. To take a
complaint to the Ombudsman, or to find out more about the service, please go to
http://www.ombudsman.org.uk or call 0345 015 4033.

Yours sincerely,

Anna Clough
Site Chief Executive Officer, Denmark Hill