Scottish Public Services Ombudsman

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  • Report number:
    201302798
  • Date:
    November 2014
  • Body:
    Forth Valley NHS Board
  • Sector(s):
    Health
  • Keywords:
    Risk assessment, clinical treatment, communication

Overview
The complainant (Mrs C) raised a number of concerns about the care and treatment provided to her daughter (Mrs A) for mental health problems by Forth Valley NHS Board (the Board) prior to her death by suicide on 11 October 2012.

Specific complaints and conclusions
The complaints which have been investigated are that the Board did not:

  • offer a reasonable diagnosis (not upheld); and
  • provide a reasonable standard of care and treatment (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

  • review the approach taken by the Intensive Home Treatment Team to the assessment of risk to ensure that presenting risk factors are systematically considered and recorded and that the rationale behind clinical decision making is transparent;
  • remind medical staff of the importance of accurate and signed contemporaneous notes;
  • review the process for communicating medical reviews of patients to IHTT staff, to ensure that all relevant information is made available timeously;
  • review the process for discharging patients from the IHTT to ensure that medical staff's opinions are considered; and
  • apologise for the failings identified in this report.

The Board have accepted the recommendations and will act on them accordingly.

Download report number 201302798 as a PDF (84.23 KB)

Updated: November 19, 2014