Summary
Mr C complained to the Ombudsman about the standard of care provided to his son (Mr A) in the community and in Stratheden Hospital, where he was taken by his parents in a moment of crisis. Mr A had been diagnosed several years previously with paranoid schizophrenia, and he had a history of self-harming and attempting suicide. Mr A was admitted to hospital, but absconded within hours and was found dead on a nearby railway line. Mr C believed that Mr A's suicide risk was not properly assessed on admission, and that actions were not taken that could have ensured his safety.
I obtained independent advice from a mental health nursing adviser and a consultant psychiatrist adviser. Both advisers noted the risk assessment in Mr A's medical records that was done when he was admitted to hospital. They said that the form was unsigned and that important sections were either left blank or completed without much detail. The form did, however, record Mr A's history of self-harm, suicide attempts and absconding behaviour. Both advisers said that the assessment should have been collaborative, including Mr A, his parents and all involved staff. It also should have assessed and discussed the many known factors that increased Mr A's risk of serious self-harm or suicide. As this was not the case, my advisers considered that this risk assessment was inadequate, and I agreed.
Further to this, on the day after admission, a doctor began the process to detain Mr A under a Short Term Detention Certificate. My adviser on mental health noted that this showed the doctor must have considered Mr A to be a significant risk to himself, yet did not ensure that Mr A was under constant observation from that time. Both advisers considered this to be unreasonable. They said that Mr A's detention was not recorded in his notes so it was not clear if nursing staff knew about the decision to detain him. My adviser on mental health was also concerned that Mr A was able to leave the ward and hospital without staff realising, which was unreasonable.
Given the advice received, I considered that the care and treatment provided to Mr A in the hospital was below a reasonable standard. I upheld the complaint and made several recommendations.
Mr C also complained about the medical care and treatment provided to Mr A in the community. The advice I received is that Mr A's care package was appropriately planned and delivered, and his needs were met. However, the needs of his parents, who played an essential role in supporting him, were not examined. Mr C and his wife would have been entitled to a carer's assessment, which would have explored how much choice they had in their provision of care, and the impact on them, including their health, domestic needs and relationships. I considered this to be unreasonable. I therefore upheld the complaint and made recommendations.
Redress and recommendations
The Ombudsman recommends that Fife NHS Board:
- review their admission procedures to ensure there is multi-disciplinary involvement in the risk assessment of emergency admissions;
- remind all staff of the importance of accurate contemporaneous record-keeping;
- contact Doctor 1's current employer and ask them to ensure that this report is considered and reflected on in his next appraisal;
- review the risk assessment tools used by staff to ensure they include an adequate review of historical risk factors;
- review the procedures followed during nursing handover to ensure that patients are adequately monitored during this period;
- review the procedure followed for Short Term Detention Certificates, to ensure both multi-disciplinary involvement, including carers and named persons;
- review their procedures for community care provision to ensure the needs of carers are pro-actively considered; and
- apologise unreservedly to Mr C and his family.