COVID-19 update

Our office is currently not open to visitors. We are responding to emails; however, due to the impact on our staffing resources, our response times will be affected.  From Monday 25 May 2020, we will also be operating a limited telephone service.  Our Scottish Welfare Fund review service is still available by telephone as normal.  Please read our information for customers and organisations

Decision Report 201702012

  • Case ref:
  • Date:
    June 2018
  • Body:
    Inverclyde Health and Social Care Partnership
  • Sector:
    Health and Social Care
  • Outcome:
    Upheld, recommendations
  • Subject:
    clinical treatment / diagnosis


Mrs C complained on behalf of her late husband (Mr A) who had been a patient at a clinic within the partnership. Mr A was admitted to the clinic as a voluntary patient after he attempted to take his own life. A number of days later, Mr A was allowed to leave the clinic on pass and return home. Within a day of returning home, Mr A completed suicide. Mrs C complained that the partnership failed to provide Mr A with reasonable care and treatment both when and after he was admitted to the clinic. Mrs C also complained that the partnership failed to follow their complaints procedure.

We took independent advice from a consultant psychiatrist and from a mental health nurse. We found that as Mr A was admitted as a voluntary patient with capacity, he was able to leave the clinic any time he wished. However, it was noted that there was no record of Mr A undergoing a full assessment. A comprehensive mental state assessment should have been completed both on admission and before Mr A left the clinic on pass. We also found that there was no evidence of planned, structured nursing engagement in Mr A's care. Therefore, we upheld this complaint. However, we were also clear that even had these shortcomings not occurred, the outcome for Mr A would have been unlikely to have been different.

In regards to complaints handling, we found that the partnership failed to respond correctly to Mrs C in line with their complaints procedure. Therefore, we upheld Mrs C's complaint.


What we asked the organisation to do in this case:

  • Apologise to Mrs C for failing to deal with her complaint in a timely manner in accordance with stated procedures. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.

What we said should change to put things right in future:

  • The quality of medical note-taking should be improved.
  • Nursing staff must ensure that there is a daily, structured engagement with patients, and that there is a record made of this engagement.

In relation to complaints handling, we recommended:

  • Complaints should be responded to in accordance with stated procedures.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Updated: December 2, 2018