Summary
Miss C, who had a previous history of mental illness, had a psychotic episode and was taken by ambulance in the early hours of the morning to the emergency department at Wishaw General Hospital. An initial mental health assessment was carried out identifying that she was seriously unwell and should be assessed by a doctor as soon as possible. However, she was not assessed for over three hours. A junior doctor examined her, took blood tests and contacted the on-call psychiatrist for advice. The psychiatrist said that out-patient follow-up may be the best option and that they would review Miss C after her blood tests were done. A couple of hours later, Miss C's parents were told that she was being admitted to the hospital for assessment. However, Miss C was agitated, received sedation and was restrained by the police. Later that morning her parents were told that she had been detained under mental health legislation. She was transferred to Monklands Hospital as there were no beds available.
Miss C’s mother (Mrs C) complained that if Miss C had initially been properly assessed by a psychiatrist and admitted to Wishaw General Hospital, then the police would not have become involved and she would not have been detained.
As part of my investigation of Mrs C's complaint, I obtained independent advice from advisers in emergency medicine and psychiatry. My adviser in emergency medicine considered that the triage nurse in the emergency department had appropriately assessed Miss C. He said that the delay in assessment by a doctor was not ideal but, unfortunately, was not unusual in a busy emergency department at night. My adviser found that the junior doctor's assessment was thorough and of a good standard, but that the junior doctor failed to recognise the severity of Miss C's illness. Due to a lack of detail in Miss C’s records, my emergency medicine adviser could not state definitively that she required hospital admission but, in his opinion, it was highly likely that she did. He said that the junior doctor should have questioned the advice of the on-call psychiatrist and insisted on an urgent psychiatric assessment in the emergency department, escalating this to a consultant if the request was refused. He also said that when Miss C's condition deteriorated and three doses of sedatives were required, she should have been thoroughly re-assessed.
My psychiatric adviser considered that Miss C's psychiatric assessment was unduly delayed and that her condition was allowed to deteriorate during this delay. He said that it had been unreasonable for the on-call psychiatrist to say that out-patient follow-up may be the best option for Miss C, and he also considered that the standard of note-keeping was inadequate. In view of all of these failings, I upheld this aspect of Mrs C's complaint and made recommendations.
Mrs C also complained that the board's handling of her complaint was inadequate. Having carefully considered their initial response to her complaint, I do not consider that it was an adequate response to the issues she had raised about Miss C's treatment, as they failed to show how these had been investigated. After this, Mrs C met staff from the board, then wrote to them. The board's response again did not acknowledge their failings or address all of Mrs C's concerns about Miss C's treatment in the emergency department. Therefore, I also upheld this aspect of the complaint.
Redress and recommendations
The Ombudsman recommends that the Board:
- issue a written apology to Mrs C for the failure to provide reasonable care and treatment to Miss C in hospital on 18 September 2013;
- remind medical and nursing staff in the Emergency Department that acute mental health patients are high-risk patients;
- take steps to try to put a low threshold in place for the involvement of senior medical staff in decision-making regarding the discharge of such patients;
- take steps to ensure that the assessment and management of acute mental health presentations is discussed during the induction programme for new junior doctors in the Hospital's Emergency Department;
- take steps to ensure that it is emphasised in the induction programme of junior on-call psychiatrists that it should normally be the case that acute mental health patients attending the Emergency Department following an emergency should have a thorough psychiatric assessment;
- remind relevant psychiatric staff that patients being considered for discharge directly from the Emergency Department should have their follow-up and circumstances taken into consideration;
- consider if there should be a change to the process to allow the member of staff carrying out the triage to consider direct referral for psychiatric assessment in high-risk cases;
- emphasise to relevant staff involved in the complaint the importance of keeping accurate records that would be fully adequate for the purposes of later scrutiny;
- consider if there should be a protocol for emergency tranquilisation in the Emergency Department;
- issue a written apology to Mrs C for the failure to satisfactorily respond to her complaint; and
- make the staff involved in the handling of Mrs C's complaint aware of our decision on this matter.