Health

Overview

Mr C, a prisoner, complained that the prison health centre's handling of his complaint forms was unreasonable.  He also complained that he had problems in accessing the relevant complaint forms.

Specific complaint and conclusion

The complaints which have been investigated are that:

(a) the prison health centre's handling of his complaint forms from 1 to 3 November 2012 was unreasonable (upheld); and,
(b) prisoners' access to Board complaint forms has been unreasonable (upheld).

Redress and recommendation

The Ombudsman recommends that the Board:

(i)  issue a written apology to Mr C for the failure to deal with his complaint in line with their complaints procedure;
(ii)  ensure that the local process in place for the management of prison health care complaints is in line with the good practice outlined in the Scottish Government guidance 'Can I Help You?'; and
(iii)  take steps to confirm that complaint forms are readily available for prisoners to access.

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

Overview

The complainant (Mr C) raised concerns in relation to delays in diagnosing his late wife (Mrs C) with lung cancer, and specifically that an x-ray taken over five months before her eventual diagnosis had not been properly read. Mr C complained that this mis-led clinicians into dismissing lung cancer as a diagnosis, despite other serious, persistent symptoms.

Specific complaints and conclusions

The complaints which have been investigated are that the Board:

(a) unreasonably failed to properly read an x-ray taken in January 2012
(upheld); and
(b) unreasonably delayed in diagnosing Mrs C’s illness (upheld).

Redress and recommendations

The Ombudsman recommends that Fife NHS Board:

(i) arrange an external review of their radiology practice and procedures, in consultation with The Royal College of Radiologists, and provide evidence of this review to the SPSO;
(ii) highlight to all clinical staff the need to review x-rays as well as x-ray reports, when diagnosing patients; and
(iii) apologise to Mr C for the failings identified in this report.

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

Summary
Mr C had an abdominal tumour, and saw a consultant who recommended that the tumour should be surgically removed.  The consultant started Mr C on medication that helps to prevent dangerous rises in blood pressure related to the surgery he was due to undergo.  In January 2013 Mr C completed a consent form agreeing to undergo surgery to remove the tumour.  The form did not specify any potential risks of the operation that the surgeon performing the procedure had discussed with Mr C, or that any discussion had taken place around any extra procedures which may become necessary. Surgery took place the next day.

Mr C was then reviewed the following month by the surgeon who wrote to Mr C’s GP to say that Mr C had reported difficulty with ejaculation but had experienced problems with this in the past.  Mr C was seen by a urology doctor (specialising in problems of the urinary tract and reproductive organs) in November 2013, where Mr C said he was still having problems with ejaculation.  Tests confirmed that Mr C had retrograde ejaculation (where semen enters the bladder rather than coming out of the penis).  Mr C had further follow-up appointments with the consultant who had recommended the surgery, and the surgeon who had carried it out.  Mr C complained to the Board about the lack of information he was given about retrograde ejaculation before the planned surgery, and that the surgeon had told him that he did not foresee any complications arising.

In the Board’s response to Mr C’s complaint, they did not clearly respond to Mr C’s complaint about the information he was provided with during the consent process.  Instead, they focused on the reasons why they felt it was unlikely that Mr C’s operation was the cause of the retrograde ejaculation, and said that this was a problem Mr C suffered from in the past, which Mr C disputed. Mr C then complained to my office.

In considering Mr C’s complaint, I took independent medical advice from a consultant urological surgeon who specialises in sexual dysfunction, who said that whilst the medication Mr C had been prescribed prior to the surgery (to regulate blood pressure) does have a side effect of causing retrograde ejaculation, this would only last for the short time the drug was prescribed and administered.  My Adviser said that the surgical procedure Mr C had was not very common, and, therefore, it is logical to refer to data for similar and more common operations which take place in the same region of the body but for different conditions.  For operations of a similar nature, my Adviser said that retrograde ejaculation is a rare but recognised side effect and this should have been discussed with Mr C when consent was obtained for the procedure.  The Adviser also noted that there are other potentially very serious risks to major arteries and veins when undertaking surgery in this area.

Whether or not Mr C previously reported problems with retrograde ejaculation prior to surgery, I found this was only documented in the post-surgery notes taken a month after the surgery was carried out.  There was nothing in the notes leading up to the surgery about this. In relation to the information Mr C was given, I consider that the surgeon should have warned Mr C about the possible risks or complications.  Whilst the risk of this side effect occurring is very small, General Medical Council guidance says that patients must be told about recognised serious adverse outcomes, even if they are rare.  There is no clear evidence to demonstrate this was done or indeed that discussion took place about other major structures close to the operative area being at risk of injury with possible significant consequences.

Redress and recommendations
The Ombudsman recommends that the Board:

• (i)  apologise to Mr C for failing to ensure that he was fully informed of the risks associated with his surgery; and
• (ii)  ensure that their consent policy includes guidance on the importance of accurately recording conversations with patients regarding risks and complications as part of the consent process.

Summary
Mr C was an older man with multiple health problems; in July 2013 he suffered a fall at home and fractured his hip.  He was taken to his local hospital, with the intention being he should be transferred to Raigmore Hospital for surgery.  Mr C was not transferred until two days after the fall, and surgery was performed three days after the fall.  He spent time recovering in another hospital after the surgery, and was discharged in August 2013. Mr C died in May 2014.

Mr C's wife (Mrs C) complained to Highland NHS Board (the Board) about the length of time taken to transfer Mr C to Raigmore Hospital, particularly taking into account the amount of pain relief that he was being given at the local hospital.  She felt he should have had surgery within one day, given his multiple health problems, and that the delay and use of pain relief had contributed to his poor recovery and subsequent decline in health.  The Board apologised for the distress caused and said that due to bed pressures it had not been possible to transfer Mr C earlier, but that appropriate care was being given by the local hospital and that there had been no detrimental effect on Mr C. I obtained further information about the other hip operations being performed over the relevant period.  The Board said those operated on earlier had been admitted to Raigmore Hospital directly, and that Mr C's transfer had been delayed further by a lack of available orthopaedic receiving beds.

My investigation found that whilst the standard of care provided at the local hospital was reasonable, the delayed transfer meant Mr C received a large quantity of morphine, which has potential side effects which Mr C went on to suffer.  In addition, the local hospital did not have the facilities required to provide the type of care outlined within the relevant national guidelines for patients with hip fractures.  I found that Mr C was an emergency trauma patient and that, despite the Board's position that such patients would be prioritised over routine and elective patients, he was not prioritised appropriately.  The information provided about the other procedures performed over the relevant period indicated there were no issues with theatre or surgical team availability.  Mr C had to wait on the basis that he was admitted to a local hospital rather than Raigmore Hospital directly.  The importance of the timing of such surgery, in terms of the outcome, is also highlighted in the relevant national guidelines.  I was critical of the Board's actions, particularly given the adverse outcome for Mr C.

Redress and recommendations
The Ombudsman recommends that the Board:

• (i)  provide evidence that they have procedures in place to ensure that when emergency trauma patients require transfer to an orthopaedic unit for treatment, they appropriately prioritise in accordance with their clinical need;
• (ii)  carry out an audit of the last 50 patients admitted to Raigmore Hospital for hip fracture surgery and detailing those who presented at the emergency department (at Raigmore Hospital) and those who presented elsewhere and required transfer;
• (iii)  bring the Medical Adviser's comments to the attention of the bed management team (at Raigmore Hospital) and the relevant medical director; and
• (iv)  apologise to Mrs C for the failures this investigation identified.

Summary
Mrs C complained about the way her late mother Mrs A had been treated while in hospital.  Mrs A, who had dementia, was admitted to Borders General Hospital on 20 November and discharged on 4 December 2012.  She was readmitted on 6 December and then discharged again on 17 December 2012.  Mrs C was concerned about aspects of her mother's treatment while in hospital and that she was discharged too soon.  She felt that Mrs A had been treated poorly because of her cognitive impairment.  I sought independent expert advice from a nursing adviser and a medical adviser.  I did not find that Mrs C had been deliberately discriminated against because of her dementia.  However, my investigation identified a significant number of failings in her care, many of which related to a failure to provide appropriate care and support to someone with cognitive impairment or to follow the legislation that provides protection for someone with cognitive impairment who requires medical treatment.  As a result of these failings, it is likely that, taken together, the failings were such that Mrs A's rights as an NHS patient and a dementia patient were infringed.

Care seemed to be poorly led and coordinated.  There was no evidence of a full care plan and, despite the fact that she had been admitted to the hospital because of a fall and had five falls during her stay, there was no completed falls assessments in the clinical records or any evidence of a falls prevention plan.  There was limited evidence of the involvement of medical staff and communication with the family was sporadic and poor.  Pain and nutritional assessments were inadequate.  There was also a specific incident of which I am critical when Mrs A required but was not provided with adequate pain relief and this meant her journey to the care home on 4 December was very uncomfortable.  While the report identifies a number of medical and nursing failures, I did not uphold a complaint about physiotherapy and occupational therapy.  There was evidence in the records of appropriate physiotherapy involvement and while I am critical that an occupational therapy assessment was only carried out after prompting by the care home, I found that overall care in these areas had been reasonable.

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) monitor practice to ensure national dementia standards are being met including specifically that the presence of cognitive impairment is given due regard in the planning of care, and that the level of observation, supervision and provision of support provided to people with delirium and/or dementia is appropriate for their impaired capacity;
• (ii) ensure that staff comply with adults with incapacity legislation, in particular completing section 47 certificates and accompanying care plans;
• (iii) take steps to ensure communication with relatives and carers of patients with cognitive impairment is proactive and systematic;
• (iv)  ensure that falls prevention clinical practice is administered within the Hospital in line with recognised good practice and Board policy;
• (v) ensure that nutritional care is carried out in line with national policy and that nutritional care plans are developed, implemented and evaluated for each patient as appropriate;
• (vi) explore all options to implement an observational pain assessment tool for use with patients with cognitive impairment;
• (vii) undertake an audit of record-keeping in wards caring for patients with cognitive impairment to ensure compliance with record-keeping guidelines and a reasonable standard of practice;
• (viii) review their discharge policy to ensure:  its continued relevance in light of the failings arising from this case; it meets the needs of people with cognitive impairment and the need to fully involve the family in decision-making; a more systematic approach to discharge planning; and pre-discharge assessments are clearly identified at an early stage and carried out within a reasonable time to inform follow-up care;
• (ix) ensure the failures identified are raised as part of the annual appraisal process of relevant staff and address any training needs particularly in relation to falls prevention and adults with incapacity legislation; and
• (x) apologise to Mrs C for the failures this investigation identified.

Summary
Mrs C was suffering from abdominal pain, and was seen at a gynaecology out-patient clinic following referral by her GP Practice in November 2012.  She was diagnosed with uterine fibroids in January 2013.  Mrs C was admitted to a ward at her local hospital (in another NHS board area) due to the pain.  In February 2013, Mrs C's GP contacted the consultant gynaecologist (Consultant 1) in charge of the out-patient clinic, requesting that she be placed on the list for surgery due to the impact her condition was having on her life.  Consultant 1 replied to say further discussion was required within the multi-disciplinary team; Mrs C was offered another appointment at the clinic on 2 April 2013.  Mrs C decided to seek private treatment, and had successful private surgery on 4 April 2013.

Mrs C made a complaint in June 2013 about the care and treatment she received, as well as communicative difficulties she had had when trying to contact Consultant 1.  She received a reply in August 2013, apologising for the administrative backlog that caused delay with her care and treatment.  The Board also said it was unlikely Mrs C would have been seen earlier than 2 April 2013 due to the gynaecology service's waiting times overall.  Mrs C complained again and the Board issued a final response in February 2014.  At this time, Mrs C was told that, in February 2013, Consultant 1 had made a decision that she should be referred for surgery.  An appointment for 4 April 2013 was to be offered; a telephone call was made by the Board to her GP Practice on 4 March 2013.  Consultant 1 told us that this had been left with the GP to discuss with Mrs C.

My investigation found that more prompt action should have been taken by the Board given Mrs C's worsening condition, and that there was a lack of urgency which meant Mrs C's care plan was not re-assessed.  I concluded that to expect Mrs C to wait for a further clinic appointment in April 2013 was not reasonable.  In addition, it was not reasonable that Consultant 1 had only contacted the GP Practice by telephone to advise of the offer of surgery; contact should have been made in writing to ensure Mrs C was aware of her options.  It was not reasonable to expect the GP Practice to pass on a message about the offer of surgery.  In my view, it was likely Mrs C would not have sought private treatment had she known the same procedure would have been available via the NHS at the same time.  I also found that the Board's responses to Mrs C's complaints were delayed, having been received well outwith the timeframes within the Board's complaints handling procedure.

Redress and recommendations
The Ombudsman recommends that the Board:

• (i)  reimburse Mrs C for the cost of her private surgery on production of receipts;
• (ii)  apologise to Mrs C for the failures in communication identified in this investigation;
• (iii)  confirm that steps have been taken to address the administrative communication failings identified during their investigation of Mrs C's complaints;
• (iv)  review the gynaecology department's internal and external communication arrangements to determine what improvements can be made;
• (v)  review the management procedure for the care and treatment of patients like Mrs C who live in another NHS board area;
• (vi)  apologise to Mrs C for the delays in responding to her complaints;
• (vii)  confirm that a process has been put in place to ensure that a complainant's further comments are addressed timeously; and
• (viii)  review arrangements with Mrs C's local NHS board for management of similar joint complaints.

Summary
Mr A suffered from anxiety, depression and panic attacks for many years; he attended his GP regularly and was prescribed Citalopram and, on occasion, diazepam.  In March 2013, Mr A saw an out-of-hours GP, describing worsening symptoms and feeling suicidal.  He was prescribed lorazepam and told to see his GP the next day; Mr A attended the out-of-hours GP again the next day and reported suicidal feelings again; he was then seen by a Duty Psychiatrist and discharged with a plan to refer for a medication review.  Two days later, Mr A attended the Accident and Emergency Department at the Victoria Hospital after taking an overdose.  He was discharged, and his parents (Mr and Mrs C) contacted his GP to say they felt they could not leave him alone due to his state.  The following day, Mr A took his own life.

Mr and Mrs C complained to the Board and, along with Mr A's partner, met with Board staff.  The Board said that, because Mr A's suicidal thoughts had been fleeting and intermittent, a decision was made that he could be treated safely in the community.  He had also been declined further medication, which he had requested, due to the risk of overdose.  A Significant Events Analysis was then carried out, where it was identified that benzodiazepine withdrawal may have been a factor in Mr A's mental health deterioration.  It concluded that, in hindsight, Mr A's level of risk to himself had not been anticipated.  A number of recommendations were made.

My investigation was mindful that we were reviewing what happened with the benefit of hindsight; nevertheless, I found that although the initial assessment by the out-of-hours GP was reasonable, the Duty Psychiatrist's assessment did not detail suicide risk factors and there was no evidence that Mr A's partner, who had attended with him, was included in discussions.  Mr A was not told what to do should his condition deteriorate further.  When Mr A attended A&E, staff did not know that he had already presented twice to NHS services with suicidal feelings, which he was now acting upon.  Had staff known this, they would have been able to see that Mr A's condition was developing, and different, more urgent action may have been taken.  I upheld Mr C's complaint that the Board failed to provide Mr A with appropriate care, support and treatment following his visits to hospital in April 2013.

Mr C also complained that the Board unreasonably failed to provide Mr C's family with sufficient information about Mr A's health to allow them to support him, and I upheld this complaint too.  The Board's SEA had already recommended that, in cases where suicide plans have been expressed and hospital admission is not taking place, it would be best practice to agree with patients that partners, family or carers are fully informed to help prevent harm.  We found that Mr A's partner, who had attended all the hospital assessments, did not appear to have been involved in decisions about treatment.  In addition, neither Mr A's partner nor Mr and Mrs C appeared to have been given any advice about how to deal with the on-going situation.

Redress and recommendations
The Ombudsman recommends that the Board:

• (i)  apologise to Mr and Mrs C and Mr A's partner for the failings identified in this report;
• (ii)  provide me with evidence of the action taken in response to the recommendations of the Significant Event Analysis;
• (iii)  review Mr A's case with a view to improving the level and effectiveness of communication between frontline staff likely to deal with self-harm cases particularly where a patient has presented to multiple services with the same issue; and
• (iv)  review how patient records are maintained and shared between departments to ensure that escalating levels of risk are identified at the earliest opportunity.

Summary
Mrs C complained about the care and treatment provided to her late husband Mr A.  Mr A was admitted to Wishaw General Hospital on 24 February 2014 and died there on 6 March 2014.  Mr A had been unwell for some time prior to admission and cared for by family members at home.  In the days leading up to his admission his condition had deteriorated and he had been hallucinating and unable to swallow.  Mrs C complained about a number of the aspects of care provided to Mr A.  In their response to her complaint, the board accepted some failings and apologised.  Mrs C remained unhappy and asked the SPSO to investigate.  I took independent advice from a consultant physician and a nursing adviser.

My investigation found that although her complaint had been upheld, the complaints process had only looked at Mr A's care in a superficial manner.  Not all the clinical staff involved in the case had commented and may have been left unaware of the outcome of the board's investigation.  I also found a number of significant failings.  There was a lack of any overall plan for Mr A's care and treatment, and the treatment he did receive fell well below a level that Mr A should have expected on a number of points.  There was no specific assessment of his swallowing difficulties or monitoring of the dehydration that he presented with on admission.  Significantly, there was evidence of confusion between staff about whether Mr A was being provided with active or end of life care.  Mr A was being proposed for referrals and investigations just two days before palliative care and a possible transfer to a hospice was considered although there was no apparent change in his condition.  One doctor noted on file that Mrs C wrongly believed Mr A was dying.  However, there is also evidence that other staff did think Mr A was dying and the board acknowledged in their investigation that end of life care would have been more appropriate throughout this admission.  Mrs C told us she received conflicting information about his condition and received a call from occupational therapy about physical aids she may need to care for him at home when it should have been clear he would not be discharged.  Alongside the failings in the treatment and the confusion around this, I was also critical that there was no evidence Mr A's family were appropriately involved in decision-making.  On the day he died, Mr A had a gastroscopy to investigate some of his symptoms.  We found that there had been no clear assessment of the risks of such a procedure and further, that, at the time, Mr A did not have the capacity to consent to such a procedure.  A certificate of incapacity was in place that allowed medical staff to provide general treatment as Mr A could not legally consent to this.  It did not provide for this specific procedure which would normally require additional consent and Mrs C and her family should have been involved in this decision.  This means that Mr A was denied safeguards put in place by legislation to protect adults with incapacity when the decision whether or not to go ahead with the gastroscopy was made.  Mr A did not recover well from this procedure and, while there was some treatment following his return to the ward, there was little evidence this deterioration was properly assessed.

I found there were also failings around the very sensitive issue of when Mr A had died and who should be informed of his death.  The records indicate Mr A died around 13.40 to 13.50.  However the death certificate recorded the time as 15.13.  This difference happened because it was not until then that a doctor confirmed the death.  However, advice by the Chief Medical Officer makes it clear that this approach is wrong and that doctors should seek to put on the certificate as accurate an actual time as possible based on the available information and not simply the time they confirm the death.  Following Mr A's death, the decision was made not to notify the procurator fiscal.  This assessment was made using a standard checklist.  I found no problems with the checklist but it had been wrongly completed and said there were no reasons for Mr A's death to be reported.  In fact, Mr A potentially met two criteria – deaths which were clinically unexplained and which may be due to an anaesthetic.  Mr A died from unknown causes on the day he had had an invasive procedure and there was evidence he had deteriorated following that procedure.  I made a number of recommendations as a result of my investigation.  They reflect that some action had been taken by the board prior to my investigation and the significant changes to the procedures around certification of death introduced on 13 May 2015.

Redress and recommendations
The Ombudsman recommends that the Board:

• (i)  apologise to Mrs C for the failure to report her husband's death to the Procurator Fiscal and the use of an inaccurate time of death;
• (ii)  notify the Crown Office and Procurator Fiscal Service of the omission to report Mr A's death to the Procurator Fiscal on 6 March 2014;
• (iii)  ensure that all relevant staff are aware of the current requirements for reporting a death to the Procurator Fiscal;
• (iv)  ensure that relevant staff are aware of the Code of Practice for practitioners authorised to carry out medical treatment under Part 5 of the Adults with Incapacity (Scotland) Act 2000;
• (v)  present this case and the findings of this report at a medical/respiratory departmental meeting; and
• (vi)  ensure that this case is included in the appraisals of the relevant consultants and the educational portfolios of relevant trainee staff.

Summary
Mrs C complained that her late husband (Mr A) was not provided with appropriate care and treatment after he was admitted to Dumfries and Galloway Royal Infirmary.  Mr A was admitted with a suspected stroke but developed severe diarrhoea.  His condition deteriorated significantly over the next few days and he developed a number of other symptoms, including problems with his oxygen levels, his heart and his breathing.  He was transferred to intensive care, but died some four weeks after he was admitted.  Mrs C said that although she was very concerned about her husband's condition, he was not seen by a consultant until about a week after he was admitted.  She repeatedly raised her concerns with staff, but felt these were dismissed.  Mrs C felt it took too long to recognise that Mr A had had a heart attack, and said he lost all his dignity while in hospital and suffered unnecessarily.

The board met with Mrs C some months after she first complained, and wrote two months after that to further clarify what had been said, acknowledging her concerns that the heart attack was not diagnosed sooner.  They said, however, that they hoped she was reassured that they had carried out a series of appropriate tests to diagnose Mr A's condition, although with hindsight this could have been done more quickly.  They apologised for Mrs C's experience.

The records did not show what was said at the meeting, but there were statements from two doctors within the complaints papers.  Both acknowledged that it was unfortunate that Mr A was not reviewed earlier, and that there were issues with availability of consultants.  I also took independent advice on the complaint from a consultant cardiologist, who said that Mr A died following a critical illness, which culminated in multi-organ failure.  Although he already had underlying health conditions, there was evidence of a recent heart attack and a related life-threatening condition.  My adviser identified a number of failings in Mr A's clinical care, including that the heart attack could have been diagnosed sooner, fluid therapy was not appropriately managed, and medical records were inadequate, with electrocardiogram (heart function monitor) results that were not properly labelled and that did not appear to have been compared in sequence.  This meant that Mr A was not adequately reviewed and his heart problems not considered early enough - critical omissions when planning his treatment.

I accepted this advice and upheld Mrs C's complaint.  I found that Mr A was not reviewed by a cardiac consultant early enough, and was placed on inappropriate fluid therapy, which compromised his treatment and meant that his care fell below a reasonable standard.  I also found the board's complaints handling and apology inadequate, given that two senior members of board staff identified failures in Mr A's care, and that I saw no evidence of the board taking action to improve procedures as a result of Mrs C's complaint.

Redress and recommendations
I recommended that the Board:

• (i)  carry out a critical incident review into Mr A's death;
• (ii)  remind all staff of the importance of contemporaneous, accurate and full medical notes;
• (iii)  provide evidence that the complaint investigation has been reviewed, to establish why failings by the Board identified by staff members were not acted upon;
• (iv)  remind all staff of the importance of discussing completion of the decision to designate a patient as 'not for resuscitation' with either the patient or appropriate family members;
• (v)  provide evidence that the full report has been discussed by the Board at the first meeting following its publication; and
• (vi)  apologise unreservedly to Mrs C for the failings identified in this report.

Summary
Mr A had a history of mental illness and of self-harm, and had been in and out of hospital as a result.  He was admitted to the Royal Edinburgh Hospital for treatment after an apparent suicide attempt.  He was given a pass to walk unescorted in the hospital grounds, but did not return when expected.  Staff decided not to contact the police to report him missing until some two hours after his expected return time.  Mr A was found dead outwith the hospital a number of days later.  Ms C (Mr A's fiancée and carer) complained that Mr A was not provided with appropriate care and treatment, in that the decision to allow him off the ward unescorted was inappropriate.  She also complained that she was not properly involved in the decision making in Mr A's care.

The board carried out an internal review, which found that although the decision to issue the pass was high-risk, the professional judgment of staff was reasonable in the circumstances.  They also said that it was reasonable not to contact police earlier, but made five recommendations, including reviews of what should happen if a patient did not return when expected, of liaison with the police and of the risk assessment tool.  The board met with Ms C, who had also met the leader of the review team.  Ms C remained concerned that the board had failed in its duty of care to Mr A and wanted them to admit this.  She wanted a further, independent review.  The board did not agree to this, and said that they had taken appropriate action through the review recommendations.  They did, however, apologise to Ms C for failures in communication with her in relation to care planning.

I took independent advice on this case from a mental health nursing adviser and a consultant psychiatrist.  Mr A was recognised as having unpredictable behaviour, and had returned very late from a previous pass, so both advisers were critical of the assessment of risk, and that this was not updated during treatment, as his condition appeared to be fluctuating.  Poor risk recording made it difficult to understand how it had been taken into account when making decisions, there was no mention of what was done to reduce risk and there was no plan of what should happen if he did not return from a pass.  Both advisers came to the view that in the absence of a structured assessment of risk, it was unreasonable to grant Mr A an unescorted pass.

I upheld both Ms C's complaints. On the first, I accepted my advisers' view that Mr A's care fell below a reasonable standard in terms of the assessment and recording of risk. I also found that the board's review reached contradictory conclusions on whether it was reasonable for staff not to take action until two hours after Mr A failed to return.  Although I cannot say whether this led directly to Mr A's death, such omissions represent a significant failing, and I criticised the board for this.  As, however, the board's own review addressed many of these issues through an action plan I made limited recommendations.  On the second complaint, appropriate communication with carers is a requirement of the Mental Health (Scotland) Act 2003, and it was not clear from the records whether staff viewed Ms C's as Mr A's main carer.  Her status should have been documented so that staff could communicate appropriately with her.

Redress and recommendations
I recommended that the Board:

• (i)  provide evidence that the action plan produced following the SAER has been implemented in full;
• (ii)  ask the internal review team to reflect on our advisers' assessment of the care and treatment provided to Mr A;
• (iii)  provide evidence that they have reviewed the procedures for carer involvement in patient care and management decisions;
• (iv)  provide evidence that the procedural review includes a system for the timeous identification of the patient's carer or named person; and
• (v)  apologise for the failings identified in this report.