Decision report 201100069

Summary
Mr C was referred to the board's mental health team by his GP. Mr C was initially seen by mental health staff over a period of months. He was not satisfied with their response to his needs and so he complained to the board. Mr C was not happy with the board's response to his complaint, and complained to us. He complained that the board failed to provide him with appropriate care and treatment following the referral from his GP. He also complained that the board failed to provide him with adequate information on his assessment and treatment.

We did not uphold the complaint about appropriate care and treatment. We found from looking at the medical records, and taking advice from one of our professional medical advisers, that the mental health team's response to Mr C's clinical presentation was adequate, reasonable and based on assessed need and that, overall, the care and treatment provided to him following the referral from his GP was appropriate.

We did uphold the complaint about adequate information. We found that the board did not provide Mr C with sufficient detailed information about his care and treatment, in the form of a written and agreed care plan.

Recommendations
We recommended that the board:
• apologise to Mr C for failing to provide him with adequate information on his assessment and treatment, in particular failing to provide him with a written and agreed care plan; and
• review the Primary Care Mental Health Team's practice on written care plans, to ensure that all relevant information is included, and that patients are aware of the care plan and can countersign their agreement to it. This should be in line with the Mental Welfare Commission for Scotland's best practice guidance on Mental Health Act care plans, and NHS Quality Improvement Scotland's Standards for integrated care pathways for mental health.