Decision report 201103889

Summary

Mrs C's daughter (Ms A) has a history of anorexia nervosa and depression. Ms A was assessed by an on-call psychiatrist after her mother expressed a concern about a deterioration in her mental health. Ms A was allowed to go home and was to be followed up by the crisis care team. The next day, following an incident that concerned Mrs C, police brought Ms A to hospital for assessment. Mrs C attended with her. Ms A was seen by a mental health assessment nurse and a doctor in the early hours of the morning. They offered to admit her to hospital, but she refused and she and her mother returned home. However, later that day, after what Mrs C described as a violent outburst in the presence of the family doctor, police officers brought Ms A back to hospital for a further assessment. The assessing nurse decided not to detain Ms A or to offer to admit her to hospital. The next day, Ms A was detained under a short-term certificate. She was admitted to another hospital and remained there for six weeks. Mrs C was unhappy about the standard of psychiatric assessments Ms A received at the first hospital, particularly the second assessment.

Our investigation found that the first assessment was reasonable and that it was unlikely that Ms A met short-term detention criteria under the relevant legislation. We also found that the follow-up arrangements after her discharge were reasonable. However, in relation to the second assessment, we found that while the critical factors relating to her risk of suicide were assessed and the diagnosis reached was reasonable, there were instances of poor practice. In reaching their decision, the assessing nurse did not make use of all the available information which would have significantly strengthened the assessment and decision making.

Recommendations

We recommended that the board:

• put quality assurance measures in place to ensure that evidence based assessment templates are completed by relevant staff in full and as intended;
• ensure that staff involved in conducting out-of-hours and urgent assessments have (and utilise) access to previous clinical records whenever practicable, especially when considerations of risk are involved; and
• apologise to Mrs C for the failings identified in relation to the second assessment.