Decision report 201200419

Summary

Mr C was admitted to a mental health ward in hospital after taking an overdose. A few days after his admission, he was transferred to another mental health ward. Several days later, Mr C was assaulted by another patient. He was examined by medical staff who concluded that he had not suffered a significant head injury but noted that he was upset and distressed by what happened. Mr C suffered from a headache on several occasions in the weeks following the assault and was again examined. Medical staff again concluded that he did not have a significant head injury. A CT scan (a special scan using a computer to produce an image of the body) was carried out shortly after Mr C's discharge and showed nothing abnormal. Mr C said he expressed his concerns about his safety when he was transferred, and received assurances from staff that he would be safe. He complained that he was inappropriately placed in a ward where he was vulnerable to an unprovoked attack and that the after-care provided to him following the assault was inadequate.

Our investigation found that, while there were failures to update Mr C's risk assessment at certain points, there was nothing to suggest that the assessment would have changed or that Mr C was at particular risk of assault from others whilst in hospital. The independent advice from our medical adviser was that it would, however, be helpful if the board's guidelines were more specific in relation to key times when risk assessments should be completed. We found that the transfer was reasonable as was Mr C's care and treatment after the assault. We did not uphold Mr C's complaints, but made recommendations because we had identified failures in relation to record-keeping and risk assessment.

Recommendations

We recommended that the board:

• review its guidelines on risk assessment in light of our adviser's comments; and
• bring the failures in record-keeping to the attention of relevant staff.