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Case ref:201302649
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Date:December 2014
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Body:A Health Board
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Sector:Health
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Outcome:Some upheld, recommendations
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Subject:clinical treatment / diagnosis
Summary
Mr C complained that the board failed to provide him with appropriate ongoing psychiatric treatment and support after he was admitted to a hospital psychiatric unit. After taking independent advice from one of our medical advisers - a consultant psychiatrist - we found that Mr C was treated appropriately whilst he was in the hospital. However, several months after he left there, he was diagnosed with borderline personality disorder. We found that psychiatrists had failed to adequately document a detailed medical history, and that the diagnosis was not adequately founded or justified. It was not made with sufficient rigour and was not reviewed appropriately.
There was no evidence that assessment for psychological treatments was carried out so that Mr C could be offered treatment promptly. His care and management were not coordinated and there was no evidence that his care plan had been reviewed. In addition, it was not clear whether the findings of a scan were adequately communicated to him. We found that this delayed Mr C's treatment for a number of months. In view of all of this, we upheld the complaint. However, we found that a psychiatrist who had later taken over Mr C's care had been following an appropriate plan of further investigation in collaboration with Mr C's GP.
Mr C also complained that staff had failed to admit him to the psychiatric unit when he was discharged from another hospital after attempting suicide. The discharge letters from the other hospital, however, did not say that Mr C should be admitted to the unit. We found that it had been reasonable for the board not to readmit Mr C at that time and did not uphold this aspect of his complaint.
Recommendations
We recommended that the board:
- issue a written apology to Mr C for the delay in providing him with appropriate psychiatric treatment and support;
- review his current treatment to ensure that it is appropriate;
- take steps to ensure that clinicians are more rigorous in the way that they diagnose personality disorders and that appropriate treatment is provided; and
- take steps to ensure that care management for psychiatric patients is co-ordinated.