Decision Report 201403308

Summary

Mr C complained that the board had contributed to the decision that he no longer needed to be managed under the Scottish Prison Service's process for prisoners at risk of suicide or self-harm (the ACT 2 Care process). Mr C had been managed under this process for a number of days, as he had carried out acts of self-harm. During that period, two medical reports had been obtained identifying that he was at risk of further self-harm, and successive case conferences had also reached the decision that he was at risk of this. However, a further case conference decided that Mr C was not at risk. A mental health nurse was a participant at this case conference and agreed with the decision reached. Mr C carried out a further act of self-harm and was put back on the process.

We took independent medical advice from our mental health nurse adviser. Our adviser said that Mr C was removed from the process on the basis that he was not suicidal, however, as it is also a strategy for minimising the risk of self-harm this was not a reasonable decision. We found that the risk of life-threatening self-harm had not been sufficiently taken into account when the board contributed to the decision to remove Mr C from the process. The adviser also said that an entry that had been made in Mr C's healthcare record was unreasonable in both tone and clinical approach to self-harming behaviour. We also upheld a second complaint that Mr C made about the board's failure to provide him with a legible copy of his completed complaint form.

Recommendations

We recommended that the board:

• issue a written apology to Mr C for their role in the decision to remove him from the ACT 2 Care process at the meeting in question, and also for the inappropriate entry made in his healthcare record;
• ensure all relevant staff are aware of the ACT 2 Care approach to self-harm;
• make the mental health nurse involved in this case aware of the adviser's comments and ensure that this is included for discussion at their next appraisal; and
• issue Mr C with a legible copy of the complaint form.