Decision Report 201502086

Summary

Mr A was admitted to Forth Valley Royal Hospital after taking an overdose of drugs. His sister (Ms C) said that it was considered that he had suffered an organically induced psychotic state and a few days later, after his blood pressure and temperature returned to normal, he was discharged. Ms C, however, remained concerned about Mr A's state of mind and wrote to his psychiatrist but her contact was rebuffed. Mr A took his life five months after the overdose. Ms C complained that the board had failed to contribute positively to Mr A's care and perhaps change his outcome. She also complained about the psychiatrist's attitude to the family and that he had focussed incorrectly on Mr A's physical, rather than his mental health.

We took independent advice from a consultant psychiatrist and we found that, initially, it had been reasonable to conclude that Mr A's behaviour was due to a transient illness caused by an organically induced psychotic state, and to treat him for this. However, Mr A's psychiatrist later declined important information from Ms C which should have been included in decision-making and clinical management (although it could not be concluded that this would have changed the outcome for Mr A). Subsequently, when Ms C complained, it took too long to provide her with an explanation. We upheld the complaint.

Recommendations

We recommended that the board:

• provide confirmation that the psychiatrist has completed a specialist training programme in communication style and technique;
• bring the General Medical Council document on confidentiality to the psychiatrist's attention and consider whether training on information governance is required; and
• remind all staff involved of their obligations in terms of their own complaints handling procedures. Furthermore, ensure that any changes anticipated to the complaints procedure are first discussed with the complainant and receive their prior permission.