Decision Report 201508670

Summary

Miss C complained about her son (Mr A)'s admission to the Langhill Clinic at Inverclyde Royal Hospital. Mr A was admitted with suicidal thoughts and diagnosed with personality disorder, but requested a second opinion. This was provided by a different psychiatrist about a week later, and supported the clinical team's view that Mr A did not suffer from a major psychiatric illness, with his presentation relating to personality traits and recent trauma and bereavement. The following day, Mr A was found to have taken illicit drugs while absent from the hospital on a day pass. In view of this and increasing incidents of aggression towards staff, the doctor decided to discharge Mr A the following morning. Mr A then became aggressive and staff called the police to escort him from the hospital. Miss C was concerned that Mr A was not appropriately assessed and felt he should not have been discharged so early. She also raised concerns about the board's handling of her complaint.

After taking independent psychiatric advice, we did not uphold Miss C's complaints. We found that Mr A received reasonable assessments which appropriately took into account his risk of self-harm. He was also given a second opinion when he requested this. We also found the discharge was reasonable and in line with the board's policy on the management of violence and aggression. In particular, we noted that Mr A's admission was intended to be short and there were numerous documented instances of aggressive behaviour not caused by a major psychotic illness. However, we found the board failed to handle Miss C's complaint in line with Scottish Government guidance as they did not accept her complaint at first because it was not in writing, there were significant delays in the investigation and there was no evidence that staff contacted Miss C to explain the delay.

Recommendations

We recommended that the board:

• apologise to Mrs C for failing to handle her complaint in a timely manner;
• feed back findings to the staff involved for reflection and learning;
• take action to ensure that all complaints to the clinic are appropriately recognised and acknowledged, including verbal complaints made to clinic staff; and
• put in place clear procedures to ensure that complaints are investigated within 20 days where possible, and that complainants are updated when the investigation is expected to exceed 20 days.