Decision Report 201508769

Summary

Mrs C complained about the care and treatment provided to her late grandson (Mr A) during an admission to Royal Cornhill Hospital. Mr A had a history of mild learning disability, drug and alcohol misuse and self-harm. He had a previous admission a couple of months earlier following attempted hanging and also attempted to hang himself while an in-patient when his discharge was planned. Mr A was discharged with support in the community but was readmitted following a further attempted hanging several weeks later. Mr A remained on the ward for two weeks and was then discharged again. Mr A completed suicide by hanging that evening. Mrs C complained that staff had not adequately assessed Mr A and that the discharge decision was unreasonable.

Following Mr A's death the board conducted an adverse event review. The board did not consider Mr A suffered from a major mental illness and although he was at risk of harming himself, staff did not consider an ongoing hospital admission would be in his best interests.

After taking independent psychiatric advice, we did not uphold Mrs C's complaints. We found that staff had appropriately assessed Mr A and reasonably concluded he did not have a major mental illness and would not benefit from ongoing hospitalisation. The adviser also explained that hospitalisation does not necessarily prevent attempts to self-harm (and noted that one of Mr A's previous attempts at suicide occurred in the in-patient setting). In view of Mr A's participation in the discharge planning and his previous pattern of behaviour, the adviser considered there was no indication that Mr A planned to harm himself that evening and it was reasonable for staff to predict that, although Mr A may attempt self-harm in future, he would likely warn someone before doing so. Overall, we considered that Mr A's suicide was an event that could not have been predicted by staff at the time of discharge.