Decision Report 201508883

Summary

Mrs C complained to us about the care, treatment and support provided to her son (Mr A) by the board's mental health services before his death from an overdose. We took independent advice on Mrs C's complaint from a psychiatrist. We found that the clinical care provided to Mr A by the mental health services was reasonable and was consistent with current practice. We also found that there had been appropriate communication with other relevant parties. It had been reasonable to delay psychotherapy treatment for Mr A as the uncovering of previous trauma during therapy can sometimes lead to distress and increased suicidal ideation. We did not uphold this aspect of Mrs C's complaint.

Mrs C also complained to us that the board had failed to communicate with her adequately about the significant event review that was carried out after Mr A's death. We found that the conduct of the review had been consistent with good practice and was reasonable. However, the completion of the review was delayed and there were also errors in the draft report that was issued. In addition, Mrs C had not been signposted to support in relation to bereavement. We upheld this aspect of the complaint.

Finally, Mrs C complained that the board had failed to deal with her complaints about Mr A's care and treatment appropriately. Whilst we recognised that there had been a large number of complex issues to cover, we considered that the time taken by the board to respond had been unreasonable. We upheld this aspect of the complaint.

Recommendations

We recommended that the board:

• provide evidence that they have considered how they communicate with relatives and other interested parties where an investigation becomes protracted and delayed and whether setting a standard for this would be beneficial; and
• provide evidence of the steps they have taken to avoid delays of this nature in the future.