Decision Report 201705043

Summary

Ms C complained about matters related to the care and treatment of her son (Mr  A), who had been an in-patient at the Royal Edinburgh Hospital. Mr A had a diagnosis of schizophrenia (a long term mental health condition that causes a range of different psychological symptoms) and had been subject to a Compulsory Treatment Order (an order that allows professionals to treat a person's mental illness). During the in-patient admission, the local authority's social work staff were working towards finding a suitable supported accommodation vacancy for Mr A, with input from clinicians. Ms C firstly raised concerns that board staff had contributed to delays in progressing Mr A towards discharge. We received independent advice from a consultant psychiatrist. We found that the clinical team reasonably fulfilled their responsibilities to identify a suitable accommodation placement for Mr A. We did not uphold this complaint.

On a particular occasion during the admission, Mr A did not return to the hospital following an agreed one hour period of leave. The hospital notified the police the next morning and informed Ms C later that day. Ms C raised concerns that the board failed to apply the correct risk level to Mr A's absence. We did not find evidence that the board had acted in accordance with the procedure for missing persons that was in use at the time. We upheld this complaint, however, we noted that the board had since revised and improved this procedure.

We also noted that the board's complaint investigation referred to the relevant procedure but did not identify that staff had not complied with this. We were critical of the complaint investigation and made a recommendation in relation to this.

Ms C was also unhappy with the level of communication with her during the time Mr A was absent from the hospital. In response to her complaint, the board acknowledged that there had been a delay in contacting Ms C to notify her. We found limited documentation of communication with Ms C and we concluded that communication was not in line with the procedure in place at the time. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C and Mr A for the failure to follow their Standard Operating Procedure for Missing Persons. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

What we said should change to put things right in future:

• Staff should be familiar with the procedures to follow when a patient goes missing, and confident in applying these correctly.
• When a detained patient is missing, factual details such as dates/times of significant events and information discussed with next of kin and police should be recorded.

In relation to complaints handling, we recommended:

• A complaint investigation should identify any applicable policies or procedures and assess whether these have been followed (and if not, why).

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.