Decision Report 201607293

Summary

Mrs C complained on behalf of her child (Child A) about the care and treatment they received at the Royal Edinburgh Hospital. Child A was admitted to hospital and diagnosed with a severe depressive episode and suicidal thoughts. Child A remained in hospital some months, and mental health staff consulted with social work about alternative accommodation (as it was not appropriate for Child A to return to the family home at that time). However, Child A's behaviour became increasingly violent, and Child A was discharged with a few days' notice to social work staff, who arranged accommodation at a young people's centre. Child A ran away from the centre threatening to harm themselves on several occasions, and had to be detained by the police. Child A was then transferred to secure accommodation, where they remained for several months.

Mrs C complained that the board inappropriately discharged Child A without ensuring adequate arrangements were in place for their safety and welfare. We took independent advice from a psychiatrist and found Child A's discharge to be unreasonable. We found that the discharge decision was made at short notice, without adequate planning for Child A's future accomodation and follow up care. We were also critical that a psychiatrist at the hospital instructed other staff not to detain Child A under the Mental Health Act if they returned to hospital. The adviser noted that detention under this Act is an important option to protect people who are a risk to themselves or others, and it was unreasonable for staff to try and remove the availability of this protection. Therefore, we upheld this aspect of Mrs C's complaint.

Mrs C also complained that the board used different diagnostic labels at different times to influence the management of Child A's care. We found that a mixture of diagnostic labels were used during Child A's admission, and it was not clear that a structured approach was used to formulate a diagnosis. However, we did not find that staff used these labels for the purpose of influencing the management of Child A's care. We did not uphold this aspect of Mrs C's complaint. However, we made recommendations to the board in relation to the use of different diagnostic labels.

Mrs C also felt that communication with her in relation to Child A's different diagnoses was poor. We found that the board had failed to respond to specific questions raised by Mrs C in a letter and could not explain why these had not been answered. We upheld this aspect of Mrs C's complaint.

Finally, Mrs C complained that the board failed to keep clear and accurate medical records. We found that the board's record-keeping was reasonable and that Child A's discharge letter contained sufficient information. We did not uphold this aspect of Mrs C's complaint. However, the adviser noted that some records were unclear and that several emails had not been recorded. While we did not uphold this complaint, we made recommendations to the board in relation to improvements in record-keeping.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Child A and their family for unreasonably discharging Child A (with inappropriate instructions not to re-detain them under the Mental  Health Act), for the lack of clarity in diagnostic terms used, and for failing to respond to the questions Mrs C raised in her letter. 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:

• Child and Adolescent Mental Health Service (CAMHS) patients should not be discharged without safe accommodation and adequate support in place, with specific follow-up plans in place and explained to the patient and their family in advance.
• A diagnosis should be clearly formulated based on symptoms reported and observed. Diagnoses (including provisional and differential diagnoses) should use an accepted diagnostic system (usually International Classification of Diseases (ICD-10)).
• Detention under the Mental Health Act should be available as an option to protect people when they are a risk to themselves or others. Staff should not try to remove the availability of this protection for a patient.
• Medical records should include all records relevant to the admission (including emails) and entries should clearly identify the author and their role.

In relation to complaints handling, we recommended:

• Responses to complaints should address the points raised (or explain why information cannot be provided).

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.