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Case ref:201909468
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Date:December 2020
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Body:Ayrshire and Arran NHS Board
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Sector:Health
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Outcome:Not upheld, no recommendations
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Subject:Clinical treatment / diagnosis
Summary
C complained about the care and treatment their ex-partner (A) received from the board during a hospital admission. A was taken to hospital after self-harming. They had also written a suicide note, which was taken to hospital with them. After being assessed by psychiatric clinicians, it was decided that A did not require hospital admission for psychiatric observation or detoxification. It was also concluded that A showed no evidence of a specific plan or intent to carry out suicide and did not present with a mental illness. A was discharged that day but completed suicide the following day.
C complained to us about the general care and treatment provided to A and the fact that they were discharged home. In addition to this, C complained that they were not informed that A had been admitted to and discharged from hospital, given that they were still A’s next of kin.
We took advice on this complaint from an appropriately qualified adviser with a background as a consultant psychiatrist. We found that staff carried out an appropriately detailed assessment of A and made decisions that were in line with relevant guidance, based on the information available to them at the time. The board had previously acknowledged that the suicide note had not been reviewed by the clinicians who attended A and we agreed that this was a shortcoming. However, despite the outcome, we were satisfied that the board had provided a reasonable and appropriate level of care and treatment to A overall. Therefore, we did not uphold this aspect of the complaint.
In respect of whether C should have been notified of A’s admission and discharge, we concluded that the board’s actions were reasonable. Although C was listed as A’s next of kin, A was living with their father at the time. It was reasonable for the hospital to conclude that A’s father was the most appropriate point of contact at that time. Therefore, it was reasonable for the hospital to discuss matters with A’s father rather than with C. With this in mind, we did not uphold this aspect of the complaint.