Decision Report 201810159

Summary

Mrs C, an MSP, complained on behalf of her constituent (Ms A). The complaint related to the care and treatment provided by the board to Ms A's late partner (Mr B) who died by suicide.

Mrs C complained that the board had failed to provide appropriate care and treatment in respect of Mr B's mental health. We took independent advice from a consultant psychiatrist. We found that the care and treatment the board provided was reasonable and appropriate. We acknowledged that we could not know for certain what was discussed between clinicians and Mr B or Ms A. However, we concluded that the records made by different clinicians were consistent with each other and the board provided appropriate care and treatment to Mr B, based on the information known at the time. The board had acknowledged some failings in respect of providing information about self-referral to addiction services. However, we considered that this related to communication rather than care and treatment. As such, we did not uphold this complaint.

Mrs C's second complaint was that Mr B's medical records repeatedly state he was using cannabis in the days before his death. However, the post-mortem and toxicology report indicated that there were no drugs in his system when he died. Mrs C complained that the board had not provided a satisfactory explanation for this. The board said that they could not establish why the post-mortem and toxicology report did not find drugs in Mr B's system or explain the apparent contradiction between this and the medical records. We were not able to confirm exactly what was discussed during the consultations before Mr B's death. However, given the consistency of the medical records, it was reasonable to conclude that the understanding of the clinical staff who reviewed Mr B was that he was using cannabis on an ongoing basis at that time. Therefore, we did not uphold this complaint.

Mrs C also complained that the board's out-of-hours service failed to respond to Ms A's request to provide medication for Mr B in a reasonable or appropriate manner. Ms A stated she was told that urgent medication to calm Mr B down could not be issued and that she felt her concerns were dismissed. We took independent advice from a GP. We found that the care and treatment provided by the out-of-hours service was reasonable and appropriate. We found that the decision not to provide or prescribe medication was appropriate and in line with relevant guidance. The out-of-hours service appropriately arranged an appointment with the Community Mental Health Team and advised Mr B to attend the emergency department if necessary. We did not uphold this complaint.

Finally, Mrs C complained about how the board handled Ms A's complaint and the standard of their communication during the complaint process and related reviews. In particular, Mrs C highlighted what they considered to be miscommunication over the scope and process of the review, delays in the board issuing their stage two complaint response, and questioned the investigating officers impartiality.

We found that it was appropriate for the board to carry out a Suicide Review before issuing a stage two complaint response. Although it took longer than the standard 20 working day timescale for the board to provide a stage two response, we did not consider their handling of the complaint to be unreasonable. We did not consider there to be any evidence that the investigating officer failed to investigate the complaint impartially. We also noted that comments provided by other senior staff during the course of the complaint investigation were reflected accurately in the stage two response. We considered the handling of the complaint to be reasonable and did not uphold this complaint. However, we acknowledged there was some confusion caused by the board referring to both a Significant Adverse Event Review and a Suicide Review and fed this back to them.