Decision Report 201804741

Summary

Ms C complained to us about the care and treatment provided to her late partner (Mr A) by Raigmore Hospital during an admission. Mr A was assessed and a crisis plan was agreed; Mr A was then discharged home, but soon after he died. Ms C complained that the board unreasonably discharged her partner home. She also raised concerns about the significant adverse event review (SAER) carried out by the board into Mr A's care and treatment.

We took independent advice from a mental health nurse and from a consultant psychiatrist (a medical practitioner who specialises in the diagnosis and treatment of mental illness). We found that the board carried out an appropriate and systemic risk assessment. We found that a coherent short-term crisis plan was agreed with Mr A, until he could engage with his local mental health services. We found that the decision to discharge Mr A home was reasonable. We did not uphold this aspect of Ms C's complaint.

We found that the board's SAER process and report was reasonable; and it identified appropriate learning. However, we noted that when Ms C complained to the board, they said that they would address her concerns through the SAER. In the circumstances and given the time it took to complete the SAER, we considered that the board should have kept Ms C updated more regularly on its progress. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to keep her appropriately updated. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets

In relation to complaints handling, we recommended:

• If the board decides to address a complaint through their SAER, they should then keep the complainant appropriately and regularly updated on its progress.

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.