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Case ref:202209846
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Date:April 2024
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Body:Western Isles NHS Board
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Sector:Health
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Outcome:Upheld, recommendations
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Subject:Clinical treatment / Diagnosis
Summary
C complained about the care and treatment that they received from the community mental health team, after C was referred due to suicidal ideation. C said that they did not have a reasonable level of contact with the team and had difficulty changing the frequency of a prescription. C also said that the board unreasonably made reference to a historical referral to a befriending service in their complaint response.
We took independent advice from a specialist in adult mental health nursing. We found that the board’s position that prescribing is a matter for C’s GP to be reasonable. However, we found that C did not receive reasonable or adequate contact from the community mental health team and the board failed to follow through on a plan for C to have a face-to-face appointment with a consultant psychiatrist.
We also found that the board failed to follow through with a plan to discuss a referral to a befriending service with the clinical team. The board’s complaint response made reference to a referral submitted several years previously, which we found unreasonable with respect to complaints handling. We upheld C’s complaint.
Recommendations
What we asked the organisation to do in this case:
- Apologise to C for the failings identified by this investigation. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
What we said should change to put things right in future:
- The community mental health team should have robust administrative systems in place to ensure that planned appointments are arranged as intended and that patients are effectively notified of their personal appointment arrangements in a timely manner.
In relation to complaints handling, we recommended:
- Complaint responses should include information relevant to the events complained about.
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.