Decision Report 202304694

Summary

C complained on behalf of their parent (A). A had a long history of contact with mental health services at the board. They had a diagnosis of paranoid and antisocial personality disorder for several years before it was changed to paranoid schizophrenia. A later received an occupational therapy assessment but did not receive support and was referred to social work. A few months later, A was referred to mental health services by their GP due to confusion. A failed to attend two appointments and was discharged. The following year, A was admitted to hospital with confusion and left side weakness. A CT head scan showed an established infarct (an area of necrosis (tissue death) due to blood vessel blockage, often caused by a stroke). A was discharged from hospital and mental health services two months later. A did not receive a psychiatric assessment prior to, or following, discharge and did not receive any community support. C complained that A had not received appropriate support, had not received a psychiatric assessment for several years, and was unsure of their diagnosis. C requested a second opinion but this was refused.

The board said that A had received consultant psychiatric assessments, including two prior to their discharge. They advised that the diagnosis was paranoid and antisocial personality disorder and refused to offer a second opinion.

We took independent advice from a consultant psychiatrist. We found that the board’s response could not be verified by the records and seemed to contradict the diagnosis of paranoid schizophrenia that was given previously. The records did not offer a clear clinical rationale for changing the diagnosis to paranoid schizophrenia and it was not clear that the A had been informed. Given the confusion around A’s diagnosis and lack of psychiatric assessment, we considered that it was unreasonable not to offer a second opinion. Therefore, we upheld C’s complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for the inconsistencies and contradictions in the complaint response. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to A for the lack of clear diagnosis, the lack of psychiatric assessment, the lack of rationale in not offering mental health input following A’s stroke and the refusal to offer a second opinion. 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:

• Assurance that diagnostic rationale and patient symptoms including clearly documented Mental State Examination are clearly and consistently recorded.
• Assurance that all staff are aware of and follow the policy “Mental Health and Learning Disability Services Standard operating Procedure – Managing Second Opinions”.

In relation to complaints handling, we recommended:

• The board’s complaint responses and responses to SPSO enquiries should be consistent and supported by the medical records available.

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.