Overview
The complainant (Mr C) complained about the care and treatment provided to his sister-in-law (Mrs A) while she was in the care of Dumfries and Galloway NHS Board (the Board). He alleged that the Board failed to provide appropriate mental health care for Mrs A during a period when she was physically unwell.
Specific complaints and conclusions
The complaints which have been investigated are that:
- (a) Mrs A's anti-depressant medication, phenelzine, was stopped without reasonable psychiatric consultation in April 2010 (upheld);
- (b) keyhole surgery was undertaken inappropriately on Mrs A in April 2010 (not upheld);
- (c) following surgery for bowel cancer in April 2010, Mrs A was sent home without reasonable aftercare instructions, which led to further health problems and the need for her bowel to be extended (upheld); and
- (d) Mrs A was unreasonably able to acquire the means and opportunity to self-harm in Dumfries and Galloway Infirmary and Crichton Royal Hospital (upheld).
Redress and recommendations
The Ombudsman recommends that the Board:
- (i) apologise to Mr C for the fact that no proper advice was given to Mrs A pre and post-operatively;
- (ii) when presented with patients for surgery with known mental health issues for which they take medication, ensure that the circumstances are discussed with the patient, the GP and clinicians involved;
- (iii) ensure that all relevant discussions with the patient, GP and clinicians (and any subsequent outcomes) are recorded properly;
- (iv) give consideration to the terms of their permission forms for operations, given the failures with regard to Mrs A;
- (v) apologise to Mr C for their failure to provide Mrs A with adequate aftercare instructions in April 2010;
- (vi) review their procedures to ensure that such an occurrence does not occur again;
- (vii) apologise to Mr C for the insufficient care they took to prevent Mrs A from accessing the means to harm herself; and
- (viii) where patients have expressed thoughts of suicide, carry out (and fully record and act on) risk assessments.
The Board have accepted the recommendations and will act on them accordingly.