Overview
The complainant (Mrs C) raised a number of concerns about the treatment her adult son (Mr A) received at hospital (Hospital 1) following an attempted suicide at her home on 17 August 2010. Her complaints included that Mr A was inadequately supervised in a general ward and that he had the opportunity to make a further suicide attempt. Mrs C also complained that despite her request that Mr A should remain in Hospital 1 he was transferred to another hospital (Hospital 2) which was in another health board area where Mr A normally lived.
Specific complaints and conclusions
The complaints which have been investigated are that the Board:
- (a) failed to provide an acceptable standard of care to Mr A, an individual whose psychiatric problems had been highlighted to staff, who was suffering from extreme paranoia and who had recently attempted suicide (upheld);
- (b) failed to operate an effective or flexible transfer procedure and failed to ensure that the Bed Manager acted reasonably in response to Mrs C's requests that Mr A remain in Hospital 1 (upheld);
- (c) allowed some staff to act in a hostile way towards Mrs C after she had contacted the Mental Welfare Commission for advice (upheld);
- (d) failed to ensure satisfactory conditions in a psychiatric ward (not upheld); and
- (e) failed to ensure that Mr A's wounds were managed appropriately (upheld).
Redress and recommendations
The Ombudsman recommends that the Board:
- (i) share this report with the Task and Finish Group to ensure that the Adviser's concerns about mental health assessment staff training and inadequate record-keeping are taken into account in their review of clinical processes etc;
- (ii) review hand-over procedures to ensure an adequate level of observation is maintained during that time;
- (iii) remind staff of their responsibilities under the Mental Health (Care and Treatment) (Scotland) Act 2003 in relation to transfer of patients to another hospital;
- (iv) conduct an audit/review systems for safe management of non-clinical sharps;
- (v) conduct an audit of wound care practice in the Mental Health Ward; and
- (vi) apologise to Mrs C and Mr A for the failings which have been identified in this report.
The Board have accepted the recommendations and will act on them accordingly.