Overview
The complainant (Mr C) raised a number of concerns about the standard of care and treatment provided to his son (Mr A) by Tayside NHS Board (the Board)'s Mental Health Service during the 13 months prior to his death by suicide in July 2010. Mr C also raised concerns about the communication between health staff and Mr A's family during this period.
Specific complaints and conclusions
The complaints which have been investigated are that the Board:
- (a) did not provide Mr A with appropriate care and treatment for his depression (upheld); and
- (b) failed to communicate effectively with Mr A's parents (Mr and Mrs C) or consult with them regarding Mr A's treatment and progress (upheld).
Redress and recommendations
The Ombudsman recommends that the Board:
- (i) make the use and review of the risk screening tool to complement and inform the risk assessment process mandatory for all patient assessments following a self-harm / suicide attempt;
- (ii) review their process for conducting RCAs to ensure a degree of independence;
- (iii) revise procedures in responding to Ombudsman's investigations to ensure no documents are omitted or withheld;
- (iv) review their practice with respect to the involvement of family and others, to ensure it is in line with the good practice contained in the NES framework;
- (v) review their process for involving families in SIRs and RCAs; and
- (vi) issue Mr C with a formal written apology for the failures identified in this report.