Overview
The complainant (Mrs C) complained about the transfer of her son (Mr A) to the Intensive Psychiatric Care Unit (the IPCU) at Carseview Centre (the Centre), Ninewells Hospital (Hospital 1), Dundee, on 8 January 2008. Mr A had been transferred from the Forensic Unit (the Unit), Murray Royal Hospital, Perth, where he was being treated under a Compulsory Treatment Order (CTO). She also complained that, on 16 January 2008, Mr A was granted a period of escorted leave within the vicinity of the Centre, from where he was able to abscond. Mrs C complained that when Mr A returned to the IPCU that same evening, he was not provided with adequate physical care and treatment. Mr A died in the early hours of 17 January 2008.
Specific complaints and conclusions
The complaints which have been investigated are that:
- (a) Tayside NHS Board (the Board)'s decision making processes to transfer Mr A from the Unit to the IPCU at Hospital 1 were unclear (upheld);
- (b) the decision taken to allow escorted leave from the IPCU was inappropriate for Mr A on 16 January 2008 (upheld); and
- (c) Mr A's physical care and treatment was inadequate on his return to the IPCU from a period of unescorted leave on 16 January 2008 (upheld).
Redress and recommendations
The Ombudsman recommends that the Board:
- (i) urgently review their procedures for the transfer of patients under a CTO to ensure that non urgent transfers are properly categorised and dealt with as such; and that decisions are properly recorded;
- (ii) ensure that, where there is a statutory right of appeal against the decision to transfer, the appropriate persons are formally notified of that right;
- (iii) ensure that every consideration is given for the named person to have the opportunity to provide their views formally and for these views to be recorded and considered as part of the decision making process;
- (iv) ensure that decisions taken about the level of leave allowed during any episode of care and the level of escorts are explained and understood by the patient and their relatives (where appropriate) and a full record is made of these;
- (v) consider the introduction of a locally based alert system within the vicinity, which would enable staff to draw attention to potential incidents sooner than the time taken to return to the ward;
- (vi) review the escort arrangement at the IPCU for accompanied time out, to ensure that the arrangement is clinically appropriate in terms of the risk assessment for the patient;
- (vii) provide training to ensure the adequate medical examination, nursing observation and assessment of vital signs within the IPCU, when managing a patient recently having consumed an illicit substance;
- (viii) ensure that there is appropriate consideration for review of the procedure or protocol for referring a patient to the local Accident and Emergency department for further consideration of physical care and treatment when they admit to having consumed illicit substances;
- (ix) remind staff of their professional responsibilities towards the care and treatment of a patient received into their care with or without prior advice provided by other professional disciplines;
- (x) conduct an audit to ensure full compliance of the use of assessment tools and measures and completion of monitoring charts and vital signs monitoring charts;
- (xi) ensure that this report is shared with all staff involved in Mr A's care when he returned to the IPCU on 16 January 2008, so that they can learn from the findings of this report; and
- (xii) provide an apology to Mrs C for the failures identified in this report.
The Board have accepted the recommendations and will act on them accordingly.