Overview
The complainant (Mr C) raised a number of concerns about the care and treatment provided to his son (Mr A) for mental health problems by Tayside NHS Board (the Board) prior to his death by suicide in July 2010. Mr C also raised concerns about the level of the family's involvement in the Board's Adverse Significant Incident review and their root cause analysis after Mr A's death.
Specific complaints and conclusions
The complaints which have been investigated are that:
- (a) mental health care and treatment from June 2009 until Mr A's death in July 2010 were below an acceptable standard (upheld); and,
- (b) the level of family involvement in the Board's Adverse Significant Incident review and their root cause analysis was below an acceptable standard (upheld).
Redress and recommendations
The Ombudsman recommends that the Board:
- (i) take steps to ensure that systems are in place in order that the care of vulnerable people is co-ordinated effectively and with due urgency, to minimise the danger of people at risk inappropriately disengaging or being lost to follow up;
- (ii) take steps to ensure that systems are in place in order that therapeutic engagement is planned with the patient's full participation. One-to-one therapeutic time should be negotiated and agreed on an individual basis and solitary, withdrawn and /or difficult to engage patients should have access to a range of interventions matched to their needs and wishes. They should also be consistently encouraged to engage with agreed interventions;
- (iii) ensure that clinical observation practice is in line with national guidance;
- (iv) take steps to ensure that no patient is de facto detained;
- (v) take steps to ensure that the eligibility criteria for engagement with secondary community mental health services are sufficiently flexible to allow vulnerable people to access appropriate services in situations where the person does not wish to (or does not require to) go into hospital but has complex needs which may be receptive to psycho-social interventions and which require a greater intensity of input than can reasonably be provided in the primary care setting;
- (vi) take steps to ensure that systems are in place in order that people who are vulnerable and difficult to engage are proactively followed-up by community services and all reasonable and appropriate steps are taken to minimise the risk of scheduled appointments being missed;
- (vii) ensure that the care plans of vulnerable patients, especially those who are difficult to engage or have a history of defaulting from care, include steps to be taken when scheduled appointments are missed;
- (viii) take steps to ensure that discharge letters which promote the delivery and continuity of safe and effective care are timeously received by GPs;
- (ix) take steps to ensure that up-to-date training records are maintained which enable performance against national or internal training targets to be judged; and
- (x) issue a written apology to Mr C for the failings identified in this report.
The Board have accepted the recommendations and will act on them accordingly.