Overview
The complainant (Ms C) raised a number of issues about the service she received from Lothian NHS Board (the Board)’s Mental Health Services in 2011. Ms C was admitted to Meadows Ward of the Royal Edinburgh Hospital on 8 December 2011. Ms C said that, despite her sleeplessness, erratic and strange behaviour and despite her friends' concerns that she was clearly not herself, she was diagnosed with a personality disorder and discharged on 14 December 2011 without any medication.
Specific complaints and conclusions
The complaints which have been investigated are that the Board's staff:
- (a) unreasonably diagnosed that Ms C was suffering from a personality disorder (upheld);
- (b) inappropriately discharged Ms C from hospital on 14 December 2011 (upheld); and
- (c) failed to prescribe Ms C with medication on discharge from hospital (upheld).
Redress and recommendations
The Ombudsman recommends that the Board:
- issue a formal written apology to Ms C for the failings identified in this investigation;
- further annotate Ms C's clinical records from Meadows Ward, to clarify that: the letters referred to in the clinical note of 9 December 2011 did not exist and no diagnosis of personality disorder had been made by the perinatal psychiatrist;
- raise the findings of this investigation with the relevant clinical staff for consideration as part of their next annual performance appraisals;
- develop a strategy for improving carer involvement and communication on Meadows Ward;
- develop a strategy for improving information sharing within multi-disciplinary teams on Meadows Ward;
- develop a strategy for ensuring multi-disciplinary discharge planning on Meadows Ward;
- review record-keeping practices on Meadows Ward, to ensure that communication with carers and family is appropriately recorded; and
- meet the outstanding treatment costs Ms C incurred while in France, prior to her discharge on 13 January 2012.
The Board have accepted the recommendations and will act on them accordingly.