Summary
Mr A had a history of mental illness and of self-harm, and had been in and out of hospital as a result. He was admitted to the Royal Edinburgh Hospital for treatment after an apparent suicide attempt. He was given a pass to walk unescorted in the hospital grounds, but did not return when expected. Staff decided not to contact the police to report him missing until some two hours after his expected return time. Mr A was found dead outwith the hospital a number of days later. Ms C (Mr A's fiancée and carer) complained that Mr A was not provided with appropriate care and treatment, in that the decision to allow him off the ward unescorted was inappropriate. She also complained that she was not properly involved in the decision making in Mr A's care.
The board carried out an internal review, which found that although the decision to issue the pass was high-risk, the professional judgment of staff was reasonable in the circumstances. They also said that it was reasonable not to contact police earlier, but made five recommendations, including reviews of what should happen if a patient did not return when expected, of liaison with the police and of the risk assessment tool. The board met with Ms C, who had also met the leader of the review team. Ms C remained concerned that the board had failed in its duty of care to Mr A and wanted them to admit this. She wanted a further, independent review. The board did not agree to this, and said that they had taken appropriate action through the review recommendations. They did, however, apologise to Ms C for failures in communication with her in relation to care planning.
I took independent advice on this case from a mental health nursing adviser and a consultant psychiatrist. Mr A was recognised as having unpredictable behaviour, and had returned very late from a previous pass, so both advisers were critical of the assessment of risk, and that this was not updated during treatment, as his condition appeared to be fluctuating. Poor risk recording made it difficult to understand how it had been taken into account when making decisions, there was no mention of what was done to reduce risk and there was no plan of what should happen if he did not return from a pass. Both advisers came to the view that in the absence of a structured assessment of risk, it was unreasonable to grant Mr A an unescorted pass.
I upheld both Ms C's complaints. On the first, I accepted my advisers' view that Mr A's care fell below a reasonable standard in terms of the assessment and recording of risk. I also found that the board's review reached contradictory conclusions on whether it was reasonable for staff not to take action until two hours after Mr A failed to return. Although I cannot say whether this led directly to Mr A's death, such omissions represent a significant failing, and I criticised the board for this. As, however, the board's own review addressed many of these issues through an action plan I made limited recommendations. On the second complaint, appropriate communication with carers is a requirement of the Mental Health (Scotland) Act 2003, and it was not clear from the records whether staff viewed Ms C's as Mr A's main carer. Her status should have been documented so that staff could communicate appropriately with her.
Redress and recommendations
I recommended that the Board:
- (i) provide evidence that the action plan produced following the SAER has been implemented in full;
- (ii) ask the internal review team to reflect on our advisers' assessment of the care and treatment provided to Mr A;
- (iii) provide evidence that they have reviewed the procedures for carer involvement in patient care and management decisions;
- (iv) provide evidence that the procedural review includes a system for the timeous identification of the patient's carer or named person; and
- (v) apologise for the failings identified in this report.