Summary
Mr A suffered from anxiety, depression and panic attacks for many years; he attended his GP regularly and was prescribed Citalopram and, on occasion, diazepam. In March 2013, Mr A saw an out-of-hours GP, describing worsening symptoms and feeling suicidal. He was prescribed lorazepam and told to see his GP the next day; Mr A attended the out-of-hours GP again the next day and reported suicidal feelings again; he was then seen by a Duty Psychiatrist and discharged with a plan to refer for a medication review. Two days later, Mr A attended the Accident and Emergency Department at the Victoria Hospital after taking an overdose. He was discharged, and his parents (Mr and Mrs C) contacted his GP to say they felt they could not leave him alone due to his state. The following day, Mr A took his own life.
Mr and Mrs C complained to the Board and, along with Mr A's partner, met with Board staff. The Board said that, because Mr A's suicidal thoughts had been fleeting and intermittent, a decision was made that he could be treated safely in the community. He had also been declined further medication, which he had requested, due to the risk of overdose. A Significant Events Analysis was then carried out, where it was identified that benzodiazepine withdrawal may have been a factor in Mr A's mental health deterioration. It concluded that, in hindsight, Mr A's level of risk to himself had not been anticipated. A number of recommendations were made.
My investigation was mindful that we were reviewing what happened with the benefit of hindsight; nevertheless, I found that although the initial assessment by the out-of-hours GP was reasonable, the Duty Psychiatrist's assessment did not detail suicide risk factors and there was no evidence that Mr A's partner, who had attended with him, was included in discussions. Mr A was not told what to do should his condition deteriorate further. When Mr A attended A&E, staff did not know that he had already presented twice to NHS services with suicidal feelings, which he was now acting upon. Had staff known this, they would have been able to see that Mr A's condition was developing, and different, more urgent action may have been taken. I upheld Mr C's complaint that the Board failed to provide Mr A with appropriate care, support and treatment following his visits to hospital in April 2013.
Mr C also complained that the Board unreasonably failed to provide Mr C's family with sufficient information about Mr A's health to allow them to support him, and I upheld this complaint too. The Board's SEA had already recommended that, in cases where suicide plans have been expressed and hospital admission is not taking place, it would be best practice to agree with patients that partners, family or carers are fully informed to help prevent harm. We found that Mr A's partner, who had attended all the hospital assessments, did not appear to have been involved in decisions about treatment. In addition, neither Mr A's partner nor Mr and Mrs C appeared to have been given any advice about how to deal with the on-going situation.
Redress and recommendations
The Ombudsman recommends that the Board:
- (i) apologise to Mr and Mrs C and Mr A's partner for the failings identified in this report;
- (ii) provide me with evidence of the action taken in response to the recommendations of the Significant Event Analysis;
- (iii) review Mr A's case with a view to improving the level and effectiveness of communication between frontline staff likely to deal with self-harm cases particularly where a patient has presented to multiple services with the same issue; and
- (iv) review how patient records are maintained and shared between departments to ensure that escalating levels of risk are identified at the earliest opportunity.