Summary
Mrs C complained about her late mother (Ms A)'s interaction with NHS 24, in particular their main out-of-hours telephone service, the Unscheduled Care Service (UCS), and Breathing Space, which is a confidential telephone service for people experiencing low mood, anxiety or depression, and also part of NHS 24.
Ms A suffered from anxiety and depression. One week after attempting suicide, she telephoned Mrs C and told her she needed help as she could not cope. Mrs C called NHS 24, describing Ms A as a risk to herself, and an NHS 24 call handler rang Ms A directly. Ms A was extremely distressed during the call. She told the call handler that she might harm herself again and that she wanted to be taken away under mental health legislation. The call was initially classified as 'serious and urgent' but, when no nurse was available to speak to Ms A, a senior nurse advised the call handler to downgrade the call, which set a three hour call back from a nurse practitioner. They also offered Ms A assistance from Breathing Space whilst she waited for the call back, which she accepted. The Breathing Space adviser (the BSA) spoke and did breathing exercises with Ms A, but she was still tearful when the call ended. A nurse practitioner called Ms A around two hours later but there was no answer and the call was closed. Mrs C called the police a few days later as she had been unable to contact Ms A. They forced entry to Ms A's home and found that she had completed suicide. It is understood that she died from an overdose of medication.
In investigating Mrs C's complaints, I took independent advice from a nursing adviser, a mental health adviser and a GP adviser with experience of NHS 24 and out-of-hours work.
Mrs C said that the classification of Ms A's call meant that a suicidal woman needing immediate help instead received a three hour call back. NHS 24's own investigation report noted that it was unclear why the call was downgraded, and that there seemed to have been a disregard of mental health concerns by the senior nurse. They also found that following the transfer to Breathing Space, the call should have been closed down within the UCS. The advice I received was that, given the information taken by the call handler, contact with Ms A should not have been broken. Allocating a three hour call back and leaving the call open after transferring to Breathing Space was not reasonable and, therefore, I upheld this complaint.
Mrs C complained that the BSA had not used Applied Suicide Intervention Skills Training (ASIST) during the call with Ms A and took no action to help her. NHS 24 said that ASIST techniques were not used as the BSA knew that a nurse practitioner would be calling Ms A to make a full clinical assessment of her symptoms. My mental health adviser said that this explanation was not reasonable as the BSA knew about Ms A's suicide attempt yet did not explore sufficiently the risk of suicide during the call. My adviser said that the support offered by the BSA was ineffective. The call recording showed that Ms A became increasingly distressed and my adviser commented that they would have expected the BSA to continue speaking with Ms A until her distress had reduced, instead of ending the call. I found that Breathing Space did not offer a reasonable service to Ms A so I upheld this complaint and made several recommendations.
Mrs C also complained that there was only one attempt to call Ms A back before closing the call, and that NHS 24 did not contact Ms A's GP. My investigation found that NHS 24's procedure is to attempt to call patients up to two times before closing the call, unless there is a particular clinical concern. However, there was enough evidence from Ms A's call to indicate a 'particular clinical concern' and I considered that further action should have been taken, including sharing information with Ms A's GP. Therefore, I upheld this complaint.
This significant case has raised concerns about how effectively mental health crises are managed by the UCS. The initial call handling is geared towards physical problems and gathering personal information. However, the advice I have received highlighted that, for people experiencing mental health difficulties, this is ineffective and can exacerbate their symptoms. More needs to be done to ensure that mental health is not treated with any less urgency than physical health, so I made a number of additional recommendations to address my wider concerns.
Redress and recommendations
The Ombudsman recommends that NHS 24:
- apologise to Mrs C for the allocation of a three hour call back;
- ensure that this complaint is included for discussion at the next appraisal of the Senior Nurse;
- ensure that all relevant staff are aware of the guidance on transferring calls to Breathing Space to avoid incorrect advice being offered to call handlers in future;
- apologise to Mrs C for the way this call was handled by Breathing Space;
- ensure that the findings of this report are discussed with the BSA for learning;
- ensure that Breathing Space staff are aware of when to use ASIST techniques;
- ensure that all Breathing Space staff are aware of the process to escalate calls;
- apologise to Mrs C for the failure to take appropriate action when Ms A could not be reached;
- ensure that this complaint is included for discussion at the next appraisal of the Nurse Practitioner;
- report to us on the implementation schedule of the new Patient Contact Management system system;
- and then again when the system goes live
- review their guidance for all staff on the management of suicidal thoughts and common mental health problems;
- review their procedures for triaging mental health difficulties, such as panic and depression, for patients who present in crisis; and
- review the questions used in the initial contact process to take mental health into account.