NHS Fife has been told to apologise to the family of a man who committed suicide after ‘clear and significant’ failings in his care.
Following an investigation by the Scottish Public Services Ombusdman (SPSO) the NHS Board was told to offer an apology to the family of ‘Mr A’ who killed himself just days after being treated at Kirkcaldy’s Victoria Hospital following an overdose.
NHS Fife was also told it must review how all patient records are maintained and shared between departments and provide evidence of action taken in response to the issues raised in this case. It is also to fully review Mr A’s case in a bid to improve communication between frontline NHS staff.
The SPSO report said Mr A suffered anxiety, depression and panic attacks for the last 12 years and as a result, saw his GP regularly and was prescibed drugs including citalopram and, on occasion, the sedative diazepam.
In March 2013 he saw an out-of-hours GP after suffering worsening symptoms and feeling suicidal. He was prescribed lorazepam and told to see his GP the next day. His symptoms did not improve and the next day he saw another out-of-hours GP where he reported suicidal feelings and detailed a specific plan as to how he would end his life. He was sent to a duty pyschiatrist. Mr A was then discharged with a plan to review his medication and a referral to Weston Day Hospital in Cupar for ‘anxiety management’.
Two days later he attended A&E at Victoria Hospital after taking an overdose. He was refused diazapam and discharged into the care of his parents with a list of various support groups he could contact should he reach ‘crisis point’. His parents, ‘Mr and Mrs C’, then contacted his GP to say they felt that because if his panic attacks he could not be left alone. The following day, April 6, he took his own life.
Following the death Mr A’s parents and partner made a complaint to Fife NHS Board. It 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. The family were told that a Sigificant Events Analysis (SEA) identified that benzodiazepine withdrawal may have been a factor in his mental health deterioration. The Board concluded that, in hindsight, Mr A’s risk of harm to himself had not been anticipated. The Board had noted that Mr A had a close, loving family, no history of self-harm and no problem with illicit drugs or alcohol.
The SPSO investigation determined that although care by the out-of-hours GP was reasonable the duty psychiatrists assessment did not detail suicide risk factors and there was no evidence that Mr A’s partner, who attended with him, had been included in any discussions. He was also not told what to do should his condition deteriorate.
Upholding the family’s complaint the author of the SPSP report said: “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 his condition was developing, and different, more urgent action may have been taken.”
The Ombudsman’s own consultant forensic psychiatrist pointed out that the duty junior psychiatrist did not seek advice from a more senior specialist.
A futher complaint by Mr A’s father that the Board unreasonably failed to provide his family with sufficient information about his health to allow them to support him, was also upheld. The report said the Board’s own SEA already recommended that, in cases, where suicide plans had been expressed and hospital admission is not taking place, best practice is to agree with patients that partners, family or carers will be fully informed to help prevent harm.
Responding to the report, NHS Fife General Manager Mary Porter said: “This is a particularly tragic case and I would like to extend our deepest sympathies to the family involved.
“We endeavour to provide the best possible care for all of our patients, however, we accept that on this occasion we fell short.
She added: “A number of actions have already been taken in order to minimise the risk of such an incident recurring in future. we also accept the recommendations made by the Ombudsman and these will be implemented in full.
“We will be apologising to the family in the coming days and we welcome the opportunity to reiterate that apology publicly.”