An investigation into the suicide of a patient has resulted in NHS Fife being told to apologise to his family and tighten up its procedures.
The order comes from the Scottish Public Services Ombudsman after a complaint from the victim’s father over the standard of care provided to his son in the community and in Stratheden Hospital, where he was taken by his parents in a moment of crisis.
Having been diagnosed previously with paranoid schizophrenia, the son had a history of self-harming and attempting suicide. He was admitted to hospital in June 2013, but absconded within hours and was found dead on a nearby railway line. His father believed the suicide risk was not properly assessed on admission, and actions weren’t taken that could have ensured his safety.
The Ombudsman discovered the risk assessment on the son’s medical records was unsigned and important sections were either left blank or completed without much detail.
Although the form did record a history of self-harm, suicide attempts and absconding behaviour, expert advisers said the assessment should have been collaborative, including the patient, his parents and all involved staff. It also should have assessed and discussed the factors that increased the risk of serious self-harm or suicide.
It was also discovered that on the day after admission, a doctor began the process to detain the patient under a Short Term Detention Certificate – this showed the doctor must have considered him to be a significant risk to himself.
The doctor did not ensure the patient was under constant observation from that time, and this was deemed to be unreasonable. Advisers to the Ombudsman noted the detention was not recorded inthe patient’s notes so it was not clear if nursing staff knew about the decision to detain him. Concern was also expressed that the patient was able to leave the ward and hospital without staff realising – this was also seen as unreasonable.
“Given the advice received, I considered that the care and treatment provided ... in the hospital was below a reasonable standard. I upheld the complaint,” the Ombudsman stated.
The patient’s father also complained about the medical care and treatment provided to his son in the community.
The Ombudsman added: “The care package was appropriately planned and delivered, and his needs met. However, the needs of his parents, who played an essential role in supporting him, were not examined.”
He said the parents would have been entitled to a carer’s assessment, which would have explored how much choice they had in their provision of care, and the impact on them, including their health, domestic needs and relationships. This was also considered to be unreasonable.
As a result of the investigation, the Ombudsman recommended that Fife NHS board:
– Apologise unreservedly to the family.
– Review its admission procedures to ensure there is multi-disciplinary involvement in the risk assessment of emergency admissions;
– Remind all staff of the importance of accurate contemporaneous record-keeping;
– Contact the doctor’s current employers and ask them to ensure that the investigation was considered and reflected on in his next appraisal;
– Review risk assessment tools used by staff to ensure they include an adequate review of historical risk factors;
– Review the procedures followed during nursing handover to ensure that patients are adequately monitored during this period;
– Review procedure followed for Short Term Detention Certificates, to ensure multi-disciplinary involvement;
– Review procedures for community care provision to ensure the needs of carers are pro-actively considered.