NHS Borders has been told to apologise to the mother of a man who committed suicide after being discharged by the mental health team.
A complaint about his treatment was made to the Scottish Public Services Ombudsman by his mother (Mrs C) and after investigating the case the Ombudsman upheld the complaint and recommended that the health board apologise to Mrs C “for the failings in Mr A’s agreed care plan and poor record-keeping”.
In the SPSO report it says: “We took independent advice from a mental health nurse and a consultant psychiatrist. We found that there were significant gaps and numerous retrospective entries in Mr A’s medical records which were unreasonable and not in line with national guidance on record-keeping.
“We considered that this likely impacted on the team’s ability to fully understand Mr A’s health and wellbeing. There was evidence to show that Mr A did not receive the planned number of weekly visits from the team, either because he missed appointments or because the visits were not carried out.
“Given Mr A’s complex care package, we also considered that escalation to the responsible medical officer should have taken place when there had been a nine day gap in contact or when there was a significant deviation from his care plan (only one visit a week instead of three). Therefore, we upheld this aspect of Mrs C’s complaint.
“In relation to communication with Mrs C, we noted that the rights of the named person are limited and there was no requirement for the team to have shared all aspects of Mr A’s care with her. However, we considered it is generally good practice to communicate with the named person/family which had been part of Mr A’s care plan. We found that the mental health team did not communicate reasonably with Mrs C. However, we noted that the board had acknowledged these failings.
“The board carried out a significant adverse event review and in their response to Mrs C, they concluded that the care Mr A received was person-centred. The board also identified some learning points in relation to managing the expectations of the named person.
“We did not have significant concerns about the information Mrs C felt was missing. However, we were critical that she had not been provided with the opportunity to raise such concerns. The SAER should have identified the failings in record-keeping.
“When significant deviation from an agreed care plans occurs, this should be escalated to the responsible medical officer for discussion and a record made of what the response to this should be. We have asked the organisation to provide us with evidence that they have implemented the recommendations made.
A spokesman for NHS Borders said: “The delivery of care in line with the agreed care plan and record upkeep in this case were unacceptable. We have accepted all recommendations that were identified and have started to implement changes in line with these recommendations so that failings of this nature are not repeated.
“Relevant discussions will now take place and will also be documented if significant deviation from an agreed care plan occurs in future.
“We are very sorry for the additional upset our failings have caused [the patient’s mother] and her family at a sad and already difficult time.”