An investigation into the care and treatment of Mr D prior to his death

NHS A must complete their responsibilities under organisational duty of candour to offer an explanation for Mr D’s unexpected death and an apology where indicated, and ensure local policies fully reflect Scottish Government’s non-statutory guidance.

NHS A should audit their compliance with the now established Principles of Transition in Scotland in the care of child and adolescent patients with a diagnosis of psychosis who require ongoing treatment and transition to adult mental health services and demonstrate that robust and clear processes are in place.

NHS A to ensure staff are fully aware of and supported during the process of an SAER involving their care area or the treatment of patients under their care.

NHS B must complete their responsibilities under organisational duty of candour to offer an explanation for Mr D’s unexpected death and an apology where indicated, and ensure local policies fully reflect Scottish Government’s non-statutory guidance.

Mental health service managers should ensure they have robust local procedures in place for the acute or planned transfer of patients between services and between health boards, staff are aware of the local requirements and safeguards required, and audit their implementation.

Uncommon acute physical health scenarios can occur in patients in mental health inpatient services. To reduce the risk of harm, mental health service managers should ensure staff have information on recognising and responding to uncommon acute physical health scenarios including polydipsia and water intoxication. This may take the form of alerting staff to CPD opportunities to build and maintain competence and should be auditable.

All health boards must raise awareness among staff of the organisation’s obligations under duty of candour and related local policies. This should include a focus on organisational duty of candour when training staff to undertake SAERs and especially the requirement for a full apology (which is not the same as an admission of liability or blame).

In partnership with stakeholders, NES should support educational and workforce developments on the recognition of uncommon acute physical health scenarios which can occur in psychiatric inpatients including polydipsia and water intoxication and make this available nationally.

The Royal College of Psychiatrists CAMHS faculty should explore with its members whether barriers exist to the use of clozapine in young people who meet established clinical criteria for its use.

Considering the different digital record systems across mental health services in NHS Scotland, the Scottish Government should set standards within the next six months for the safe transfer to, or management of patients who present from other health boards, including minimum standards for information sharing and use of a standardised form.