Investigation into the care and treatment of Mr QR

When a family, friend, or carer challenges the interpretation of information shared and conclusions drawn from it, services should make a clear record of the consideration of the challenge. The rationale for any changes, or the decision not to make changes, to the patient’s management plan should be clearly recorded.

NHS Boards should ensure there are clear guidelines for:
• Seeking a second medical opinion.
• Dealing with disagreement with the second opinion.

NHS Boards should ensure that their teams and services adhere to good practice standards in discharge planning, including what to do should re-presentation occur a short time after discharge. On occasions where there is an extended holiday period, planned discharges should be avoided unless there is confirmed community support in place. Patients should be discharged at short notice only in exceptional circumstances and then only when their crisis plan has been agreed.

Mental health service managers should reflect on the effectiveness of their multidisciplinary team-working. NHS Health Boards should promote this work and specifically the use of the Patient Safety Climate tools for staff and service users is recommended to help identify issues and barriers to true multidisciplinary working.

NHS Boards should review the way that multidisciplinary team meetings are conducted to ensure that staff of appropriate seniority attend when key decisions are being made.

NHS Boards should advise psychiatrists that, in cases where the doctor is making an unusual diagnosis that does not correspond with a second opinion, they should treat the case as complex and seek advice from their clinical director.