Source · SPSO (Scottish Public Services Ombudsman)

A Health Board

SPSO (Scottish Public Services Ombudsman) Partly Upheld Reference 201302649 Sector Health Category clinical treatment / diagnosis Decided 01 December 2014

Full decision

Summary

Mr C complained that the board failed to provide him with appropriate ongoing psychiatric treatment and support after he was admitted to a hospital psychiatric unit. After taking independent advice from one of our medical advisers - a consultant psychiatrist - we found that Mr C was treated appropriately whilst he was in the hospital. However, several months after he left there, he was diagnosed with borderline personality disorder. We found that psychiatrists had failed to adequately document a detailed medical history, and that the diagnosis was not adequately founded or justified. It was not made with sufficient rigour and was not reviewed appropriately.

There was no evidence that assessment for psychological treatments was carried out so that Mr C could be offered treatment promptly. His care and management were not coordinated and there was no evidence that his care plan had been reviewed. In addition, it was not clear whether the findings of a scan were adequately communicated to him. We found that this delayed Mr C's treatment for a number of months. In view of all of this, we upheld the complaint. However, we found that a psychiatrist who had later taken over Mr C's care had been following an appropriate plan of further investigation in collaboration with Mr C's GP.

Mr C also complained that staff had failed to admit him to the psychiatric unit when he was discharged from another hospital after attempting suicide. The discharge letters from the other hospital, however, did not say that Mr C should be admitted to the unit. We found that it had been reasonable for the board not to readmit Mr C at that time and did not uphold this aspect of his complaint.

Recommendations

We recommended that the board: issue a written apology to Mr C for the delay in providing him with appropriate psychiatric treatment and support; review his current treatment to ensure that it is appropriate; take steps to ensure that clinicians are more rigorous in the way that they diagnose personality disorders and that appropriate treatment is provided; and take steps to ensure that care management for psychiatric patients is co-ordinated.

Related reading

View Decision Report 201302649 as a PDF (13.63 KB) Updated: March 13, 2018

View original on SPSO (Scottish Publ… website

Other decisions involving A Health Board

Reference Date Summary Outcome
201700618 01 Jul 2018 Ms C has type 1 diabetes and needed a consultant-led maternity unit for the delivery of her baby. The board … Upheld
201702191 01 May 2018 Mr C complained about the care and treatment his late father (Mr A) received at the Royal Alexandra Hospital. In … Upheld
201608303 01 Apr 2018 Ms C, who works for an advocacy and support agency, complained on behalf of her client (Mrs B). Ms C … Upheld
View all decisions for this organisation