Source · SPSO (Scottish Public Services Ombudsman)

Lothian NHS Board - Acute Division

SPSO (Scottish Public Services Ombudsman) Not Upheld Reference 202103398 Sector Health Category Clinical treatment / diagnosis Decided 01 July 2022

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Full decision

Summary

C, an advocate for A, complained about the way A was treated by the board for their chronic psychotic illness. A experienced a relapse when administration of their medication was changed from a depot injection (a slow release method) to an oral route. A subsequently required two in-patient admissions. C complained the second admission only occurred due to a failure by the board to manage A's medication properly, and to being discharged from their first admission when they were still experiencing psychotic symptoms.

We took independent clinical advice from a consultant psychiatrist on the board’s management of A's medication and the circumstances of their discharge from hospital during their first in-patient admission. In reference to the board managing A's transition back onto their medication by depot injection, we found that this had been managed appropriately, and in agreement with A. However, we noted that the documentation of this could have been better. While we did not uphold this aspect of the complaint, we gave feedback to the board in respect of record-keeping.

Regarding the timing of A's discharge from hospital, we found that this had been reasonable and person-centred in approach, noting there was no reference in the medical records to A experiencing psychotic symptoms at the time of their discharge. As such, we did not uphold this aspect of the complaint.

Related reading

View Decision Report 202103398 as a PDF (24.38 KB) Updated: July 20, 2022

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