Summary
C complained about the care and treatment provided to their adult child (A) by the partnership. A had received care from mental health services for several years prior to their death by suicide. C complained that the partnership failed to reasonably share information with A’s family and failed to involve them in A’s care. C also complained about the HSCP’s complaint handling.
We took independent advice from a consultant psychiatrist. We found that the partnership had failed to evidence that there was any discussion with A about sharing information with their family or involving family in care and treatment, including risk assessment. We considered that not to have had this discussion, or to have had the discussion and failed to document it, was unreasonable. We upheld this aspect of C’s complaint.
We found that there were delays in the partnership responding to C, and that they did not answer all points of the complaint. We upheld this complaint about complaint handlings.
Recommendations
What we asked the organisation to do in this case: Apologise to C for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.
What we said should change to put things right in future: Records should be comprehensive and completed in line with professional standards. In particular, mental health services should seek to discuss involving family in care planning and risk assessment. These discussions and outcomes of such should be documented; and revisited regularly.
In relation to complaints handling, we recommended: Complaints should be responded to in a timely manner and in line with obligations under the NHS Model Complaint Handling Procedure. Complaint responses should attempt to address individual concerns, or explain why that is not possible.
We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.
Related reading
View Decision Report 202400112 as a PDF (27.17 KB) Updated: April 30, 2025