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Case ref:201300533
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Date:December 2013
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Body:Tayside NHS Board
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Sector:Health
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Outcome:Not upheld, recommendations
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Subject:clinical treatment / diagnosis
Summary
Mr C complained on behalf of his daughter (Ms A) about the care and treatment she received when twice admitted to hospital. Mr C questioned whether Ms A was properly assessed on both admissions and why, although he said she had suicidal thoughts, she was discharged on the second occasion with a large amount of drugs, before taking an overdose. He believed that this would not have happened if things had been handled differently, and that they should have dealt with her medical problems holistically.
The complaint was investigated and all the relevant information, including the complaints correspondence and the relevant medical records, was given careful consideration. We also obtained independent psychiatric advice from one of our medical advisers. As part of the investigation, the adviser reviewed Ms C's records with specific reference to the assessments made on her admissions and the circumstances of her discharge. He was satisfied with these and had no criticism to make about them. While Mr C believed his daughter had psychiatric problems which meant she should have stayed in hospital, our investigation found that on both admissions, she was a voluntary patient. She had been admitted primarily in relation to her excessive drinking and her admissions were based on an agreement that if she was found to possess or use alcohol she would be discharged. As Ms C had broken that agreement, she was discharged, and the records showed that reasonable outside support arrangements had been put in place for her. We did not uphold the complaint but as our adviser said that, though they would not have changed the outcome, there were some things that could have been done better, including the use of ICD10 (a classification of mental and behavioural disorders - clinical descriptions and diagnostic guidelines) we made some related recommendations.
Recommendations
We recommended that the board:
- consider using ICD 10 diagnoses;
- give attention to the dates on which letters are compiled and dispatched to satisfy themselves that they are issued in a timely manner;
- identify the responsibilities of agencies involved, and further, identify the lead; and
- review the procedure for passing information to carers and satisfy themselves that it is fit for purpose.