Decision Report 201200270

Summary

Mr C complained about the care and treatment that his wife (Mrs C) received from the perinatal (period before and after birth) psychiatric service. In particular he complained that his wife was not adequately or correctly assessed; her medication might have contributed to her illness, she was allowed unsupervised leave with their daughter when she was an assessed risk to her daughter, she was subject to undue pressure to breastfeed and that a flawed decision was made to refer his daughter to social services as a child protection case.

Our investigation, which included taking independent advice from a clinical adviser, found that the care and treatment provided to Mrs C had been reasonable overall. There was no evidence to suggest that she had not been adequately or correctly assessed or that her medication was inappropriate. The adviser was satisfied that Mrs C was appropriately supervised and there was no evidence of undue pressure to breastfeed. However, the adviser raised some concerns over a lack of consultation with and involvement of, Mr C in his wife's care and we made recommendations to address these points.

Recommendations

We recommended that the board:

• apologise to Mr and Mrs C for the failure to complete assessment documentation as required and to involve a carer in a manner consistent with the relevant care pathway documentation; and
• audit the use of completion of the care pathway documentation relevant to this case and consider what changes are needed to ensure documentation is properly completed and utilised.