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Case ref:201508695
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Date:October 2016
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Body:Greater Glasgow and Clyde NHS Board
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Sector:Health
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Outcome:Upheld, recommendations
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Subject:clinical treatment / diagnosis
Summary
Mr C complained about a lack of measures taken by the mental health team based within the prison after he reported thoughts of harming himself or others. Several days later, Mr C caused damage to his arm and hand requiring surgical treatment at hospital.
We took independent advice from a mental health adviser. We found that a team approach should have been taken towards assessing and making a joint decision on Mr C's risk of harming in light of historic factors which do not appear to have been considered after he reported concerning thoughts.
We concluded that Mr C should have been managed under ACT 2 Care arrangements (a strategy for the care of individuals assessed to be at risk of self-harm or suicide) until such time that a multi-disciplinary team decided that his level of risk no longer needed such measures to be in place.
Recommendations
We recommended that the board:
- issue a written apology to Mr C for the failings identified;
- ensure all relevant staff in the health centre team at the prison are aware of the ACT 2 Care approach to self-harm where 'at risk' prisoners should be subject to the individualised risk management arrangements; and
- share these findings with the staff involved in Mr C's care.