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Case ref:201803262
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Date:September 2020
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Body:Inverclyde Health and Social Care Partnership
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Sector:Health and Social Care
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Outcome:Not upheld, no recommendations
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Subject:clinical treatment / diagnosis
Summary
C complained about the care and treatment A had received at Inverclyde Royal Hospital before their death. A was admitted to the hospital where they saw a liaison community psychiatric nurse (CPN) who carried out an assessment. The decision reached was that admission for in-patient psychiatric care was not indicated and that A should re-engage with community services. They were discharged from the hospital that afternoon. A completed suicide on the following day.
We found that whilst the assessment completed by the CPN was not entirely transparent and lacked structure, on balance, it was adequate. The decision not to admit A to hospital was reasonable. It was also reasonable for the CPN to explore A's past and current substance misuse and there was no sense from the records that they did so disproportionately. The CPN also checked that A's case with addiction services was still open and we found that a psychiatrist had both sufficient and current knowledge to make an informed decision on the case. Whilst there was an error in the CPN's assessment letter, there was nothing to suggest that this error made a material difference to the CPN's decision-making. We found that there were no significant errors in A's care and treatment and therefore, we did not uphold the complaint.