NHS Fife is to apologise to the family of a mentally ill man who went on to kill himself.
The board was criticised by the Scottish Ombudsman after the family of the man, known only as Mr A, complained about his treatment.
He upheld the complaint that NHS Fife had “failed to provide Mr A with appropriate care, support and treatment” after his visit to hospital in April 2013 and that it had unreasonably failed to provide his family with enough information about his health to allow them to support him.
Suffering from anxiety, depression and panic attacks for many years, Mr A had regularly attended his GP.
Describing worsening symptoms and feeling suicidal he saw an out-of-hours GP on two consecutive days in March 2013. He was then seen by a duty psychiatrist and discharged with a referral for a medication review.
Two days later he ended up in Victoria Hospital’s A&E department after taking an overdose.
He was discharged and his parents, Mr and Mrs C, contacted his GP to say they felt they could not leave him because of the state he was in.
Mr A took his own life the next day.
At a meeting the board said because his suicidal thoughts had been fleeting and intermittent, the decision was taken he could be treated in the community.
He had also been declined further medication due to an overdose risk.
A significant events analysis (SEA) concluded in hindsight Mr A’s level of risk to himself had not been anticipated.
Mindful he was reviewing the case with the benefit of hindsight, the ombudsman felt although the out-of-hours GP’s initial assessment was reasonable, the duty psychiatrist’s analysis did not detail suicide risk factors. There was also no evidence Mr A’s partner had been included in discussions.
Mr A was not told what to do if his condition deteriorated and when he went to A&E staff were unaware he had already been to the NHS twice before with suicidal feelings.
Had staff known, they would have been able to see his condition was developing and more urgent action may have been taken. The ombudsman recommended NHS Fife apologise, provide evidence of action taken in reply to the SEA recommendations, review this case and how patient records are maintained and shared.
NHS Fife general manager Mary Porter said a number of actions had already been taken to minimise the risk of this happening again and accepted the ombudsman’s recommendations which would be implemented in full.