Investigation into the death of Mr D - a young man who died in hospital while being treated for mental ill health

An investigation into the death of an 18-year-old man in hospital in Scotland found that there were aspects of his care and treatment that, had they been conducted differently, might have prevented his death. 

The new investigation, by the Mental Welfare Commission, is anonymised, as all the Commission’s investigations are.

Mr D died in hospital in December 2018 from the consequences of drinking an excessive quantity of water. This happened when he was detained under the Mental Health Act for urgent treatment on an adult ward.

Mr D had previous contact with child and adolescent mental health services (CAMHS), where he had been treated after drinking an excessive quantity of water. He was diagnosed with early onset psychosis and received two years of community based CAMHS care.

Mr D turned 18 while still under the care of the CAMHS specialist psychosis service. The service was moving away from a treatment model that supported young people with first onset psychosis for at least three years from the point of diagnosis, towards one in which transition to adult mental health services began around the age of 18 years. 

At a point of crisis in early December 2018, Mr D was admitted out of hours to an adult mental health service inpatient unit in a neighbouring health board to his own, as there were no local beds available. 

During the 70 hours of this admission Mr D’s case records from his years of contact with the CAMHS community team were unavailable. Relevant clinical information was passed to members of the new treating team. There was also telephone and face-to-face contact between Mr D’s parents and the receiving general adult consultant psychiatrist and ward staff. Not all of this valuable clinical information made it into the care plan in use during Mr D’s admission.

Mr D drank excessive water during that hospital stay and died three days later in intensive care.

Suzanne McGuinness, executive director (social work), Mental Welfare Commission, said:

“This was a tragic death of a young man while he was being cared for in hospital. 

“Our report details the actions and decisions taken by teams at the two health boards involved in the lead-up to his death. We found that a more assertive approach to the treatment of Mr D’s psychotic illness in the two years before his death was warranted. The risks associated with psychotic illness were not coherently managed.

“We also found that there were problems in Mr D’s transition from child and adolescent mental health services to adult mental health services. Existing guidance was not adhered to.
“We found that although the service had no other viable option, the transfer of a very unwell young man with a complex clinical history to another health board area during the night was a high-risk action.

“Mr D’s family told us they felt that they had not been listened to. They felt their concerns were not given due credence.

“We ask mental health services across Scotland to read this report, consider our findings carefully, and take action where they believe they can make improvements. 

“We make 10 specific recommendations for change to, amongst others, the health boards involved, the Royal College of Psychiatrists, NHS Education Scotland and Scottish Government.”

Note
This report is one of a series of investigations carried out by the Mental Welfare Commission as part of Commission proposals to review how deaths of people detained for mental health care and treatment are reviewed across Scotland. Further information can be found here.