Publication date: 4 Oct, 2017
The purpose of the Commission's investigation was to assess Mr QR's care prior to his death, and to provide the Commission's views on:
The Commission found that Mr QR was not treated properly, and the manner of his discharge was completely unacceptable.
This investigation, like all such investigations by the Commission, is anonymised. Its purpose is to identify lessons that can be learned, not only by the health board concerned, but by all mental health services across Scotland.
The Commission found that the process of arriving at Mr QR's diagnosis was seriously flawed, and this had serious implications for his care, particularly with respect to the way he was discharged from hospital.
Staff who had contact with Mr QR were genuine in their intent to help him, and to support him in achieving recovery within the confines of the diagnostic approach.
Mr QR's consultant sought a second opinion about Mr QR and his presentation, but disregarded it.
The discharge planning and actual discharge of Mr QR in the days preceding his death fell well below the standard of what is expected.
It was known and accepted by the clinical team that Mr QR remained a suicide risk. What was not predicable was when he might try to harm himself.
Mike Diamond, Executive Director (Social Work) at the Mental Welfare Commission, said:
Notes to editors
Following Mr QR's death, a significant event review was conducted by NHS Board D on 9 February 2015, and its findings are referred to in the Commission's report.
The case was brought to the attention of the Commission by the Crown Office and Procurator Fiscal Service.
The Commission interviewed health service staff, Mr QR's wife, family and two friends for the report, in addition to examining clinical records.
Mental Welfare Commission
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