Patient's diagnosis and discharge from psychiatric unit 'unacceptable'
A report on the treatment of a man who took his own life two days after being discharged from a psychiatric hospital has found serious failings.
The Mental Welfare Commission has published its investigation into the care of the patient, referred to as Mr QR, by a Scottish health board.
The man was treated for a personality disorder and a consultant judged him fit to leave the unit in the Highlands.
The commission said the patient's diagnosis was "seriously flawed".
Its report also concluded that the manner of his discharge from the psychiatric hospital where he was being treated was "completely unacceptable".
Mr QR died on 31 December 2014 - six months after he and his wife had their first contact with mental health services.
The commission said the man had been diagnosed with faking his mental illness.
The report criticised a consultant who treated him for disregarding a second opinion which he had asked another colleague to provide.
The commission found that had "serious implications" for Mr QR's care.
On the day he was discharged, Mr QR was given a copy of the Yellow Pages by hospital staff and told to find somewhere to stay, the report found.
He was warned the police would be called if he did not leave hospital.
A significant event review was conducted by NHS Highland. The report included the findings from this review.
The commission interviewed health service staff, Mr QR's wife, family and two friends, in addition to examining clinical records.
It looked at:
- the reasonableness of Mr QR's management by health services,
- the predictability of him carrying out a serious act of self-harm, and
- any opportunity for prevention of the act.
It found that it was known and accepted by the clinical team that Mr QR remained a suicide risk.
"What was not predicable," the report said, "was when he might try to harm himself".
Mike Diamond, executive director (Social Work) at the Mental Welfare Commission, said the question of whether Mr QR's death may have been preventable under different mental health management "could not be stated with certainty".
However, he said that after a thorough investigation, "I can say we have serious concerns that Mr QR was not rigorously treated".
He added: "We question the diagnosis given to Mr QR, and we believe that diagnosis - of personality disorder and factitious disorder - affected the way in which Mr QR was treated.
"Every patient, no matter their diagnosis, should be treated with dignity and respect and we do not believe that happened in this case."
A number of recommendations for NHS boards have also been outlined in the report.
Mr Diamond added: "Our recommendations are not only for the health board that was involved with Mr QR, but for all mental health services throughout Scotland.
"We expect them all to reflect on this tragic case and on our recommendations.
"We ask that all mental health services undertake a self-assessment their own and make any necessary adjustments."
Names and locations were anonymised in the report to protect identities.
NHS Highland said it was aware of the findings of the Mental Welfare Commission report.
It said: "All health boards in Scotland have been asked to ensure the report's findings are acted on and we will be making sure that we do that."
A Scottish government spokeswoman said: "Any death by suicide is a tragedy and the Minister for Mental Health offers her deepest condolences to the family and friends of Mr QR who have been bereaved in this sad way.
"The Scottish government takes the issue of mental health very seriously and the minister thanks the Mental Welfare Commission for this very thorough report.
"The minister expects the board with responsibility for the consideration and implementation of the report's recommendations to do so."