Health board slated over suicide of 20-year-old

A HEALTH board has been condemned by Scotland’s public services watchdog following an investigation into the death of a man who took his own life, despite being seen by a psychiatric nurse following previous suicide attempts.

Jim Martin, the Scottish Public Services Ombudsman, has ordered NHS Tayside to issue a formal written apology to the father of the 20-year-old who died in July last year.

He told the health authority to implement a major review of its risk assessment procedures following self harm or suicide attempts by patients.

His detailed report reveals the investigation found that there was no written care and treatment plan for the 20-year-old, known as Mr A, anywhere in his medical records.

Mr Martin also expresses “serious concern” that copies of both the board’s significant incident review (SIR), held in August 2010, and the root cause analysis (RCA), undertaken in August this year, were only provided to his office following the completion of the investigation into Mr A’s death and after a draft report had been issued to NHS Tayside.

The ombudsman began his investigation after being contacted by the young man’s father, known as Mr C, who had raised a number of concerns about the standard of care and treatment provided to his son by the authority’s Mental Health Service during the 13 months prior to his suicide.

According to the report, Mr A was first admitted to Ninewells Hospital in June 2009 after an intentional overdose. His case was reviewed by a clinical nurse specialist, who saw him another 12 times over the next year. But in late March 2010, following two missed appointments, Mr A was discharged from the psychiatric nurse’s caseload.

A NHS Tayside spokeswoman said the report and its recommendations will be discussed by Tayside NHS Board at a meeting on 26 January.