NHS Dumfries and Galloway has been ordered by a watchdog to apologise to the family of a patient who took their own life.
A parent of patient A said the health board failed to appropriately assess the risk to life, and filed a complaint with the Scottish Public Services Ombudsman (SPSO).
The parent highlighted concerns about treatment in the months leading up to patient A’s death, including that staff had failed to take follow up action when A had communicated suicidal thoughts.
The SPSO took independent advice from a mental health nurse and a psychiatrist, and found that an assessment prior to A’s death “did not explain how it was concluded that there was no immediate risk when A was exhibiting a number of risk factors”.
It added that there was no evidence of these risk factors being effectively weighed against protective factors, and no evidence of hospital admission having been considered and ruled out.
The SPSO report stated that there had been a failure to record or act upon communication from a GP about the case, although it noted that may not have had any “material impact” on the eventual outcome.
The parent also complained about a reduction in dosage of A’s anti-psychotic medication during the admission.
The watchdog found that, while A was appropriately involved in this, there was no evidence of proactive involvement of family members in these discussions.
It upheld the complaint entirely, and told the health board to apologise to the family – alongside six other recommendations, including working better with families, a more robust approach to risk assessment and more thorough investigation processes.
NHS Dumfries and Galloway has been approached for comment.