Mental health assessment did not identify key risk factors

What happened

In spring 2014 Mrs G's counsellor referred her to the Trust's Crisis Resolution Team (CRT). She was assessed the next day by a community psychiatric nurse (CPN) working as part of the CRT. Mrs G said she reported having a 'stockpile' of medication and 'overwhelming' thoughts of suicide as she was planning to take an overdose the next day. Although Mrs G's husband pointed out that intervention from the Home Treatment Team (HTT) had been beneficial in the past, based on the assessment that day, the CPN decided it would not be helpful on that occasion.

The following day Mrs G took a massive overdose and needed emergency treatment at hospital. Mrs G complained to the Trust saying that intervention from the HTT would have prevented her from taking an overdose.

The Trust investigated and explained to Mrs G why she had not been referred to the HTT. The Trust acknowledged that although the CPN felt Mr and Mrs G had understood and agreed with their assessment, this was clearly not the case. They apologised for 'any misunderstanding' and said the CPN's manager would speak to the CPN. Mrs G and her husband met the Trust in summer 2014 but felt that this didn't resolve their concerns. Mrs G was told that the Trust would contact her again after the meeting but when she had heard nothing further she asked us to investigate her complaint.

What we found

We decided it was more likely than not that Mrs G did inform the CPNshe had a stockpile of medication, and that she intended to take an overdose the next day. We saw adequate evidence in the assessment that Mrs G reported she had stored up her medication although we were unable to say why there was no record of her informing the CPN of her intentions. We found this was crucial information that should have been documented.

If this information had been clearly recorded, then it was likely that the assessment would have reached an outcome that was consistent with the outcome of Mrs G's previous assessments that she needed referral to the HTT.

Mrs G said there would have been a different outcome if she had been referred to the HTT. We could not say for certain that Mrs G would not have taken an overdose even if she had been offered intervention from the HTT. However, we accepted that it was less likely that she would have felt the need to take this course of action and that she would have been reassured that the support she wanted was available to her on the day she most needed it.

Putting it right

The Trust apologised to Mrs G and provided her with the written reassurance that she could request a review by the on-call psychiatrist if she was unhappy with the outcome of any future assessments.