Trust's poor communication with vulnerable patient caused unnecessary stress

What happened

Mr P had a history of low mood and went to his GP feeling low and agitated. The GP prescribed him diazepam for ten days but Mr P took all the diazepam in two doses. Mr P went to see his GP again and said he had suicidal thoughts. The GP referred him for an urgent assessment.

Mr P went to the Trust with his mother, Ms K, for the assessment and they were told to wait in the A&E department of a nearby mental health trust (which was not part of this investigation). They regularly asked when they were likely to be seen, but the A&E staff could not get hold of the psychiatrist who was performing the assessment. Ms K thought that they may have been forgotten. After around three hours of waiting, Ms K's son could not cope waiting any longer and they left without the assessment being done.

Ms K complained that she found it upsetting that they were not updated regularly while waiting and worrying that someone as vulnerable as her son was, may not receive the urgent care they need. She wanted the psychiatrist involved to know exactly what she and her son went through that night, and for the Trust to take steps to make sure it did not happen again.

What we found

The Trust failed to communicate with Ms K and her son, which led to them walking out without the assessment being done. The Trust was separate to the mental health trust, where Ms K and her son were told to wait, and it did not have any policies or procedures in place to keep people who are waiting updated.

We found that it was not good practice to leave vulnerable people waiting with no idea when they would be seen. We concluded that the two Trusts should agree a procedure between them for keeping patients updated.

Putting it right

The Trust wrote to Ms K and explained how it had improved communication with vulnerable people while waiting in A&E for psychiatric assessments.