Possible missed opportunity to prevent suicide

What happened

Miss J had a history of depression and took an overdose in autumn 2012. She was briefly admitted to the Trust but as she preferred to be cared for by her family she was discharged home under the care of the Crisis and Home Treatment Team (the Crisis Team), and other agencies.

Miss J remained unwell and took a second overdose just over three weeks later. She was again discharged under the care of the Crisis Team. When Miss J deteriorated a few days later she was readmitted and then allowed home on leave a short while later with medication.

A few days afterwards, Miss J made a further suicide attempt. She was admitted to hospital, and assessed as having significant suicidal intent. The Trust reassessed her risk of self‑harm as 'low' a few days later and discharged her. Two days later she went missing from home and her mother tried to call the Crisis Team to raise the alarm but nobody answered the phone. Miss J's son found her body the same day; she had hanged herself.

Her sister Mrs K said the Trust did not adequately manage the risks to her sister's health, provide adequate medicine, or enough contact with the family. She believed her sister's suicide might have been avoided if she had received the right level of care. She said the whole family, especially Miss J's son, had been totally devastated by Miss J's death.

What we found

We partly upheld this case. The medication the Trust gave Miss J was in line with recognised quality standards and established good practice and there were no failings. However, the Trust's risk assessments and the way it managed Miss J's carewere not reasonable. This meant there were missed opportunities to give her appropriate care and treatment that could have reduced her risk of committing suicide.  As a result her family will never know whether appropriate care and treatment might have saved her life.

The family also did not have appropriate access to the Crisis Team.We acknowledged that even if the Crisis Team had answered the phone, this would not have prevented the sad events that followed. However, it could have alleviated some of the distress Miss J's sister and mother felt at that time and offered them some support.

Putting it right

The Trust apologised to the family and paid them £2,500 in recognition of the distress caused. It also put a plan in place to learn lessons from its failings and to make sure they do not happen again.