Two trusts failed vulnerable patient

What happened

Mr A went to Norfolk and Norwich University Hospitals NHS Foundation Trust (the first Trust) with Ms B because he was having suicidal thoughts. He waited a long time for a doctor's assessment, and then waited all night for the crisis team from the neighbouring Trust (Norfolk and Suffolk NHS Foundation Trust ‑ the second Trust) to see him.

During the night, the first Trust did not support Mr A and Ms B adequately, and this caused both of them considerable distress. The second Trust's crisis team did not arrive, although the first Trust telephoned several times.

A mental health nurse assessed Mr A the following morning. The nurse discharged him and recommended he went to his GP surgery to arrange counselling.  Mr A was found dead some days later. An inquest reached a narrative verdict.

What we found

The initial triage that the first Trust completed was inadequate. However, the decision to not complete toxicology tests or detain Mr A under mental health legislation was reasonable.

There were shortcomings in the level of support that the first Trust gave Ms B and Mr A overnight. The Trust addressed this by apologising to Ms B and giving staff feedback.

The second Trust's crisis team's failure to come to see Mr A was unreasonable, particularly given the length of time that he waited to be assessed. The eventual assessment and discharge by the mental health nurse was not as comprehensive as it should have been. It was likely, however, that the outcome would have been the same even if the assessment had been thorough and properly recorded.

Putting it right

Both Trusts apologised to Ms B and told her that they had relayed the lessons they had learnt from her complaint to staff.

The first Trust took steps to make sure that complaints involving both Trusts are better managed in future to avoid the delays Ms B experienced. The second Trust agreed to do likewise.