Mr S had a history of depression and had had previous psychiatric inpatient stays. During an inpatient stay, the Trust did not keep clear records that showed his clinician's working diagnosis and treatment plans. It also did not properly appreciate how risks to him changed as his mental health deteriorated.
What happened
Mr S had a history of depression and previous psychiatric admissions. He went into hospital at the Trust voluntarily after he had taken an overdose with the intention of killing himself. Although he initially responded to treatment plans put in place, his mental health started to deteriorate. He told the health care professionals involved in his care about his deterioration. A few days after an incident when he was on unescorted leave from the hospital, Mr S's leave was changed to escorted leave. Shortly after, he left the hospital alone and took his own life.
What we found
We partly upheld this complaint. Record keeping was inadequate because it was not clear what Mr S's working diagnosis was from the records alone. The Trust had also failed to appreciate the increased risk to Mr S.
We did not find that these shortcomings affected Mr S's care.
Putting it right
The Trust agreed to complete an action plan to prevent the failings occurring again.
Lancashire Care NHS Foundation Trust
Lancashire
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