Trust let down former inpatient of mental health unit

What happened

Mr B received inpatient mental health care at the Trust for two months. He was then discharged into community services. Staff did not give him a written care plan on discharge but arranged monthly reviews with a community psychiatric nurse. One month after his discharge, Mr B reported a downturn in his mood and asked if he could see his psychiatrist sooner than the planned appointment, which was in two months' time.

The Trust decided that this was not necessary. When the psychiatrist reviewed Mr B, he increased the dosage of his medication. Mr B died suddenly nine days after this appointment.

Mrs B subsequently complained to us about the treatment her husband received and said that she believed his death could have been avoided. Mrs B also complained about the poor standard of record keeping and said the response to her complaint was inadequate.

What we found

We partly upheld this complaint. The Trust failed Mr and Mrs B in many ways. There was a lack of written information, care planning, crisis planning and risk assessment. There was also no evidence that staff gave Mr B information about relevant community services. We also found that the community psychiatric nurse failed to take appropriate action when Mr B reported that his mood had worsened. In addition, the Trust's record keeping was poor in parts, and the response to Mrs B's complaint was not adequate.

These failings had a significant impact on Mr and Mrs B, but we were unable to conclude that these led to Mr B's death. For this reason we partly upheld the complaint.

Putting it right

The Trust apologised to Mrs B and her family, and produced an action plan to address the concerns we identified.