Trust did not apologise for failings it had identified

What happened

Miss T had previously suffered from depression and became unwell again in 2012. She spent several weeks at the Trust as an inpatient before she was well enough to be discharged. About a month after her discharge from hospital, Miss T took her own life.

Ms B contacted the Trust, which carried out a serious incident investigation. This highlighted some concerns about Miss T's management. There was no psychologist at the Trust during Miss T's inpatient stay in hospital and there was poor communication about her discharge. However, the Trust's investigation concluded that Miss T's suicide could not have been predicted or prevented.

Ms B complained to us because she felt the Trust had failed to accept any responsibility or apologise to her.

What we found

For the most part, the Trust's management of Miss T as an inpatient and in the community was appropriate and in line with the relevant local and national guidance. There were some failings in Miss T's treatment, but the Trust had already identified most of these.

These failings may have affected Miss T's engagement with some inpatient therapies and caused her additional anxiety when she was in the community. Despite this, there was no evidence that the Trust missed any opportunities to identify that Miss T may have had suicidal thoughts or to stop her from taking her life. However, because of the way the Trust had investigated Ms B's concerns, it had not apologised to her or acknowledged the impact of its failings.

Putting it right

The Trust apologised to Ms B for its failings. It also reviewed its investigative processes to ensure that when it identifies shortcomings, it formally recognises and addresses them.