Trust assessed man as at high risk of suicide 11 days before he took his own life

What happened

In spring 2013 Ms D's son was urgently referred by his GP to the Trust's mental health unit. A registered mental health nurse carried out an assessment and it was decided not to admit him to hospital but to refer him to local drug and alcohol services. The assessment identified Ms D's son as at high risk of suicide. Ms D's son was also advised to stop taking medication his GP had prescribed. Very sadly, he died 11 days later.

What we found

We partly upheld this complaint. Ms D's son was properly assessed by the Trust and that assessment included sufficient detail to support the conclusions reached. However, the nurse did not discuss the case with more senior colleagues as should have happened. Although the Trust had recognised that was the case, it had not adequately addressed that failing. In relation to the advice given about medication, the Trust had already explained what had happened and had taken appropriate action to address the failing it had identified.

We found no evidence that Ms D's son's death would have been prevented but we recognised that Ms D had been left with uncertainty because of this failing.

Putting it right

The Trust wrote to Ms D to apologise for the upset, worry and uncertainty she suffered and continues to suffer because her son's case was not escalated as it should have been. It paid her £500 compensation.

It also explained what action it has taken to make sure that escalating high–risk cases is embedded in the culture of the team and how that is being monitored to make sure it happens.