A mental health trust failed to adequately assess a patient and did not handle a subsequent complaint appropriately. An acute trust also failed to handle the complaint appropriately

What happened

Mr Y was admitted to A&E at the Acute Trust after taking an overdose of paracetamol while he was drunk. A doctor reviewed him and gave him treatment to counteract the effect of the paracetamol. Mr Y was also referred to a mental health nurse from the Mental Health Trust for assessment. The nurse concluded that Mr Y was not at risk of further self–harm and could be discharged once he had completed his medical treatment. Mr Y was discharged from A&E after his treatment ended, but committed suicide shortly afterwards.

Mr N complained about the care Mr Y received, and this was the subject of two joint investigations by the Trusts. Mr N said that had the Trusts acted appropriately, Mr Y would not have killed himself. Mr N also complained about how both Trusts had handled his complaint. He said that if the Trusts had done what they should have, his Family could have avoided unnecessary distress.

What we found

We partly upheld complaints against both organisations. The Acute Trust adequately considered Mr Y's condition before discharging him. But the Mental Health Trust failed to adequately assess Mr Y and take account of his physical health or a previous overdose, or ask questions about these issues. The Mental Health Trust also failed to give Mr Y information on what to do should he suffer a crisis shortly after leaving hospital. We found that the inadequate assessment was partly due to a number of poor systems in place at the Trust.

In relation to the handling of Mr N's complaint, the Acute Trust failed to adequately co–ordinate its responses with the Mental Health Trust. The Mental Health Trust failed to thoroughly investigate Mr N's complaint and failed to establish the facts of the case before responding.

We could not speculate as to what Mr Y's responses might have been had the Mental Health Trust asked the questions it should have. Therefore, we could not conclude that the Mental Health Trust's management plan (to discharge Mr Y) would have been any different, or that Mr Y would have followed any short term crisis advice. However, knowing that the assessment was inadequate caused Mr N and his Family distress. This distress was compounded by inadequate complaint handling by both organisations.

Putting it right

The Mental Health Trust paid Mr N £1,000 compensation, and explained what it would do to prevent a recurrence of the service failings. The Mental Health Trust had already apologised to Mr N for its poor complaint handling before our involvement. We found that this was appropriate, but recommended that it take further action to improve its process for handling complaints.

The Acute Trust apologised to Mr N and paid him £250 to compensate for its poor complaint handling. It also drew up plans to improve its service and the

co–ordination of joint responses to complaints.