Trust failed to conduct adequate mental health assessments

What happened

Mrs Y's son, Mr Y, had a history of mental health problems. He became unwell in 2013 and was twice reviewed by a multidisciplinary team (MDT) at the Trust. The team concluded that his behaviour was caused by substance abuse and discharged him from mental health services. The crisis team subsequently saw Mr Y at home but they decided that he did not need treatment. A different consultant psychiatrist from another trust assessed Mr Y later that year and diagnosed him with mental health problems. The psychiatrist detained him under section 3 of the Mental Health Act and Mr Y remains in hospital.

What we found

The MDT failed to take sufficient account of Mr Y's medical history or the information Mr Y's family and other Trust staff gave them. The Trust failed to adequately consider the family's request to amend inaccurate information in their son's discharge summary. The crisis team also failed to properly assess Mr Y before deciding that he did not need treatment.

As a consequence of the Trust's failure to adequately assess Mr Y, it lost opportunities to consider steps that might have reduced the possibility of him exposing himself to risk. Although we did not conclude that Mr Y's mental health would have improved had he been adequately assessed, the family suffered distress because the Trust failed to support them and their son. The distress was compounded by the Trust's failure to properly consider Mrs Y's request to amend her son's discharge summaries.

Putting it right

The Trust acknowledged its failings and apologised for the injustice Mrs Y suffered as a consequence. The Trust made a consolatory payment of £1,500, and produced an action plan to prevent the failings from recurring.