A Scottish mental health assessment unit had “missed opportunities” to help a school lunch woman who committed suicide two days after being discharged from hospital, an inquiry has found.
The Mental Welfare Commission’s report into the death of the woman, identified only as Ms F, said the force had not spoken to her husband, who had “highly relevant information” about her mental state. There was found.
The report also said no information was shared between the force and the emergency department and no “safety plan” was created for her after she was discharged from hospital.
The Scottish Government said, anonymously in the report, that the committee’s recommendations would be “fully implemented” in the force.
Dr. Arun Chopra, executive director of the Mental Welfare Commission, called the incident a “tragic situation” and said it shows that families should be deeply involved in mental health cases.
“One of our key messages is that families and carers must always be involved in mental health assessments,” he told BBC Radio’s Good Morning Scotland programme.
“The family was fully involved in the A&E department. [later] In the mental health unit, families did not have the opportunity to talk to staff. Staff felt unable to speak to families due to patient confidentiality obligations. ”
Dr Chopra said the “important lesson” to be learned is that confidentiality can be respected while listening to family members.
“I left in a hurry.”
Ms. F. experienced mental health problems while working as a school cafeteria worker, believing that she had harmed children by serving them food to which she was allergic.
The woman, in her 50s, thought she may have mixed up the bags of food distributed to students and told her husband, “I’m worried that killers will come after me.”
She attempted suicide twice due to this belief and failed, but she hid her attempts from her husband.
Concerned, her husband (referred to as Mr. F in the report) took her to the nearest emergency room, where she was deemed at risk and sent for a more detailed evaluation. Referral to mental health assessment department.
However, the force did not speak to Mr F as staff stated that his wife had not consented to sharing information with him.
The report said this meant “highly relevant information” was missed by staff.
Because emergency department information was also not available or used by the evaluation department, the evaluation department discharged Ms. F. home and scheduled no further mental health visits.
Mr F told the committee that he felt he had been “rushed out” of the unit.
Mr. F died two days later.
The report added that there were questions regarding the health board’s “oversight, training and governance processes”.
Ms F’s family told the press that they received “insufficient” communication from the health board after her death, and that they were not provided with any support or counseling.
Marie Todd, the Scottish Government’s Minister for Mental Wellbeing, expressed her “deepest sympathies” to Mrs Kennedy’s family.
She added: “Specific recommendations and learning points have been set out for relevant health and social care services and we look forward to their full implementation.”
This recommendation is expected to be implemented within six months.
