NHS Fife has been criticised for “inadequate” care given to a mentally-ill man who walked out of a hospital and died on a railway track.
Fife’s health chief has apologised to a grieving family after the Ombudsman criticised standards of care given to the patient, Mr A, who was a paranoid schizophrenic with a history of self-harming and suicide attempts.
Mr A was taken by his concerned parents to Stratheden Hospital in “a moment of crisis”, but he absconded within hours of being admitted and was found dead on a nearby railway line.
His father believed his suicide risk had not been properly assessed and action that could have ensured his safety had not been taken.
The Ombudsman took independent advice from two experts who considered a risk assessment carried out on admission was inadequate.
While it mentioned his history of self-harm, suicide attempts and absconding behaviour, it had “important sections” left blank or completed without much detail.
They said it should have assessed the many known factors that raised his risk of serious self-harm or suicide. A day later a doctor started the process to detain Mr A under a short-term certificate, which an adviser said showed the doctor must have considered his patient to be a significant risk to himself.
Yet it did not ensure Mr A was under constant observation from that time.
“My adviser on mental health was also concerned that Mr A was able to leave the ward and hospital without staff realising, which was unreasonable,” the report noted.
Mr A’s father also complained about medical care and treatment provided in the community.
While his care package was appropriately planned and delivered and his needs met, the investigation found his parents’ needs were not examined and the Ombudsman found this unreasonable.
Describing the case as tragic, NHS Fife chief executive Paul Hawkins said: “We endeavour to offer the best possible care for all of our patients however, we accept that the care provided in this case fell considerably short of the standard that should be expected.
“We accept the recommendations made by the Ombudsman and are committed to learning everything that we possibly can in order to improve the care we provide.
“We have already undertaken a number of actions which have included improving security within our facilities to ensure a safer caring environment for patients.
“On behalf of the board, I would like to apologise unreservedly to the family involved and we will be apologising formally in the coming weeks.”