Decision Report 201504188

Summary

Mrs C complained to us that the medical practice had failed to provide appropriate care and treatment to her late husband (Mr C) who died following an overdose. Mrs C said that her family had reported their concerns about Mr C's behaviour and that he should have been referred to the mental health services but the practice did not listen to their concerns.

The practice maintained that, on examination, there was no indication that Mr C suffered from mental health issues or that there was the possibility of a suicide risk.

We took independent advice from a GP. We concluded that as Mr C was showing signs of paranoid ideation (having beliefs that you are being harassed or persecuted, or beliefs involving general suspiciousness about others' motives or intent), verbal aggression, and transient confusion this would warrant a mental health assessment in the first instance with the possibility of referral for a specialist opinion. We also found that the practice should have taken action in view of the concerns voiced by the family. Although there was no evidence that the inactions of the practice directly led to Mr C taking an overdose, we upheld the complaint in light of the failings identified.

Recommendations

We recommended that the practice:

• apologise to Mrs C for the failings identified in this report;
• make contact with the Health Board Clinical Support Group for guidance on training regarding patients with mental health problems; and
• ensure that the GP discusses this case as part of their annual appraisal.