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Mrs H complained about the standard of care afforded to her late husband, X, by the Health Board’s Mental Health Services and his GP practice, before his death in January 2013 (when he took his own life). X’s clinical history included a number of incidents – he had self harmed, abused both alcohol and drugs and taken overdoses.

In 2012, X continued to be treated by the GP Practice with increasing regularity, being prescribed a number of different medications to treat anxiety/mood disorders and/or depression. These included drugs known as benzodiazepines (known to be potentially addictive). X took an overdose of anti-depressants in January 2013, two weeks before his death, but was discharged from hospital and remained on a waiting list for counselling (which he had been on for some time). However, before he could be seen, X took his own life. Mrs H also complained that she had subsequently received a letter addressed to X inviting him for a counselling appointment at the Practice, which compounded her distress. An inquest touching upon X’s death returned a verdict of suicide but noted “That there was a failure by those treating him to identify his suicidal intent.”

Following advice from the Ombudsman’s clinical advisers, the complaint was mostly upheld. Whilst the Ombudsman could not conclude with any certainty that the outcome would have been different, were it not for the failings found during the investigation, failures on the part of both the Health Board and the Practice, included the following:

• Lost opportunities on the part of the Health Board to properly evaluate X’s mental health following earlier serious incidents and to comprehensively assess him when he was seen.

• A failure on the part of the Health Board to discuss X’s discharge after an overdose two weeks before his death, and a failure to provide discharge information to the Practice in a timely way.

• Numerous errors in the Health Board’s own investigation, following X’s death, which indicated a lack of proper care and attention.

• A failure on the part of the Practice to refer to secondary care and/or a failure to properly assess X’s suicide risk.

• The Practice’s continued prescribing of benzodiazepines was contrary to national guidance.

The Ombudsman recommended that both the Health Board and the Practice apologise to Mrs H, and offer her redress of £1500 each, for the failures identified, her distress, and her time in pursuing the complaint.

Further recommendations included the provision of evidence by the Health Board of its audit of discharge communication with GPs, its reminder to staff conducting investigations of serious incidents and reminders about comprehensive risk assessments. In relation to the Practice, further recommendations were made about continued auditing and monitoring of its benzodiazepine prescribing and that it should produce a Practice Prescribing Policy. Both the Health Board and the Practice accepted the Ombudsman’s recommendations in full.

A full copy of the report is available below.