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Missed opportunities - an investigation into the death of Mrs F

Publication date: 2 May, 2024

A new investigation by the Mental Welfare Commission examines the care and treatment of Mrs F, a woman who died by suicide two days after being discharged from a mental health assessment unit in Scotland.

The report finds missed opportunities in three areas at the mental health assessment unit - in engaging with Mrs F’s husband; in sharing information between departments, and in creating a meaningful safety plan.

The investigation is anonymised, as all Commission investigations are.

Mrs F was in her 50s, worked part time in catering, and enjoyed her job. In April 2021 she experienced unfounded beliefs that she’d caused harm to a child by providing food they were allergic to. This caused a rapid decline in her mental health over a short period of time. She had never been in contact with mental health services before.

Mrs F unsuccessfully attempted suicide twice, concealing her actions from her husband but later asking him to take her to a police station.  Mr F was concerned about his wife’s mental health and instead took her to a hospital emergency department, where a consultant, who spoke to both Mr and Mrs F, judged that Mrs F required an urgent mental health assessment and made a telephone referral. Mr F drove his wife to the mental health assessment unit.

Mental health assessment

Mrs F was seen quickly at the unit and interviewed by two staff members. Mr F was not involved in the assessment, as staff said his wife did not give consent to sharing information with him. 

Information that had been created at the emergency department was not all available to, or was not used by, the mental health assessment unit during their assessment.

Mrs F was discharged to go home, with no further mental health appointments planned. Mr F was not involved in the discharge process and said he felt rushed out of the unit. He said he was told his wife would explain it in the car on the way home. 

Mrs F tragically died by suicide two days later.

What we found

Our investigation found that mental health assessment unit staff did not act in accordance with the mental health assessment unit risk screening and management service operating procedures. 

We identified issues relating to record keeping, information sharing and documentation at the time of Mrs F’s assessment in the unit.

We found that supervision arrangements were not considered in the service operating procedures. We could find no guidance relating to when mental health assessment unit staff should consider seeking a senior opinion. We found that one staff nurse had not completed their training as was expected by service managers and the other was unsure if they had.

These issues indicate that the expected supervision, training, and governance processes were not functioning as intended.

If information from the emergency department and from Mr F had been sought and considered during the assessment process, the possibility of a major mental illness contributing to Mrs F’s self-harm could have been explored, and the increased risk to Mrs F resulting from any mental illness considered in the subsequent management planning.

Dr Arun Chopra, executive director (medical), Mental Welfare Commission, said: 

“This was a tragic situation for Mrs F’s family. As well as the specific service involved, we want mental health crisis services across Scotland to read our investigation, and to consider the lessons than can be learned from it.

“Mental health assessment units have a critical role to play in our health service, yet we found missed opportunities in the mental health unit assessment in this case. 

“One vital issue is that staff must have a clear understanding of their responsibilities to families, especially when they come to hospital with someone who is unwell. Whilst it is right that consent should be sought from patients to share information with others, this should not act as an impediment to listening to their concerns; and where possible involving them in care planning and safety planning. Staff must listen to them because they know the person and know what has happened. Mr F was not listened to.

“We also found there was a focus in the mental health assessment unit on risk assessment – meaning whether Mrs F was of harm to herself or others at that moment. However, a risk assessment must always be part of a full assessment to identify whether a person is seriously mentally unwell. The focus on risk led to Mrs F being sent home into the care of her GP rather than being identified as seriously mentally unwell.”