Home > Publications > Selected Cases > Selected Investigations Completed December 2002March 2003 > Case no. E.7/02-03
Complaint against Local Health Partnerships NHS Trust
Summary of Case
Mrs D, who was six and a half months pregnant and who suffered from mental health problems, was admitted to an open ward at St Clements Hospital under Section 2 of the Mental Health Act. Continuous assessment was not deemed necessary. Fearing that she had begun labour, Mrs D tried to abscond to the maternity unit at a neighbouring hospital. However, her attempt was unsuccessful and she was brought back to the ward. Late that night, Mr D received a telephone call from ward staff informing him that his wife could not be found and that the police had been informed of her disappearance. Mr D subsequently organised a search party and, through his own efforts, Mrs D was found the following morning and returned to the ward. Mrs D was then placed under 24 hour observation.
Mr D wanted to know how his wife had managed to abscond on two separate occasions in August 2001. Mr D also complained that on one occasion, when he enquired whether his wife had been given her medication, he was told that she had not, because the duty doctor had written down the prescription wrongly – an error that Mr D considered had worsened her relapse.
Findings
With regard to Mrs D’s medication, the Ombudsman’s assessors concluded from the available evidence that, although Mr D had been told the mis-spelling of the drug was the reason it was not administered to Mrs D, this was not likely. The ward manager and duty manager were quite clear that nursing staff would have known which drug to prescribe in spite of the spelling error, and would have contacted the doctor had any confusion remained. Mrs D had been refusing her medication when first admitted, and ‘patient refusal’ was the reason recorded on her drug chart. The Ombudsman agreed that the more likely explanation was that Mrs D refused medication.
With regard to the episodes of absconding, the assessors agreed that there was no clinical evidence for Mrs D to have been placed under continuous observation. The assessors concluded that when Mrs D first absconded, staff dealt with this episode very well. The Ombudsman concluded that there were a number of contributory factors, which made it possible for Mrs D to abscond again. There was a violent male patient on the only secure ward at the time, which ruled it out as a possible option for Mrs D. The Trust’s ward door policy referred to an ‘expectation’ that internal ward doors on an open ward would be locked between the hours of 9.00pm and 7.00am. However, in practice, doors were not locked until all the patients had gone to bedusually around midnightand in this case had not been locked by the time Mrs D had absconded. Furthermore, at that time of the night, Mrs D’s observation checks had been relaxed to 30 minute intervals. Another contributory factor was that, unknown to the night staff at the time, the external door to the building had not been locked as it should, because the lock was faulty. The Ombudsman agreed that these factors had led to a situation whereby staff had incorrectly assumed that Mrs D would be unable to abscond. She also accepted the assessors’ advice that Trust staff had been confused as to which documentation to complete following episodes of absconding such as these. She upheld this aspect of the complaint to the extent of the shortcomings identified.
Remedy
The Ombudsman recommended the Trust review the application of the locked door policy, so that staff are clear as to what is required practice and what is discretionary. She also recommended that the Trust ensures that all staff understand their responsibility with regard to matters of health and safety; that they are made aware of their duty to report any such faults to the appropriate department; and ensure that in the interim period, measures are put in place to secure patient safety.
Furthermore, she recommended that the guidelines dealing with ‘missing patients’ should be reviewed, in order to clarify which documentation should be completed for which particular set of circumstances.
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