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Good records in a worst-case scenario

01 May 2009

Mrs Q was a 29-year-old new mother of a two-month old baby daughter. She had an established history from the age of 21 of recurrent depressive disorder without psychotic symptoms. The management of two previous episodes had been shared between secondary psychiatric outpatient services and her GP. Her last episode, which had occurred three years previously after a miscarriage, was associated with fleeting suicidal ideation and she was briefly admitted as a voluntary patient. Between episodes she made a good functional recovery and had a successful career as a legal secretary.

Unfortunately, her relationship with her husband was strained. Whilst the new baby was welcomed, it further highlighted the difficulties around him working away from home during the week in his role as an account manager. Mrs Q’s family lived locally and she had a supportive relationship with her elder sister who was a housewife.

Late one Wednesday evening she was brought to the emergency medicine department by her sister, in whom she had confided that she was experiencing intrusive, upsetting thoughts of killing herself by jumping from a motorway bridge. She knew this was wrong and felt extremely guilty towards her baby, whom she loved. She had been feeling low ever since the birth, but in the last three weeks she had felt this way all day and nothing brought her any pleasure at all. She was admitted to a psychiatric ward for treatment.

She agreed she needed to be somewhere safe and was admitted voluntarily. Her GP had recently started a Selective Serotonin Reuptake Inhibitor (SSRI) antidepressant and this was continued, along with a long-acting benzodiazepine for agitation, when necessary. Her rapport with staff was good and her mental state was recorded frequently by medical and nursing staff.

She had regular 1:1 sessions with her named nurse, which she reported as being helpful. After a couple of days she was experiencing no further suicidal ideation. However, persistent biological symptoms including insomnia and anergia impaired her ability to function independently so her admission continued for another couple of weeks. During this time her baby was being cared for by her sister, to the satisfaction of Mrs Q who didn’t want her daughter brought into hospital.

As Mrs Q’s energy returned she went on increasing periods of unescorted leave to her sister’s house. Careful recordings of her mental state with appropriate risk assessments were made before and after each leave and Mrs Q always returned at the agreed time. She wasn’t suffering any side effects from the pharmacological treatment given to her. The social worker contacted her sister who confirmed that the leave periods were going well and, in her view, her sister was getting better.

In the third week, Mrs Q went on a fourth period of leave, but failed to return. Ward staff called her sister who said she had left her house hours earlier at the appointed time. Later that day Mrs Q jumped to her death from a multi-storey car park.

Subsequently, there was an inquest, an internal hospital enquiry and an independent homicide enquiry, all of which received considerable media attention. The high quality of the medical records was invaluable in demonstrating the level of care which had been given.

However, Mrs Q’s husband made a claim against the hospital and the consultant psychiatrist for failing to provide good care and not preventing her suicide. The case was defended based on the quality of the healthcare record, where every step was reflected upon and every decision explained. The case duly went to trial and the judge found in favour of the defendants.

Learning points

  • As with any other mental disorder, multidisciplinary interventions are required to provide appropriate management of patients with depression, as was provided in this case. 
  • Risks can never be eradicated, even with best practice, only reduced. Good record keeping helps to maintain best practice, aiding clear communication between professionals, and demonstrates that best practice has been followed. 
  • Appropriate record keeping is recognised as an important component of professional standards. Broad standards for good record keeping are included in the Royal College of Psychiatrists College Report Good Psychiatric Practice (2nd Ed) which can be found here
  • MPS assistance extends beyond clinical negligence claims and includes assistance throughout the other enquiries which can follow from tragic events such as this.
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