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Heading for a fall

01 May 2007

Ms P was 34 years old, with a seven-year history of schizophrenia. She was well known to local psychiatric services after three hospital admissions when acutely psychotic. She had a further history of post-psychotic depression and had taken two serious overdoses.

She was admitted to her local district general hospital for a routine cholecystectomy. Although she made a good postoperative recovery, the surgical team became concerned about her mental state as she complained of voices telling her she was evil and that God wanted her to kill herself. She agreed to be transferred to a psychiatric unit under the care of Dr D, and arrived with a brief note explaining only that she was “delusional”.

On arrival she was interviewed by Dr D without the benefit of her old notes which, he reported, had not yet been retrieved from the community mental health team base. He recorded that Ms P was well known to him and directed the reader to earlier discharge summaries for background information. He described her mental state, but made no reference to suicidal ideation and agreed an informal admission for observation on her current medication. A junior doctor later completed a brief physical examination and there were fortnightly records of her being discussed at a ward round.

However, more extensive detail of her psychiatric history was not added to the running record and the risks she presented to herself and others were not documented explicitly. The clinical team later agreed that no specific concerns of self harm had been raised, but nothing was written to this effect.

After three months her hallucinations appeared to have abated, but she remained guarded. The team was concerned she continued to experience delusions, although she did not share these with staff. She was reluctant to leave her bedroom and rejected any suggestion of escorted leave, preferring to stay and wait for “Armageddon”. She placed few demands on nursing staff.

The hospital engaged in a rolling programme of maintenance, part of which involved ward bays being closed off with room dividers while workmen painted the window frames. Ms P entered the “closed” bay and pushed open a window, which was normally retained on a safety catch, but had been left ajar.

She climbed out and fell from the first floor window, sustaining serious back injuries. Ms P began a negligence claim. 

Expert opinion

Psychiatric expert opinion was critical of Dr D’s record-keeping and of the chaotic handover from the surgical team at her admission. However, most criticism was reserved for the Mental Health Trust itself for accepting Ms P without a proper referral, poor risk-assessment procedures with respect to the clinical assessment of Ms P and to the physical security of the ward environment during maintenance works. A significant claim was settled against the Trust. The claim against Dr D was dropped.

Learning points

  • Ms P’s psychiatric history should have been recorded better and her risk of harm to herself and to others should have been reviewed regularly and documented in the notes. Even if her history of deliberate self-harm and current risk profile was felt to be known by key professionals, it needed to be stated explicitly and shared. The Royal College of Psychiatrists, in Good Psychiatric Practice, advises you to: “ensure that good clinical records are kept of all key decisions and assessments” and discharge your duty to “communicate treatment decisions, changes in care plans and other necessary information to all relevant agencies and professionals” (p23). In this case, communication needed to be in writing, given the number of personnel involved in managing a patient on a ward.
  • The surgical team should have provided a more thorough account of her presentation, although this ultimately had no influence on the claim. In the UK the General Medical Council’s Good Medical Practice offers the following guidance: “When you refer a patient, you should provide all relevant information about the patient, including their medical history and current condition.” (para 51)