Mentally Ill Teen’s Death Sparks Concerns Over Care and Treatment Delivery
The tragic death of a mentally ill teenager has raised concerns about the delivery of care and treatment for individuals suffering from mental health issues. An investigation has found that the 18-year-old’s death might have been prevented if his care had been handled differently.
The teenager, referred to as Mr. D, had a history of mental health problems and had previously been treated by child and adolescent mental health services (CAMHS) after drinking excessive amounts of water. He was diagnosed with early onset psychosis and received two years of community-based CAMHS care.
On December 5, 2018, Mr. D was admitted to an adult mental health service inpatient unit in a neighboring health board as there were no available local beds. This decision, described as a high-risk action in the investigation report, proved to have fatal consequences.
Two days later, on the evening of December 7, Mr. D suffered a seizure after consuming excessive amounts of water. He was subsequently transferred to intensive care, but sadly passed away three days later due to water intoxication.
The anonymized investigation by the Mental Welfare Commission for Scotland has concluded that there were aspects of care and treatment from both health boards that, if conducted differently, might have prevented Mr. D’s death.
The report also highlights the need for a more assertive approach to the treatment of Mr. D’s psychotic illness in the two years leading up to his death. It states that a transition in Mr. D’s care was taking place, moving away from a treatment model that supported young people with first onset psychosis for at least three years, and towards adult mental health services.
This transition period seems to have posed challenges, as Mr. D’s case records from his years of contact with the CAMHS community team were unavailable during the 70 hours after his admission to the hospital. The failure to provide key clinical details and an updated risk assessment and care plan undoubtedly contributed to the tragic outcome.
The report concludes with ten recommendations for change, addressing the involved health boards, the Royal College of Psychiatrists, NHS Education Scotland, and the Scottish Government. These include setting standards for the safe transfer or management of patients from other health boards and adhering to existing guidance for transitioning patients from child and adolescent mental health services to adult mental health services.
Suzanne McGuinness, the executive director for social work at the Mental Welfare Commission, emphasizes the need for coherent management of the risks associated with psychotic illness and acknowledges the concerns expressed by Mr. D’s family who felt that their concerns were not genuinely heard.
The Scottish Government has been called upon to comment on the matter, and mental health services across Scotland are urged to read the report and take necessary action for improvement.
The heartbreaking death of Mr. D highlights the critical importance of adequate care and treatment for individuals suffering from mental health conditions. It serves as a reminder that there is still much work to be done to ensure the safety and well-being of those who are vulnerable and in need of support.
