‘Desperately sad’ care home suicide leads to series of recommendations

A series of recommendations has been made for health authorities across Scotland after an investigation was held into the death by suicide of a woman at a care home.

The 44-year-old, who had an autistic spectrum diagnosis and complex needs, took her own life in December 2012 shortly after being moved from hospital.

The Mental Welfare Commission said the circumstances of her death and the way in which her transfer to the care home were managed raised concerns and a decision was made to carry out an investigation.

The woman, identified as Ms MN in the report published by the commission, had been in contact with mental health services since she was a teenager and had frequent admissions to hospital.

Report authors said the care home, which is not identified, was experienced in caring for people with learning disability but not autism.

The commission found the placement was not properly planned and that arrangements for managing her care, and the risk of suicide, were “confused and unsafe”.

It said the woman did not have a learning disability; her prime diagnosis was of autism/Asperger Syndrome.

Colin McKay, chief executive, said: “This is a desperately sad case of a vulnerable individual who was struggling to deal with day-to-day life.

“Services tried, with varying levels of success, to support her. While there was certainly goodwill and a genuine caring attitude, there were also serious errors of judgement and a lack of communication at key points.

“That resulted in her being in a home which was not able to meet her needs and which did not have the appropriate support from specialist services when a crisis arose.

“This report is about one tragic case but it contains lessons for all of Scotland.

“I hope it is read by all those involved in providing care and treatment for people with autistic spectrum disorder and I hope all of our recommendations are acted upon.”

The report found the woman had become used to receiving medication, mostly for anxiety, “as required” while she was cared for in hospital.

It said she found the move difficult and the care home was relying for medical advice on local GP services, who had not met her and did not have full information on her case.

The recommendations contained in the report are set out for the Scottish Government, the Care Inspectorate, health boards and joint health and social care bodies.

They include a greater use of specialist assessments where people have autistic spectrum disorder and complex needs and better discharge planning to ensure care homes and GPs have the right information and support to manage people in community settings.

It also recommends a review of the availability of specialist services for people with autistic spectrum disorders who do not fit into mental health or learning disability settings.

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