Health Service Commissioner : first report for session 1982/83 : selected investigations completed April- September 1982.

  • Great Britain. Health Service Commissioner.
Date:
1983
Catalogue details

Licence: Open Government Licence

Credit: Health Service Commissioner : first report for session 1982/83 : selected investigations completed April- September 1982. Source: Wellcome Collection.

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    14. The SHO told my officer that she had not been concerned with treatment of the patient until the registrar went on leave on 4 January. She was on duty on 12 and 13 January but she received no reports from the staff about threats of suicide made by the patient to his cousins or the com- plainant. On 13 January the nurse in charge of the ward had asked her tc come to speak to the complainant who was concerned about his brother’s discharge but when she arrived the complainant had said that he had to leave immediately to catch a bus and she had therefore had very little discussion with him. The SHO said that until she re-read the clinical notes during my investigation she had been unaware of the suicide attempt in 1977. The patient had not made any threats of suicide to her and neither the registrar nor the complainant had mentioned them. 15. The charge nurse of the ward told my officer that the patient had never made any direct threats of suicide to him although he had said that he saw little reason to continue living as there was not much left in life for him and that he might as well stay in hospital. The charge nurse had spoken to the complainant on several occasions when he visited his brother but he had not reported to him any suicide threats by his brother. If such threats were reported to the nursing staff they were recorded in the nursing kardex. 16. My officer interviewed the nurse in charge of the ward on 13 January and to whom the complainant had spoken. He said that he remembered little of his conversation with the complainant and his brother on that day but he recalled that the complainant had told him that his brother had just said that ‘he was going to go and throw himself under a car’. He had questioned the patient about this but he had denied it and said that he had just been talking generally about the cars on the road passing the hospital. He said that he would have reported the conversation to the medical staff at the shift handover. 17. My officer was unable to identify the nurse to whom the cousin [Mrs. ] spoke on 12 January but a student nurse told her that the com- plainant had reported suicide threats to her on 16 December and she had recorded this in the nursing report. Another student nurse remembered that when the patient returned from Christmas leave, his brother had said that he had threatened to kill himself with a carving knife. Many of the nurses interviewed told my officer that if suicide threats had been reported to them they would have recorded the information in the nursing report. 18. Entries made on 7 and 16 December in the nursing report record the complainant’s concern that his brother might attempt suicide. The admission notes of 7 December say: ‘that for the last two days often expressed suicidal thoughts’; and the registrar recorded in the medical notes his discussions with the complainant of 27 and 28 December when threats were also men- tioned. There is no reference in any record to the reports made by Mrs. or the complainant on 12 and 13 January. Findings 19. There were references in the medical records on 7, 16, 27 and 28 December to suicide threats and the information was thus available to the