Mentally ill teenager died after drinking too much water

by Raj Das

Tragic Death of Mentally Ill Teen Points to System Failings in Mental Health Care

The death of a mentally ill teenager in Scotland has brought attention to the systemic failings within the country’s mental health care system. According to an investigation conducted by the Mental Welfare Commission for Scotland, the death of the 18-year-old could have been prevented if proper care and treatment had been provided.

The teenager, referred to as Mr D, was admitted to an adult mental health service inpatient unit in a neighboring health board due to the lack of local beds available. This move was described as a “high-risk action” in the investigation report. Two days later, Mr D suffered a seizure after consuming excessive amounts of water, leading to his transfer to intensive care. He tragically passed away three days later as a result of water intoxication.

It was revealed that Mr D had a history of contact with child and adolescent mental health services (CAMHS) where he was previously treated for drinking excessive amounts of water. He had been diagnosed with early onset psychosis and received two years of community-based CAMHS care. The investigation concluded that there were “aspects of the care and treatment” delivered by the health boards involved that, if conducted differently, may have prevented Mr D’s death.

The report recommended a more assertive approach to the treatment of Mr D’s psychotic illness in the two years leading up to his death. It also highlighted the need for improved communication and a comprehensive care plan to manage his condition effectively. Furthermore, the investigation discovered that Mr D’s case records from his years of contact with the CAMHS community team were unavailable during his final admission to the hospital. This lack of information meant that necessary precautions and interventions to mitigate the risk of psychosis-driven behavior were not put in place.

The tragedy of Mr D’s death comes almost two years after he was first admitted to an acute general hospital at the age of 16 with a seizure caused by water intoxication. At that time, his sodium metabolism was significantly affected, nearly resulting in fatal consequences. Despite spending more time as an inpatient and remaining under the care of the CAMHS specialist psychosis service after turning 18, Mr D’s transition to adult mental health services was not adequately managed.

The report’s findings and recommendations extend beyond the individual case of Mr D. It calls for systemic changes within the mental health care system, involving the health boards, the Royal College of Psychiatrists, NHS Education Scotland, and the Scottish government. One of the key recommendations is for the government to establish standards for the safe transfer or management of patients from different health boards within the next six months.

This tragic case shines a light on the dire state of mental health care in Scotland and the urgent need for improvements. The death of a young individual with so much potential is a heartbreaking reminder of the consequences that can arise when proper care and treatment are not prioritized. It is crucial that the recommendations outlined in the investigation report are taken seriously and swiftly implemented to prevent similar tragedies in the future.

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