Ombudsman’s report slams NHS Tayside over care of young man who took his own life


A SUICIDAL young man was effectively abandoned by the NHS for five months before he took his own life, an ombudsman has found.

NHS Tayside has been ordered to improve its care of vulnerable people and to apologise to the family of Scott Nichol, who say they have been “vindicated”.

Scott, 22 hanged himself in July 2010, after suffering mental health problems for years and being diagnosed with depression.



Despite taking drug overdoses four times previously, he was discharged after a further overdose in February 2010.

Scott’s father Malcolm complained staff seemed frightened to detain him under the Mental Health Act, and discharged him after treatment in January 2010 without medication.

Scottish Public Sector Ombudsman (SPSO) Jim Martin, who refers to Scott as “Mr A”, wrote: “The adviser concluded that ineffective care coordination and a lack of cohesion and sense of urgency resulted in the Board failing to deliver all aspects of care and treatment effectively.

“This resulted in Mr A becoming disengaged from services for a full five months before his death.”

Malcolm, 48, said it took more than a month for the hospital to write to his son’s GP after he was discharged in September 2009.

He said: “I feel vindicated but very angry I had to do this. It took them 45 days to write to my sons GP after he was discharged.

“Given his lifestyle that’s a piece of nonsense.”

He said the health service “lost” Scott after he was in hospital for the final time, instead handing over his care to outside agencies.

Malcolm, from Forfar Angus, admitted he rarely saw  son, who had problems with drugs.

But he said he saw him for the last time in hospital in February 2010: “He was alright when I saw him.

“I told him not to be stupid and I loved him. He said “I love you too and I won’t do it again.'”

After learning of his son’s death Malcolm decided to look into his care: “The more I dug the more the more it became apparent there was something far from right.



 “When I asked for his medical records it was a struggle. Every time I sent a letter it was 20 to 30 days before they got back.

“At that time all I felt was sheer bloody anger. They’ve never given any reason for why it took so long.”

He called for Gerry Marr, NHS Tayside’s chief executive and former head of operations who dealt with his complaint at the time, to resign.

Malcolm said: “[Gerry Marr] said everything had been done by the book.

“Either staff didn’t know what they were talking about or they lied. He should resign.”

He continued: “In Tayside, Dundee and Angus there are only 101 mental health beds for a population of over one million.

“It’s a problem with the NHS farming out to outside agencies.”

The Ombudsman’s father upheld two complaints from the man’s father, that his treatment between June and 2009 and his death was “below an acceptable standard”, and that the family were not adequately involved in the review process.

The report, released today, said Scott had “emotional difficulties and a previous diagnosis of Attention Deficit Hyperactivity Disorder (ADHD)”, as well as being diagnosed with depression in 1997.



He had previously taken drug overdoses in 2004 and 2006.

He was admitted to Carseview Centre mental health unit at Ninewells Hospital in Dundee in September 2009 after a drug overdose, and was allowed to discharge himself despite experts considering him “high risk.”

Scott was admitted to the centre again in January 2010 after paranoid and suicidal thoughts and discharged himself later that month, before he was again admitted to hospital in February 2010.

Scott had been referred to community mental health workers and a charity but after he missed appointments nothing was done to follow this up, the ombudsman said.

After his overdose in February 2010, Scott was referred to outside agencies, but the ombusdman said the difference in what they could provide compared to in-house hospital treatment was “marked.”

The ombudsman said: “Mr A’s risk of further self-harm was high and he probably required more intensive input than the external agencies could provide.”

He concluded: “I do not consider that the care and treatment provided to Mr A from June 2009 until his death was of a reasonable standard.”

He made nine recommendations including “take steps to ensure that systems are in place in order that the care of vulnerable people is coordinated effectively and with due urgency.”

Mr Martin also recommended the board write to Scott’s father to apologise.



The ombudsman’s report noted: “[NHS Tayside’s] Chief Executive said that numerous attempts had been made to encourage Mr A to work with them, but they were unable to do so.”

An NHS Tayside spokeswoman said: “The Board has accepted the recommendations in the report and will act on them accordingly.

“A number of these have already been implemented and actions are underway in relation to the remaining recommendations.

“We know that every suicide has a profound impact on relatives and friends.

“That is why we are committed to working with Angus, Dundee City and Perth & Kinross Councils, Police Scotland and voluntary organisations under the banner of ‘Choose Life’ to improve our collective understanding of the issues involved in suicide.”