Suicidal patients were “not taken seriously” by health workers in NHS Tayside unless they had made a “serious attempt to take their own life”, a damning report has found.
An interim report into mental health services in the area highlighted a “lack of adequate risk assessment”.
Patients can wait as long as a year for treatment even after being assessed by mental health services.
The report also said staff “seem unable to control the availability and use of illegal drugs” within inpatient treatment centres – with both staff and the families of patients reporting seeing drugs being delivered, sold and taken within the Carseview Centre in Dundee.
An independent inquiry into mental health services in NHS Tayside was set up after concerns were raised by families about the level of care provided.
Inquiry chairman David Strang said there was now a “real opportunity” for the health board to “transform its provision of comprehensive mental health services to meet the needs of all people”.
The former chief inspector of prisons in Scotland was given the job in July last year and since then the inquiry has been in contact with 1,310 people and received more than 200 submissions.
The interim report noted a series of concerns about services in the area, saying the centralisation of out of hours care to Carseview has “had a detrimental effect” on patients suffering from a mental health crisis
It stated: “Many patients report that in the early crisis assessment, there is a lack of adequate risk assessment in their risk management plans.
“Patients report telling staff they were suicidal but the risk was not taken seriously until they made a serious attempt to take their own life. Patients are sometimes left to get the support they need from their family during a crisis.”
Staff on in-patient wards “voiced concerns about the overuse of restraint” on patients, the report said, adding some staff were “reportedly aggressive both verbally and physically” when restraining patients.
The report also highlighted the shortage of psychiatrists and the impact this has on both staff and patients.
The use of locums “has in some cases resulted in patients not seeing the same consultant twice”, it found, saying this is seen as a “never-ending circle of frustration by patients and families”.
The report continued: “Several patients report having been treated by many different psychiatrists when engaged in mental health services and diagnoses may change as each consultant takes a professionally different view of a patient’s presentation, which in turn results in changes to medication with associated side-effects.”
Meanwhile, it said “staff can be unsettled by a frequent turnover of senior staff” adding that this situation “inevitably this results in inconsistencies in decision-making, delayed decision-making or even no decision-making”.
Mental health services also showed “evidence of repeated poor practice, when lessons have not been learnt from previous incidents”.
The report said: “In NHS Tayside there appears to be no central point where the lessons and recommendations from adverse event reviews are considered, either within the immediate context of the event itself or organisationally across NHS Tayside’s mental health service as a whole.
“This represents a major lost opportunity for organisational learning and improvement.”
Mental health minister Clare Haughey said Mr Strang’s report had “highlighted several areas where NHS Tayside needs to take urgent action to significantly improve services”.
She said: “It is absolutely vital that people using our mental health services, as well as those delivering our services, feel safe and know they will receive the right help, in the right place when they need it.
“The health board commissioned this independent inquiry in response to concerns about both the quality of, and access to, mental health services in Tayside and it is now imperative that the board immediately act on the findings of this interim report.”
NHS Tayside bosses have already assured her “immediate action” will be taken, Ms Haughey said.
She said the Scottish Government was also setting up a national Quality and Safety Board for Mental Health to ensure “the issues raised in Tayside are not present elsewhere”.
Ms Haughey pledged: “In addition, when the inquiry concludes its work, I will ensure that the lessons learned and its recommendations will be shared widely across Scotland.”
NHS Tayside chairman John Brown said the health board accepted the findings.
He said: “The interim report will be carefully considered by NHS Tayside’s board and we will discuss what it says about mental health services with Mr Strang.
“The board has submitted details of our mental health services improvement programme to Mr Strang and he has confirmed that he will examine our plans in more detail in the next stage of the inquiry before drawing any conclusions and making recommendations.”
Mr Brown added: “Over the past year, the improvement programme has been the focus for change across mental health services in Tayside.
“This has helped deliver improvements in key areas highlighted in the interim report and contributed to the redesign of services to improve outcomes over the next 12 months.”