Teen died after drinking too much water as he tried to 'flush toxins from body'
A tragic teenager died after drinking excessive amounts of water to “flush toxins out of his body”, an investigation found.
The 18-year-old, known as Mr D, was admitted out of hours to an adult mental health service inpatient unit in December 2018. Two days later he suffered a seizure after drinking too much water and was transferred to intensive care and died three days later of water intoxication.
The unnamed youth had previous contact with child and adolescent mental health services (CAMHS), where he had been treated for drinking an excessive quantity of water. An investigation by the Mental Welfare Commission for Scotland found his death may have been prevented had aspects of his care been “conducted differently”.
According to WalesOnline, the report said: “The failure to impart key clinical details to the treating ward staff during his final admission, both in the provision of all relevant case files and the creation of an informed and updated risk assessment and care plan, meant Mr D was able to engage in risky and ultimately fatal psychosis-driven behaviour without mitigations having been put in place.”
The report made recommendations for change to bodies including the health boards involved, the Royal College of Psychiatrists, Education Scotland and the Scottish Government. They include the Government should set standards within the next six months for the safe transfer to, or management of patients who present from other health boards.
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Suzanne McGuinness, executive director for social work at the Mental Welfare Commission, said: “This was a tragic death of a young man while he was being cared for in hospital. Our report details the actions and decisions taken by teams at the two health boards involved in the lead-up to his death. We also found that there were problems in Mr D’s transition from child and adolescent mental health services to adult mental health services. Existing guidance was not adhered to.
"We found that although the service had no other viable option, the transfer of a very unwell young man with a complex clinical history to another health board area during the night was a high-risk action. Mr D’s family told us they felt that they had not been listened to. They felt their concerns were not given due credence.” She urged mental health services across Scotland to read the report and take action where they believe they can make improvements.
A Scottish Government spokesperson said: “The death of any person in care is not acceptable. It is vital people using our mental health services feel safe and know they will receive the right help, in the right place when they need it. The relevant health boards and health and social care partnerships in this case have been issued with specific recommendations and learning points alongside general recommendations for all health boards and HSCPs. We expect the commission’s recommendations to be fully implemented.
“The Mental Welfare Commission recommended that the Scottish Government set standards for the safe transfer of patients between health boards. We will publish core mental health standards in the coming weeks to set clear expectations for transitions between and within mental health services.”
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