Mentally ill teenager died after drinking too much water

The death of a mentally ill teenager after drinking excessive amounts of water could have been avoided, an inquest has heard.

The 18-year-old was admitted out of hours to an adult mental health unit at a neighboring health board on December 5, 2018, because there were no local beds available – a decision described in the report as a “high-risk decision”. action”.

Two days later, he had a seizure after drinking too much water and was transferred to intensive care. He died three days later from water intoxication.

The teenager, called Mr D, had previously been in contact with Child and Adolescent Mental Health Services (CAMHS), where he was treated after drinking an excessive amount of water.

He was diagnosed with early-onset psychosis and received two years of CAMHS community care.

An anonymous investigation by the Mental Welfare Commission for Scotland concluded that “there were aspects of the care and treatment provided by each health board which, if carried out differently, could have prevented Mr D's death”.

The report, which contained 10 recommendations, also stated: “A more assertive approach to the treatment of Mr. D.'s psychotic illness in the two years before his death was warranted.”

Mr D's death occurred almost two years after his first emergency admission to an acute general hospital in January 2017 following a seizure due to water intoxication, at the age of 16.

The seizure was brought on by drinking large quantities of water, which he believed would flush the toxins from his system.

This affected his sodium (blood salts) metabolism with near-fatal consequences.

He then spent more time in hospital and turned 18 while still in the care of the specialist psychosis service at CAMHS.

The service was moving away from a treatment model that supported young people with first onset psychosis for at least three years from diagnosis, towards one in which the transition to adult mental health services began at age 18.

He was admitted to a hospital in Scotland in December 2018 while detained under the Mental Health Act.

NHS mental health services 'at breaking point'

The investigation also found that for 70 hours following this hospital admission, Mr D's records, relating to his years of contact with the CAMHS community team, were not available.

The report states: “The failure to communicate key clinical details to treatment service staff upon final admission, both in providing all relevant records and in creating a risk assessment and An informed and up-to-date care plan allowed Mr. D to be able to engage in risky and ultimately fatal psychotic behavior without mitigation measures being put in place.

The report makes recommendations for change to agencies including relevant health boards, the Royal College of Psychiatrists, NHS Education Scotland and the Scottish Government.

They include that the government should set standards within the next six months for the safe transfer or care of patients from other health boards.