Loss of focus
A report from our investigation into the care and treatment of Ms Z, a woman with a mental illness, personality disorder and alcohol problems who died after leaving hospital while subject to a short-term detention certificate.
Our investigation identified a number of problems, particularly in relation to the fragmented nature of her care. We also found that the NHS board's Adverse Significant Incident Report did not properly assist the organisation to identify, learn from or respond to the issues raised by Ms Z's case.