The findings of an investigation by the Scottish Public Services Ombudsman (SPSO) give a damning verdict on how the 38-year-old was cared for when he was a patient at the Larbert acute facility in August 2014.
He went to hospital with a sore throat, cough and wheeze in his chest and 36 hours later was found dead on the floor of his hospital room.
The report found he had not been monitored or given oxygen in the eight hours before his death despite his serious condition and there were conflicting reports of how he spent his final hours.
Following his death and after several meetings with NHS Forth Valley officials, the man’s mother eventually raised concerns about his care to the SPSO which investigates complaints about organisations providing public services in Scotland.
The man, who is not identified in the public report, suffered from schizophrenia, a long-term mental health condition that causes a range of different psychological symptoms.
His mother complained that he did not receive “reasonable care and treatment” and that the health board failed to take into account his lack of capacity to understand how ill he was.
She also complained that the standard of record-keeping was not adequate and she was not able to obtain accurate information from staff about what had happened to her son.
In addition, she complained that she was given unclear information about whether a significant adverse event (SAE) investigation into his death would be carried out by the board.
The Ombudsman obtained independent advise from a senior doctor with experience in acute medicine and a nursing adviser, as well as considering the board’s own investigation of the complaint.
While the board acknowledged that it was unacceptable the patient’s observations were not carried out four hourly after his transfer from the Clinical Assessment Unit to Ward B12 and apologised for this failing, the senior doctor who gave advice said there were failings in the man’s care and treatment throughout his admission to the hospital.
The patient went to hospital on August 14, 2014 at 12.35pm with a sore throat, cough and wheeze in his chest and was found on the ward floor at 5am on August 16. It was not possible to resuscitate him and he was pronounced dead at 5.51am.
The man had left the unit at 11 am on August 15 saying he was going for a cigarette but did not return until 2pm the same day.
The Ombudsman noted: “I was concerned that, given his past medical history and in view of his refusal of treatment during his admission to the hospital and that he left the hospital against medical advice, a formal assessment of his mental capacity to understand the seriousness of his illness and ability to make informed decisions was not carried out.”
The report, which was published on August 31, also stated: “Both advisers said that there was a lack of recognition of the seriousness of his condition by nursing and medical staff.”
A spokesperson for NHS Forth Valley said: “We recognise that aspects of the care we provided fell below our usual high standards and several actions have already been taken to address these.
“Further work will also be undertaken to ensure we meet all of the recommendations outlined in the report and learn from the issues highlighted.”