An 18-year-old man with a history of excessive water consumption died after drinking too much water while detained under the Mental Health Act, an investigation has found. The Mental Welfare Commission report concluded that the death was preventable and highlighted several failures in his care.
The teenager, referred to as Mr D, was admitted to an adult mental health unit in a different health board area on 5 December 2018 due to a lack of local beds. He had previously been treated for drinking excessive water, believing it would cleanse toxins from his system. However, this history was not fully included in his care plan after transfer.
On 7 December, Mr D suffered a seizure after drinking large amounts of water and was transferred to intensive care. He died three days later from water intoxication. The report noted that a more assertive approach to treating his psychotic illness in the two years prior could have prevented the tragedy.
Suzanne McGuinness, executive director at the Mental Welfare Commission, expressed concern about the patient's transition from child to adult mental health services and the decision to move him to another health board at night. She urged mental health services across Scotland to review the findings and implement improvements.
The report makes 10 recommendations for changes to health boards, the Royal College of Psychiatrists, NHS Education Scotland, and the Scottish government. It also highlighted that Mr D's parents had raised concerns about his treatment multiple times before his death.
