SUICIDAL mental health patients in Tayside had to make a "serious attempt to take their own life" before under pressure medics would pay attention, an inquiry has heard.

An interim report into psychiatric services in the region also found that carers faced "unexpected and concerning" requests to contact the police of NHS 24 instead because Tayside's Crisis team was too busy to cope with patients during "sudden surges in demand".

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It added: "Many patients report that in the early crisis assessment, there is a lack of adequate risk assessment in their risk management plans.

"Patients report telling staff they were suicidal but the risk was not taken seriously until they made a serious attempt to take their own life."

The independent inquiry was commissioned by NHS Tayside following widespread concerns over its mental health service raised in the Scottish Parliament.

An investigation was initially ordered into Dundee's Carseview Centre following a BBC Scotland documentary where patients claimed they had been pinned to the floor in agony, bullied, and that drugs were rife on wards.

The inquiry was subsequently widened to cover NHS Tayside mental health service more generally following a campaign by families of people who took their own lives.

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Today's report, by inquiry chairman David Strang, states that "staff voiced concerns about the overuse of restraint on the wards, with some also reporting being expected to carry out restraint without any formal training in its effective and appropriate use".

Patients told the inquiry they felt unsafe on inpatient psychiatric wards, with some witnessing fights breaking out or having been the victim of assaults.

In relation to drugs, the report states: "Staff seem unable to control the availability and use of illegal drugs on the wards in the inpatient facilities.

"Both patients and families report seeing drugs delivered, sold and taken within the Carseview Centre site.

"Staff confirm this is a serious issue which is not being adequately addressed."

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There is alarm that patients have been able to self-discharge from inpatient facilities "without any notification being made to family or carers and with no ongoing care plans in place".

The report adds: "After discharging themselves some patients have subsequently been found in a heightened state of distress or disorientation by police patrols.

"On occasion patients have discharged themselves with a particular focus on harming someone, giving rise to public safety concerns."

Where things have gone wrong, the inquiry found inconsistencies in how serious adverse event reviews (SAERs) have been handled.

It states: "In many cases families have been told that they would be invited to participate in adverse event reviews, but have never heard anything about such a review taking place.

"Where families have participated, some have reported that the review report did not accurately reflect the facts of the case or what was said in the review meetings."

Meanwhile, long waiting times for the Tayside child and adolescent mental health service (CAMHS) mean that nearly 40 per cent of young patients are waiting more than 18 weeks to be seen, and "rejected referrals are high".

Sometimes a referral would be rejected because a teenager has turned 16 and left school while waiting, a "problematic" criteria used by NHS Tayside which means they will be transferred onto the adult mental health waiting list instead.

The report adds: "Families with the means to do so, are choosing to make provision for their children to be seen privately."

The centralisation of the out-of-hours Crisis team to the Carseview Centre in Dundee "has had a detrimental effect on those patients in Angus and Perth & Kinross", while the "many vacant posts" across the mental health service has driven a reliance on locum consultants which the report says has led to inconsistencies in treatment and a lack of continuity of care.

More than 200 submissions of written evidence have been considered along with 70 oral evidence sessions from patients, families, carers, NHS employees, charities and health professionals.

The interim findings summarise that evidence, but a final report will not be published until later this year.

NHS Tayside Chairman John Brown said: “The Board welcomes and accepts today’s interim report and acknowledges it is an important milestone as it sets out the lived experiences of people who have used mental health services in Tayside over the past few years.

"It also captures the voices of staff who work in the service, as well as other key organisations and individuals who support the delivery of mental health services."

He added that a number of improvements have been made to the mental health service already, including staff training in management of violence and aggression and cuts in waiting times for CAMHS and adult psychological therapies. 

A seven-day home treatment Crisis service will be provided in North Angus from August 2019, and 17 hours of dedicated therapeutic activities for patients are being introduced in wards at the Carseview Centre. 

Chief Executive Grant Archibald added: “It is clear that we have further work to do but since I came to Tayside, I have made mental health a top priority and I am confident we can learn lessons, strengthen our engagement with patients, service users, families and the public and make the right kinds of changes, at the right time, to transform our mental health services."