Patient's water drinking death was preventable
The death of a mentally ill teenager who died after drinking an excessive amount of water was preventable, an investigation has found.
The 18-year-old, known at Mr D, was being detained under the Mental Health Act at the time of his death.
An inquiry by the Mental Welfare Commission said he had previously been treated for drinking too much water.
It found several areas where a different course of action could have prevented his death.
The teenager was admitted out-of-hours to an adult mental health service (AMHS) inpatient unit in a health board neighbouring his own on 5 December 2018 as there were no local beds available.
This move was described in the report as a "high-risk action".
On the evening of 7 December he suffered a seizure after drinking too much water and was transferred to intensive care. He died three days later from the consequences of water intoxication.
Suzanne McGuinness, executive director (social work) at the Mental Welfare Commission, said: "This was a tragic death of a young man while he was being cared for in hospital.
"We found that a more assertive approach to the treatment of Mr D's psychotic illness in the two years before his death was warranted. The risks associated with psychotic illness were not coherently managed."
Source: BBC News, 21 September 2023