A teenage boy died after drinking too much water, which caused him to have a seizure.
The 18-year-old was being treated in an out-of-hours adult mental health service inpatient unit in December 2018.
On the evening of December 7, 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.
The teenager, referred to as Mr D, had previous contact with Child and Adolescent Mental Health Services (CAMHS).
He was diagnosed with early onset psychosis and received two years of community-based CAMHS care.
An anonymised investigation by the Mental Welfare Commission for Scotland concluded that there were “aspects of the care and treatment delivered by each health board which had it been conducted differently, might have prevented Mr D’s death”.
The report, which made 10 recommendations, also said: “A more assertive approach to the treatment of Mr D’s psychotic illness in the two years before his death was warranted.”
Mr D’s death came almost two years after he was first admitted as an emergency to an acute general hospital in January 2017, following a seizure caused by water intoxication, aged 16.
The seizure was induced by drinking large quantities of water, which he believed would remove toxins from his system.
This affected his sodium metabolism (blood salts) with near fatal consequences.
The investigation also found that during the 70 hours after that admission to hospital, Mr D’s case records from his years of contact with the CAMHS community team were unavailable.
The Scottish Government has been asked for comment.