NHS 24 has apologised to the daughter of a woman who committed suicide after her final cries for help were downgraded to a three-hour wait by call-centre staff.
The woman, who suffered from anxiety and depression, called her daughter on March 16 2014, a week after a previous suicide attempt, saying she needed help as she could not cope.
Her daughter called NHS 24, describing her mother as a risk to herself, and an NHS 24 call handler rang the mother directly.
She was described as "extremely distressed" during the call and told the call handler she might harm herself again and that she wanted to be taken away under mental health legislation.
The Scottish Public Services Ombudsman (SPSO) said: "The call was initially classified as 'serious and urgent' but, when no nurse was available to speak to (the mother), a senior nurse advised the call handler to downgrade the call, which set a three-hour call back from a nurse practitioner.
"They also offered her assistance from Breathing Space whilst she waited for the call back, which she accepted.
"The Breathing Space adviser (the BSA) spoke and did breathing exercises with (the mother), but she was still tearful when the call ended.
"A nurse practitioner called around two hours later but there was no answer and the call was closed. (Her daughter) called the police a few days later as she had been unable to contact Ms A.
The report added that police officers forced entry to Ms A's home and found that she had committed suicide.
The Ombudsman has recommended NHS 24 apologise to the woman's daughter, raise the call in next appraisals of the senior nurse and nurse practitioner, and ensure all relevant staff are aware of the guidance on transferring calls to Breathing Space.
He has also urged Breathing Space staff to learn from the call and are aware of the process for escalating calls of concern.
A review of guidance for all staff on the management of suicidal thoughts and common mental health problems has also been recommended.
Sheena Wright, NHS 24 director of nursing and care, said the group offered its "sincerest apologies" to Ms A's family "for the care she received, which was not of the standard she should have expected".
She added: "We fully accept all of the recommendations in the SPSO report and can confirm actions were taken to address the issues in 2014.
"We will continue to ensure that all relevant actions resulting from the SPSO recommendations, are fully embedded to enable NHS 24 services to improve the way we can support vulnerable patients calling with mental health issue
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