NHS failures over schizophrenic man's care in Aberdeen
The sister of a schizophrenic man hopes his death will not be in vain after complaints about failures in his care in Aberdeen were upheld.
Lawson Thain died aged 51 in 2016 and his family has sought answers since.
BBC Scotland can now reveal the Scottish Public Services Ombudsman (SPSO) has upheld three claims against NHS Grampian and a local GP practice.
Relatives hope lessons about mental health support will be learned as a result.
NHS Grampian and Albyn Medical Practice said the recommendations had been taken on board.
Died at home
Mr Thain had developed mental health problems in his late teens. His physical health declined over the years.
He was under the care of NHS Grampian's Community Mental Heath Team and his GP.
He experienced breathlessness and leg swelling and his sister Donna Ewen insisted he needed to be admitted to hospital.
In the weeks before his death, Mr Thain had declined a request by a doctor to examine him. He was no longer able to walk.
His sister does not believe he had the capacity to make decisions about his own health.
Mr Thain died at home from suspected heart failure.
The family complained to the SPSO, and it can now be revealed the ombudsman has upheld three complaints.
The SPSO found that the NHS Grampian Community Mental Health Team failed to take "reasonable action" in terms of Mr Thain's physical health needs in the months leading up to his death, and that an out-of-hours doctor failed to take reasonable action on 22 April 2016 when carrying out a home visit.
And it ruled that Albyn Medical Practice "unreasonably failed" to arrange to admit Mr Thain to hospital for investigation of his physical health in the months leading up to his death.
'All failed him'
Mrs Ewen told BBC Scotland: "To understand someone who has got paranoid schizophrenia, you are working in all these conditions - he wouldn't have a TV in his house because he felt like someone would try and communicate with him through a TV.
"He wouldn't accept any help from outside authorities, which did make things really difficult. He only wanted his family to help him.
"I cried, I broke my heart, I said please help, tell me why the hospital won't take my brother in, because he's dying and we need you to help."
In a letter to Mrs Ewen, NHS Grampian offer an "unreserved apology", saying his care was not of the standard expected.
She said: "They all failed him, they have now admitted they all failed him.
"My family, we have fought for my brother.
"It makes us feel better the ombudsman has listened to us, and given it a really fair hearing."
NHS Grampian told BBC Scotland: "We again wish to convey our condolences to the family and offer our sincere apologies.
"They can be rest assured that the recommendations set by the ombudsman will be met to the high standard we expect for our patients."
In a statement, Albyn Medical Practice said: "Albyn Medical Practice were saddened to hear of the sudden death of Mr Lawson Thain who we had looked after for many years.
"We always tried our best to provide the most appropriate care for Mr Thain.
"We have taken on board the recommendations from the ombudsman and have implemented them with immediate effect."
Mrs Ewen added: "Although the justice feels hollow to us right now, if things do change as a result of it then his death has not been in vain."