HSSIB interim report. Creating conditions for learning from deaths and near misses in inpatient and community mental health services: Assessment of suicide risk and safety planning (12 September 2024)

Summary

This Health Services Safety Investigation Body (HSSIB) interim report highlights the importance of taking a person-centred approach to biopsychosocial assessments and safety planning for patients in mental health inpatient units and community mental health teams, and of stopping the use of risk assessment tools that stratify an individual’s risk of suicide or self-harm as low, medium or high. The findings of this report may also be relevant to other services that care for people with mental health problems.

Content

Findings

• The use of risk assessment tools that provide a high, medium, or low risk score is no longer acceptable but continue to be used contrary to national guidelines for self-harm assessment.
• Patients who had expressed suicidal thinking, and their families and carers, said that they were not listened to when sharing their safety needs and their perceptions of risk were disregarded.
• Investigations into death by suicide and near misses often refer to questions and evidence associated with high, medium, and low risk stratification. These include, for example, coroners’ investigations, local and regional serious incident investigations and public inquiries.
• Staff described a fear of being blamed if a risk assessment, including risk stratification, is not completed and a patient later comes to harm.
• Some digital patient record systems still require staff to categorise risk assessments as high, medium or low risk.
• Successful implementation of person-centred approaches to patient safety assessment and safety planning is dependent on many different factors including an organisations’ leadership culture, the people that work within organisations and the emphasis on involving the patient and their families and carers, in the assessment and planning processes.
• Organisations have involved ‘digital experts’ in their electronic patient record system improvement projects. Examples of changes made include the removal of automated predictive elements of risk stratification, free-text boxes with an increased character limit for improved narrative, and added space for family/carer views.

HSSIB notes the following safety actions, commenced in 2024 by NHS England

• NHS England, working with the National Collaborating Centre for Mental Health, is identifying 10 organisations to lead work to co-produce personalised approaches to safety planning in inpatient services. The learning will be shared through national learning networks. This is expected to be complete by March 2026.
• NHS England is producing national guidance on Safety Assessment and Safety Planning, specifically relating to person-centred safety assessment and planning, to support organisations in complying with the National Institute for Health and Care Excellence guidance ‘Self-harm: assessment, management and preventing recurrence’. This is expected to be complete in April 2025.

HSSIB makes the following safety observations

• Organisations can improve patient safety by taking a person-centred approach to biopsychosocial assessments and safety planning and stop asking for evidence of risk assessment tools that stratify an individual’s risk of suicide or self-harm as high, medium, or low risk.
• Organisations can improve patient safety by ensuring that a person centred approach to biopsychosocial assessment should be offered for all patients who have contact with mental health services, when a patient has an episode of self-harm or suicidal thinking, every time they make a transition between mental health services, and at key important times in the person’s life. This is line with current guidance from the National Institute of Health and Care guidance.
• Organisations can improve patient safety by involving ‘digital experts’ in their electronic patient record system improvement projects. This will support any digital configuration and infrastructure changes required to record person-centred approaches to psychosocial assessments and safety planning.
• Organisations can improve patient safety by listening to and communicating with patients, their families and carers, about the safety and wellbeing of people who have self-harmed and/or are expressing suicidal thoughts. It is important that this involvement starts from the point of a patient’s admission through to their discharge from inpatient mental health wards and during follow up.