Summary
The Health Services Safety Investigations Body (HSSIB) engaged with a wide range of stakeholders, including clinicians and national leads, to learn more about the issues surrounding learning from patient safety events in mental health settings and to identify areas where an investigation could focus to help improve patient safety.
Although suicide has been the focus of extensive national work, it has persisted as a safety risk. The themes from incidents and complaints have remained the same over time. Evidence from the intelligence gathered suggests that greater insight into the challenges faced at an organisational level when a service user has attempted suicide, or taken their life, would be helpful.
To support NHS organisations and local investigation staff, HSSIB identified an opportunity to model approaches to patient safety incidents investigations (PSIIs) under the NHS Patient Safety Incident Response Framework (PSIRF). Stakeholders told HSSIB that this would help to increase local learning and provide examples of how PSIRF tools can be used to improve investigations. HSSIB has also used this opportunity to identify learning that may help to improve how PSIRF can support staff in carrying out incident investigations.
This investigation has used the PSII report template and PSIRF tools to investigate an attempted suicide in the community mental health setting. Findings and areas for improvement are listed for the organisations that were involved in this incident. However, the learning may be relevant to other organisations.
Content
Summary of key findings
The investigation found that:
- The Service User’s attempt to end his life was not expected by the mental health staff supporting him.
- The change to his medication meant it was a potentially vulnerable time for the Service User's mental health. This was despite him having a safety plan for how to seek help if he felt overwhelmed and planned monitoring check-ins in line with local procedure.
- The Service User’s case was complex and challenging; his mental ill-health, drug and alcohol use are likely to have impacted on his ability to reason and make informed decisions. Therefore, sharing of information across and between healthcare services was important to facilitate personalised care planning.
- Limited sharing of, and lack of ready access to, information about the Service User and his past mental health history impacted on the CMHS’s ability to provide effective and timely care.
- The Service User needed a tailored approach with reasonable adjustments to maximise his engagement with mental health services; there was a delay in his needs being identified and acted on.
- There was limited understanding and awareness by some staff of whether mental health medication can be offered to service users with mental health issues and concurrent alcohol use.
- Staff worked in a service that was overstretched and they had to make decisions about managing service user needs, service demand, and risk and safety, within limited resources. The demand for CMHT services exceeded the available capacity, impacting both service users and staff.
- Staff did not have the dedicated time and space to process and deal with distress they encountered as part of their daily work caused by incidents of patient harm.
- There are challenges to delivering the national ambition to provide a community focused model of care, many of which the mental health trust has limited or no control over.
Summary of areas for improvement
The investigation identified four areas of improvement which the mental health trust could develop safety actions to address.
Area of improvement 1: Making information about service users easily available and accessible across providers to support effective initial engagement and decision making.
Area of improvement 2: Early exploration of adjustments that individual service users might need to engage in the triage and referral processes.
Area of improvement 3: Staff knowledge and insight into how community mental health services can support service users who may require prescription medication and who use drugs and/or alcohol.
Area of improvement 4: Organisational support for protected time, resources and assistance for staff to mitigate and respond to the distress and demands they experience in their role.
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