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The phenomenon of acute behavioural disturbance (ABD) (also known as acute behavioural disorder or excited delirium) is an under recognised and potentially life-threatening syndrome, and an emergency in psychiatric settings. In this article from Cambridge University press, causes are discussed and the pathophysiology explained. The challenges faced by practitioners are highlighted, including how ‘standard’ control and restraint can exacerbate symptoms. Initial treatment strategies are suggested.

Acute behavioural disturbance (ABD) is a term used in law enforcement and healthcare, but there is a lack of clarity regarding its meaning. Common language should be used across staff groups to support the identification, prioritisation and delivery of care to this group of patients. The terminology currently used is inconsistent and confusing. This study, published in the Emergency Medicine Journal, aimed to reach a consensus on the criteria for identification and management of ABD, and to agree when other care pathways or guidelines might be more appropriately used.

This investigation by the Healthcare Safety Investigation Branch (HSIB) aimed to support improvements in the work of community mental health teams (CMHTs). Specifically, the investigation looked at the following four areas: assessing a patient’s risk of self-harm or suicide considering menopause as a risk factor for mental health conditions engaging with families caring for people with a first episode of psychosis. Reference event Ms A was 56 years old when she came into contact with mental health services for the first time in September 2019, following a suicide attempt. Ms A spent a month in hospital, and was then discharged home under the care of a community mental health team (CMHT) with a diagnosis of psychotic depression. At the end of May 2020, Ms A was again admitted to hospital following a second suicide attempt. She again stayed in the hospital for about four weeks before being discharged home under the care of a CMHT. Ms A was seen by CMHT workers regularly throughout July, and had a telephone review with a consultant psychiatrist. At the end of July, Ms A’s family became increasingly concerned about her mental state and were unable to make contact with her. On 2 August, Ms A was found deceased at home having died by suicide. Findings While national guidance says that a patient’s risk of harm should not be stratified into categories such as high, medium or low, such stratification remains common in many trusts. This is because other methods of assessing and documenting risk are not available, and because staff fear being blamed if a patient comes to harm without a risk assessment, including risk stratification, having been completed. Current research only demonstrates a link between menopause and low mood, and not between menopause and more severe mental health symptoms. Women are frequently prescribed antidepressant medication when hormone replacement therapy may be a more appropriate treatment for their symptoms. Menopause is not routinely considered as a contributing factor in women with low mood who are assessed by mental health services, and staff do not receive training in this area as standard. While there is a significant amount of national guidance relating to family engagement when treating patients with mental health conditions, mental health practitioners often find it difficult to know how and when to engage with families with complicated relationships or when the patient withdraws their consent for information sharing. There is a lack of training in this area to support staff with decision making. National guidance raised the upper age limit for referral to the Early Intervention in Psychosis pathway in 2016. Some trusts continue to prioritise younger patients for a variety of reasons – including funding, capacity and misconceptions about whether an older person can actually be experiencing a true first episode of psychosis in later life. Safety recommendations HSIB has made four safety recommendations as a result of this investigation. NHS England: HSIB recommends that NHS England works with appropriate stakeholders, including experts with appropriate experience, to create guidance on culture change. A quality improvement programme should also be developed to support practitioners in undertaking psychosocial assessments that are in line with guidance from the National Institute for Health and Care Excellence. Person-centred safety planning should be embedded within the process. Care Quality Commission (CQC): HSIB recommends that the Care Quality Commission evaluates the way in which it reviews how community mental health services assess risk of harm, to ensure its inspections are in line with the latest national guidance. National Institute for Health and Care Excellence (NICE): HSIB recommends that the National Institute for Health and Care Excellence evaluates the available research relating to the risks associated with menopause on mental health and if appropriate, updates existing guidance. Royal College of Psychiatrists (RCPsych): HSIB recommends that the Royal College of Psychiatrists forms a working group with relevant stakeholders to identify ways in which menopause can be considered during mental health assessments. Safety observations HSIB has made the following safety observations: It may be beneficial for mental health organisations to have a dedicated liaison officer who acts as a point of contact for both families and clinicians when navigating involvement in a patient’s care and decision making. It may be beneficial for organisations to involve families in care planning and assessments, and that practitioners are appropriately trained in working with families. It may be beneficial for education bodies to develop training programmes in safety planning and psychosocial assessments, once NHS England has provided guidance on how such assessments should be conducted. It may be beneficial for mental health organisations to ensure their Early Intervention in Psychosis referral process is in line with the national guidance, and that staff are clear about the upper age limit of patients accepted onto the pathway. Safety actions HSIB has noted the following safety action: NHS England has written to all mental health trusts in England to highlight the importance of taking a person-centred approach to psychosocial assessments and safety planning. The communication asks trusts to move away from risk assessment tools that stratify an individual’s risk of suicide or self-harm.

Dorit describes the assessment and subsequent death of her much loved daughter-in-law who died during a psychotic episode having been discharged the previous evening. Her story raises a number of questions: How should families be included in making judgements and assessments about the patient and their well-being? What support do they need to care for a very distressed loved one? Why aren't written care and contingency plans provided to the patient and their family? What more needs to be done to ensure standard practices are in place to protect patients with psychosis? My much loved daughter-in-law, Mariana Pinto, died on 16 October 2016. She was 32. Her tragic and unexpected death raised many questions for us about standard practice by psychiatric services and about patient safety. The evening before she died, Mariana was taken by ambulance to her local A&E department, escorted by four police officers, and handcuffed for her own safety. She was psychotic – delusional, paranoid, violent and very distressed. She had attacked her husband (my son) who had visible bite marks, scratches and bruises. It was a first episode and totally out of character. She had not eaten or slept for several days. In A&E she was brought food and drink but spat it out, believing it to be poisoned. She kept trying to escape from the cubicle. The police stayed, stating that she was extremely vulnerable. Eventually she agreed to take a sedative – but not before she had held it under her tongue for some time, and only after we, her family, were able to persuade her that she should take it. Once she was finally sedated, she was given various tests to rule out any physical cause, and a mental health act assessment. This was done with her and her husband together. There was no attempt to see him separately. She was deemed competent to make decisions about her care, and as she wanted to go home, was discharged, with a referral to the local Crisis Team, who we were told would receive the referral at 8 am the following morning and would arrange to visit. The psychiatric team operate within A&E but for a separate mental health trust. This same trust runs the Crisis Team. It is deemed outstanding by the Care Quality Commission (CQC). The following morning, there was no contact from the Crisis Team. My son rang them at midday to ask when they would visit. They said normally between 5 and 7 pm on Sundays and to ring back if he needed to. He rang back at 3.30 pm stating that she had deteriorated rapidly and asking for the visit to be brought forward. He was told that it could not be. At 4.00 pm Mari ran out of the open door to the roof terrace and jumped off it. She did not survive her injuries. The Coroner gave a narrative verdict, making it clear that Mariana did not know what she was doing, though her actions were deliberate. She also gave a Prevention of Future Deaths Report. Whilst the trust is obliged to reply, there is no statutory obligation to demonstrate that the actions they have promised have actually been taken. There was no attempt at any risk assessment. There was no attempt to check that my son could speak freely (he could not – it was a studio apartment). There was no attempt to call the emergency services on his behalf, and no attempt to check he had been able to do so. None of this is regarded as negligent or especially problematic. Since her death the Crisis Team do visit on Sunday mornings. We also found out that the number we were given to call was for service users already allocated a key worker, rather than a more general number – but as my son spoke to senior staff on each call, this should not have made a difference. After her death we raised the following questions: Surely given the bite marks and bruising, her husband should have been allowed to give his information to the psychiatric team separately? No, it turns out that while this would have been good practice, it was not negligent. Surely, given that her family knew and loved her, we should have been asked post sedation if she seemed like herself (she did not). No, it turns out that this is not seen as necessary. It’s not even regarded as good practice. Surely, given that she was paranoid and had told the police that she did not trust her husband, her husband should have been given private space to discuss the discharge and rehearse what to do if things went wrong once the sedative wore off? And surely we should have been told that the Crisis Team is not instead of calling 999 in an emergency. And efforts made to help us to decide if the situation was an emergency. No, it turns out that while this would have been good practice, it was not negligent. The mental health trust has now introduced a written discharge template for care and contingency planning. We have been told that the circumstances of Mariana’s death were unusual and could not have been foretold. That may be. But there are still lessons to be learnt. To improve patient safety in mental health crisis and to learn from deaths, we need to change standard practice. It should become standard to: See family and friends separately if someone is paranoid, to understand the family’s concerns, learn more about the patient and work together to consider how best the patient can be kept safe and helped. Provide written care and contingency plans to patients and their family Use one number for a Crisis Team helpline, with clear policies to offer help and support to service users and to their carers, and proper protocols in place to assess risk and intervene if someone is at immediate risk of harm. Make it very clear to patients that a referral to a Crisis Team is not a substitute for calling 999 in an emergency (where there is an immediate risk of harm to the patient or others) and to distinguish between a crisis and an emergency. Other professionals have a role in this too: On discharge, the A&E staff (who were very kind and very concerned) could invite the family to come back if the situation deteriorates, making it clear that it was an emergency, was a legitimate use of 999 and of A&E, and that the Crisis Teams are not for emergencies. The police could do the same, if they are trusted by the family (in many cases they are not).

Young people and expert mental healthcare staff say patients are unlikely to receive in-patient mental health care unless they “have attempted suicide multiple times”, according to a new report published by Look Ahead Care and Support. Launched in the House of Lords, the report – funded by Wates Family Enterprise Trust and produced by experts Care Research – argues Accident and Emergency departments have become an ‘accidental hub’ for children and young people experiencing crisis but are ill-equipped to offer the treatment required.   Based on in-depth interviews with service users, parents and carers, and NHS and social care staff from across England, the findings from the Look Ahead Care and Support report draws on experience of treating depression, anxiety, self-harm, suicidal thoughts and suicide attempts, eating disorders, addiction and psychosis.   Key findings Report commissioned by Look Ahead Care and Support finds increasing demand for children and young people’s crisis mental health services amidst challenges with existing services. Yet researchers heard from professionals, service users and their families and carers found that you “had to have attempted suicide multiple times to be offered inpatient support". Interviewees say A&E departments have become an ‘accidental hub’ for children and young people experiencing crisis but are ill equipped to offer the treatment required. Private sector providers now deliver the majority of support for hospitalised young people with mental health difficulties at “exceptionally high” cost. Report recommends alternative community crisis services, including supported housing away from hospital settings to reduce pressure on A&E and reduce costs by more than 50%

This article examines the lasting impact of the tragic case of Daksha Emson, a 34-year old psychiatrist who took her own life and that of her baby daughter in an episode of postpartum psychosis. Daksha had a history of bipolar disorder and had attempted suicide before, and the inquiry into her death found that she received “significantly poorer standard of care than that which her own patients might have expected.” The authors highlight the impact of her story on the development in the UK of both specialist perinatal mental health services and specialised confidential services for health professionals, which remove some of the stigma attached to help-seeking.

This survey conducted by the Care Quality Commission (CQC) explored the experiences of people who used community mental health services between September and November 2020. The results show that people are consistently reporting poor experiences of NHS community mental health services, with few positive results. Many people reported that their mental health had deteriorated as a result of changes made to their care and treatment due to the pandemic. Analysis also showed disparities in the experiences of people with different mental health diagnoses, and in the experience of people using different methods to access care, such as telephone consultations. On this webpage you can also access a benchmark report for each NHS trust, which provides detail of the survey methodology, headline results, the trust score for each evaluative question and banding for how a trust score compares with all other trusts. Key findings Positive results Of those who have been told who is in charge of organising their care, 96% said that they knew how to contact this person. 90% said the person organised their care quite well or very well. There was a statistically significant improvement since 2019 in the percentage of people who have had the possible side effects and purpose of their medicines discussed with them. Areas for improvement Accessing care Two in five people (42%) thought the waiting time for their NHS talking therapies was too long. Only 41% of people have ‘definitely’ seen services enough for their needs. Almost 1 in 5 (17%) reported care and services were not available when they needed them in the last 12 months. Two in five people (44%) were not given enough time discuss their needs. Crisis care Over a quarter of people (26%) would not know who to contact out of office hours in the NHS if they had a crisis. Almost a quarter (23%) of people did not get the help they needed or could not contact crisis care services. Involvement Only half (52%) of people were involved as much as they wanted to be in planning their care. Only 41% of people said they ‘definitely’ agreed what care they would receive with someone from NHS community mental health services. Only half of people (50%) were involved as much as they wanted to be in deciding which therapies to use.

Benjamin Lee Stroud died on the 19 March 2021 at home. He lived alone but had a partner who saw him regularly. He had a previous medical history of recreational drugs, including steroids and cannabis; he was recently diagnosed as insulin dependent diabetic and had undergone a kidney transplant. He fell and injured his back at work, and developed a dependence on pain medication, some of which were purchased on the internet. His mental health issues increased as a result of his psychical health problems. A post mortem was undertaken and the cause of death was multiple drug toxicity. Mr Stroud had been admitted from A&E under section 2 of the Mental Health Act between the 16 and 24 January 2021, to the Lindon Centre. He was then released under the ambit of The Gables and had been seen by a psychiatrist whilst under section 2. This appeared from the evidence to be the only time he was seen by such a person. On the 22 February 2021, he took an overdose of insulin; however, as his partner is a nurse, he didn’t attend hospital as she knew what to do. A PSIIR report and action plan was completed. Mr Stroud’s partner gave evidence, and it was clear from her account that she had been begging the care coordinator for Mr Stroud to have an appointment with the psychiatrist, which did not occur. From the evidence of EPUT, it was clear that Mr Stroud’s care coordinator did not make any referral to the MDT, despite his escalating psychosis. It was also clear from the evidence that none of the conversations with Mr Stroud’s care coordinator were recorded. The action plan stated that one of the actions implemented since Mr Stroud’s death was that ‘all communications with the client should be recorded’. Matters of concern: That in all cases must go before the MDT, the evidence in this inquest made it clear that had Mr Stroud’s case been discussed at an MDT then more help would have been made available to him, that he would have been seen by a psychiatrist and may have prevented his death. On the evidence from EPUT and the PSIIR it was clear that the care coordinator makes the decisions as to whether to refer a case to the MDT, in this case, no entries were made around the rational for none referral and no explanation was provided at the inquest. This is not the first time this issue has arisen at an Inquest and the reliance on a care coordinator to make a clinical decision and no written explanation provided on any clinical notes documented appears to be a way of working. If these practices continue there is a real risk of future deaths occurring.