Briefing Paper for Community of Practice December 2014 Reporting period 1 May 31 October 2014

Transcription

1 Suicide Reporting and Learning System Briefing Paper for Community of Practice December 2014 Reporting period 1 May 31 October 2014 The suicide review reports we have received reflect the general shift by mental health services. In line with the national framework for learning from adverse events services are integrating suicide reviews with their NHS board adverse event reporting and review systems. This should support NHS boards in the way information from suicide reviews is used to improve services and reduce risk. One of the issues we comment on in this briefing paper is the challenge of sustainability how to build service improvement which is lasting and effective. While suicide review processes across Scotland continue to improve, it is clear that the priority now is to make sure the way those lessons are utilised effectively and continue to drive both systematic learning and help staff develop their individual practice. Set out below are topics from the suicide reviews that we have received in the past 6 months and many of them are familiar. We also set out actions which the Suicide Reporting and Learning System (SLRS) team is taking to support mental health services. Use of Care Programme Approach in complex cases A recurring recommendation in suicide reviews is that the Care Programme Approach (CPA) should be considered in cases where there has been complex multi-agency involvement in care. Generally, CPA should provide: a formalised communication between agencies and multidisciplinary colleagues an explicit description of the roles of each professional providing care a regular review of progress of care clarity to service users and carers of the arrangements for their care and treatment a non bureaucratic approach an avoidance of duplication of effort by staff, and an effective way to manage risk. In many of the suicide reports we receive where patients face complex challenges, for example where the primary diagnosis has been of emotionally unstable personality disorder, it has been recommended that thought should be given to the use of the CPA. This would provide structure for providing care and treatment that supports the patient and staff manage the dynamics of difficult therapeutic relationships. There are particular challenges in supporting people who have very changeable mental states, chaotic behaviour and challenging relationships with helping agencies. Recommendations arising from suicide reviews have emphasised the following. There was a lack of cohesive joint working and communication between the two teams involved in care: Adult CMHT and addictions. This is particularly notable at the time of the patient s discharge from his last inpatient stay. Risk assessment took place however resultant management plans with a longer term view of the patient were not made. Social services may have been able to provide active support and advice but were not involved and it seems as though plans to make a referral were not followed through. File name: SRLS Brieing Paper December 2014 v1.15 Date: December 2014 Produced by: SRLS project team Page: 1 of 5

2 Suicide reviews often refer to improving communication between services and the patient where there are complex care arrangements involving more than one agency. This includes branches of healthcare, local authority, police, third and private sector agencies and individual therapists. Again, reference is made to the potential benefit of using the CPA in such circumstances. One review made the following statement. Persons with complex mental health and social difficulties may kill themselves despite high levels of care delivery and assertive community follow-up. The team reflected on whether convening multidisciplinary care planning meetings in such cases may assist with more effective development of crisis contingency plans (also including inpatient teams ie more clearly defining triggers for compulsory treatment or admission) it is suggested that the further development of the Care Planning Approach may be an appropriate vehicle for such discussions. To minimise disengagement of services and a loss of the patient from the services the Care Programme Approach should be utilised. Adult support and protection arrangements also provide for inter-agency communication in relation to vulnerable people and should also be considered in complex cases. Consideration requires to be given regarding the use of Adult Support and Protection Legislation in relation to individual patients who the service identify as vulnerable and who are not engaging with services. This should include options for making social work colleagues aware of our concerns regarding vulnerable adult. the use of Adult Support and Protection Legislation where patients are vulnerable and recorded to have suffered from exploitation by family members. Action by Healthcare Improvement Scotland we have included a section on this topic in our draft Discussion Framework 1 to assist mental health teams discuss and identify areas for improvement in their practice. Communication with patients, and their family, on admission to mental health services Admission to hospital may be a relief for people in difficult circumstances. However, particularly on first admission, going into an unfamiliar environment may be frightening. While hospital staff will be providing reassurance when a patient arrives, having information prior to the admission can help patients and families through the process. It is important that GPs and other relevant agencies that may be referring a patient to hospital have clear and reassuring written information about the service and what to expect. A point of additional learning that became apparent throughout the review was the need for the service to develop an education and information leaflet to assist families and carers in identifying a deteriorating patient. The panel welcomed the development of an information leaflet advising families when to seek help. The service agreed to take this forward and develop an education leaflet. 1 Healthcare Improvement Scotland. Reducing Suicide Risk Mental health team discussion framework. Testing phase January March Produced by: SRLS project team Page: 2 of 5

3 Action by Healthcare Improvement Scotland we will ask the Suicide Review Team Network for examples of mental health service patient information leaflets given to GP practices and share these on the Suicide Reviews Community of Practice website. Non-concordance with medication Suicide review reports we receive identify non-concordance with medication and apparent associated relapse as a significant factor in a number of suicides. The factors identified in reports include: initial poor engagement with services insufficient patient education about treatment non-attendance with services symptomatic improvement leading to the patient stopping treatment unpleasant side effects, and mental state interfering with ability to consistently take the medication. Recommendations made in such cases include: improving patient education about medication and side effects creating clearer protocols (for non-concordance with medication and non or erratic attendance with services) using medication boxes, particularly where there is cognitive impairment, and improving personal contact and use of reminders such as telephone calls, texting and s. Action by Healthcare Improvement Scotland we tested a section on this topic in our draft Discussion Framework at our October 2014 Suicide Review Team Network meeting. The output will inform Healthcare Improvement Scotland s Strategic Delivery Plan for Medicines. Communication with family members and carers Delays in notification Sometimes, particularly in relation to recently discharged patients, there is a delay in the service being notified of a completed suicide. This has implications for carrying out a review and, in particular, for offering support to bereaved family members and carers. One review we have received makes the recommendation that it would be useful to discuss with the local Police Scotland liaison officer ways in which police attending a suspected suicide might notify the local mental health services to establish if there had been previous contact and if so to initiate adverse event/suicide review procedures. Action by Healthcare Improvement Scotland we will invite a representative from Police Scotland to join the Suicide Review Team Network and facilitate a discussion on notifying services at a future meeting. Meeting with bereaved family members and carers There was a recognition by the adverse event panel that there would require to be investigation into the training and support needs of staff who may be expected to meet with family members/carers following the death of a patient. Produced by: SRLS project team Page: 3 of 5

4 This recommendation highlights the importance that staff need to be well prepared to support bereaved family members and carers following a completed suicide. In particular, the initial contact requires care and sensitivity. Where the person who has died has been an inpatient there are some key points for staff to remember. Review reports received have highlighted the following points. Bereaved family members should be offered a pre-arranged time to meet with staff following a suicide. It is essential to give thought to where would be the most appropriate place to meet with family members following a completed suicide. Revisiting the place where the deceased was receiving care is likely to be a stressful experience. This is a very difficult time for the family of the deceased and staff should have time available to discuss their feelings and concerns. Collecting a person s belongings from hospital following their suicide can be an emotional time. How the belongings are packed and presented can be seen as a reflection of respect. Care and sensitivity is essential in managing these situations. Staff involved in initial meetings with family members and carers should be able to answer questions and provide supportive information. Action by Healthcare Improvement Scotland through the Suicide Review Team Network we will ask services to check if their bereavement policies give guidance on the special circumstances of meeting with the families of people who have completed suicide. We will also ask the Scottish Government if the Scottish Grief and Bereavement Hub provides specific guidance for staff on suicide. Suicide reviews and terms of reference An important consideration arising from suicide reviews is whether the review itself helps to understand what led to the death or whether it is narrowly focussed on the contact the deceased had with the service and misses wider contributory factors. The danger is that the review may become simply an exercise in justifying the care that was given by services rather than an opportunity to understand what led to the person ending their life and if the service provided could be improved. Some review reports we receive begin with specific terms of reference that define the level of the review to be undertaken. Setting terms of reference for each review provides an opportunity to make sure that the review addresses the key areas to be considered. For example, recognising wider contributory factors such as social and financial pressures. Setting helpful terms of reference is best done after an initial consideration of all the available information about the completed suicide to make sure that the key aspects of the circumstances of the death are considered. It does appear from the reviews we receive that the greater the thought put in at the beginning of a review the better the lessons learnt at the end. Action by Healthcare Improvement Scotland we will include guidance on setting terms of reference in our revision of the Suicide Reviews Improvement Framework. Improvement implementation and sustainability A recommendation from a suicide review received referred to a process for making sure that learning outcomes and recommendations relating to self-harm are reviewed and immediately incorporated into care planning processes. This recommendation, and others, highlights that effective suicide/adverse event reviews are successful in identifying learning Produced by: SRLS project team Page: 4 of 5

5 for service improvement. However, one of the greatest challenges for services is not only to identify areas for immediate improvement but to sustain that improvement in everyday clinical work and processes. Our discussions with NHS boards highlight the importance of staff knowing that improvements they are being asked to engage in have come from the findings of reviews so that the context, and therefore the relevance and the importance, is not lost over time. While this is recognised by all the services we receive reports from, we think that it is helpful to remember simple, key principles in promoting sustainability of learning for improvement. Recommendations and associated action plans should include a timescale and be reviewed to make sure that they have been completed. Actions/improvement interventions implemented following reviews should be revisited at set periods of time to assess their effectiveness. There should be support for staff in the multidisciplinary team to access learning points from reviews and consider how to translate these into ways of improving their practice. Action by Healthcare Improvement Scotland consider including this topic in the Training and making it safe to learn (improvement area 10) of our draft discussion framework. Contact the SRLS team if you would like any further guidance or more information. hcis.suicidereviewteam@nhs.net Produced by: SRLS project team Page: 5 of 5