The Healthcare Safety Investigation Branch have been busy.
They are currently carrying out nine full investigations and published two interim reports in January – both relating to mental health.
Provision of mental health care to adults in the emergency department
A patient under the care of a local mental health service was treated in the local emergency department following self-harm and three suicide attempts within 18 months. The final occasion was six weeks before she took her life. There were no records of referral to psychiatric liaison. She left the department without notice following an overdose. Subsequently, the day before she took her life she presented to her GP again with an overdose. She was advised to attend the emergency department of her local hospital and eventually attended there by ambulance. No referral was made to psychiatric liaison. Again she left the department without notice. She did, however, attend her GP the next day. That afternoon she lay in the path of an oncoming train and did not survive her injuries.
Safety issues identified
- The appropriateness of assessment tools to identify patients at risk.
- Difficulties in the sharing of patient information within the emergency department.
- The emergency department may not be a place of safety for a patient experiencing a mental health crisis.
- Access to psychiatric liaison services.
Again HSIB have stated that they would welcome further information that may be relevant. They intend to compare settings with well-established, 24/7 psychiatric liaison with those yet to implement a full service.
Transition from Child and Adolescent Mental Health Services to Adult Mental Health Services
They were notified of an 18-year-old who died by suicide shortly after transitioning from CAMHS to AMHS. He had been diagnosed with Autism Spectrum Disorder aged ten and found managing change particularly difficult. His GP only referred him to CAMHS when he was 17 years and six months. Initially it was felt that treatment would be complete within six months so no AMHS referral was made. However the position then changed. The month after he turned 18 (and five days after his last appointment with CAMHS) he and his mother met his AMHS care coordinator. They were a locum which meant further change was likely. His deteriorating mental health was documented and a medication review was organised. Sadly he died that night.
HSIB note that this is a safety issue which spans mental health trusts across England.
Safety issues identified
- The transition pathway from CAMHS to AMHS.
- The variation in commissioning, service design, delivery and regulation of the transition from CAMHS and AMHS.
- The benefits of learning how other healthcare sectors manage transition.
HSIB have stated that they would welcome further information that may be relevant.
Jill Mason, Partner
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