Safety watch dog investigates variation in mental health care in emergency departments

On 23 November 2018 the Healthcare Safety Investigation Branch published their latest full investigation report into the provision of mental health care to patients presenting at the emergency department. 

It followed HSIB being notified about a patient called Diane who, unfortunately, committed suicide. She was a 57-year-old woman who had a history of mental health problems and was in the care of the community mental health service. She presented four times to the same emergency department following self-harm but received different levels of care on each occasion. She was referred for mental health assessments on the first two occasions but not thereafter.

The report will be an essential read for both providers and commissioners. The executive summary can be found at pages 6–7 and the conclusion at pages 39–40.

The report notes that emergency departments treat approximately 220,000 cases of self-harm a year (but highlights that a recent study suggests that this figure may underestimate the true rate by 60 per cent).

There are four safety recommendations aimed at improving patient care.

1. NHS England ensures there is a sustainable funding model for 24/7 urgent and emergency mental health liaison services in acute general hospitals with emergency departments.
2. National Institute for Health and Care Excellence review and amend guidance for the management of self-harm in the emergency department.
3. The Royal College of Emergency Medicine, in conjunction with the Royal College of Psychiatrists develops and disseminates national guidance for emergency department practitioners to standardise the conduct of the initial assessment of a person presenting following a mental health emergency.
4. The Care Quality Commission reviews and updates its inspections criteria for emergency departments to ensure equal weight is given to the quality of care provided to people with urgent mental health problems as they do to people with urgent physical health. This would be consistent with its commitment to parity of esteem for mental health. 

In addition, HSIB make two safety observations.

1. The data regarding mental health presentations is not sufficiently robust to allow for demand for mental health services to be adequately assessed and the impact of service provision to be measured.
2. Initial assessment of patients, on arrival at an emergency department may benefit from inclusion of key factors from the Royal College of Emergency Medicine guideline. 

And one safety action is noted:

The National Institute for Health and Care Excellence has changed the wording of clinical guideline CG16 to reflect the findings of the investigation. “Consideration should be given to introducing the Australian Mental Health Triage Scale, as it is a comprehensive assessment scale that provides an effective process for rating clinical urgency so that patients are seen in a timely manner. Do not use the Australian Mental Health Triage Scale to predict future suicide or repetition of self-harm.”  

Jill Mason, Partner