CClliinniiccaall IInncciiddeenntt RReevviieeww ffoolllloowwiinngg ssuuiicciiddee//uunneexxppllaaiinneedd ddeeaatthh
Date of incident
.12 reported to psychiatry on .12
Date of final report
.12
CIR Lead Dr A Donaldson Consultant Psychiatrist
Review team
Dr A Donaldson - Consultant Psychiatrist Mr D Monie - Service Manager Mr S Quinn – Senior Charge Nurse
Critical Incident Ref No
MH0045 Datix ref 75178
CCoonntteenntt ooff rreeppoorrtt Section 1- Introduction and background Section 2 - Analysis and findings Section 3 – Response to incident Section 4 – Action plan/recommendations Appendix
Care delivery Referral picked up by psychiatry and patient seen and assessed same day Psychiatry arranged to meet with family same day as protective factor Supportive family environment and follow up Early follow up by psychiatry
.11
Care delivery Was satisfactory, no major issues noted. No additional follow up by care team at home which could have been considered
Communication Liaison referral and follow up timeous Engagement with family at time of assessment
Communication Letter to HIS and relevant others completed Next of Kin contacts not readily accessible to CIR team GP surgery notified of patient death but psychiatric out patients unaware of circumstances
List the problems or issues that were considered to be of greatest significance (i.e. all those directly impacting on the outcome or course of this event)
Significant Problem/Issue Root Cause
Low mood and loss of functioning Adjustment disorder and possible depressive illness following death of patients
Recent symptoms of self harm and negative thoughts about self
Change in social and family circumstances as consequence of bereavement.
List any other problems or issues not directly impacting on this incident
1. The Community mental health team did not carry out a follow up home visit and this may have been helpful in establishing transition from hospital to home. It should be noted however that a request was not made for CMHT follow up with the expectation that would attend a medical out patient appointment. 2. Prior to assessment by Dr from psychiatry, the emergency detention certificate had lapsed. The issue appears to have been around notification and of administration systems in the acute hospital. The psychiatrist assessed risk and made a determination that would not have met the grounds for detention under the Mental Health Act and was unwilling to remain in hospital. This point is raised in respect of process as opposed to outcome of decision making and forms a recommendation on this basis. 3. Notes did not contain details of local NOK and CIR team have been engaged in following up via GP and other contacts attempting to establish contact for CIR process. It should be noted that the review team does not see either of these points as critical to the incident or overall care and the nursing and medical notes all highlight significant improvement in
whilst in hospital and at point of discharge. SSeeccttiioonn 33 –– RReessppoonnssee ttoo iinncciiddeenntt Immediate Action(s) Taken Action taken RMO report to Health Improvement Scotland Actioned by & date
AM associate Specialist in Psychiatry and Clinical Director DL 27.03.12
Further action required
Short Term Action taken Confirmation of suicide by drowning to Mental Health
Administrator. CIR process commenced
Actioned by & date
27.03.12
Medium Term Action(s) Action taken CIR team identified Actioned by & date
Jim Wright, Dr A Cook 10.04.12
Action taken Actioned by & date
Action taken Actioned by & date
Section 4
Ref No Action/Recommendation(s) Resource Requirement Status OWNER Due date Date completed
Local Actions (within area of incident)
1.` Feedback to MH team as part of CIR process on findings of report including recommendations
No resource implications Pending
Dr Donaldson and Steven Quinn October `12
2.
Older adults teams should consider routine
CMHT domiciliary visits where medical out
patient appointments are missed and there is
concern about a person’s mental state.
Potential increase in
home visits and
capacity Pending
Jennifer Borthwick and Damian Lynch October `12
3.
Communication should be improved between GP
practices and community mental health teams
via Clinical forum to identify significant events
using learning from CIR as focus.
No resource
implications Pending
A Thom I Hathorn P McDaid
Next clinical forum
Mental Health/Learning Disability/Addictions Service Actions (please identify and specify if actions involve more that one area or care group)
4.
Revise current administration supports to
determine alert system for reviews of detention
certificates across NHSL MH and LD Administration time Pending
David Monie. Pauline Hanlon and Lesley Fraser
December `12
Board Actions (the actions to be communicated out with MH/LD/Addiction Services for further learning)
Suggested Learning Points (please identify one or two key learning points from this report)
Actions require to be (SMART): Specific Measureable Attainable Relevant Timely
Resources identified can be met by: 1. Current 2. New (where new resources are required confirmation of funding/support must be confirmed by appropriate manager
Identify whether : 1. Pending (date) 2. Initiated (date) 3. Complete (date)
Identify: Named Person/Base
Identify: Month/Year
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