Shock report on mental care suicides

Fifty per cent of cases of unexplained deaths that took place in community mental health services had not been investigated or reviewed by the services, a recent HSE audit has found.

This was one of two recent HSE audits, seen by irishhealth.com, which highlight serious shortcomings in the way sudden unexpected deaths in mental health services, likely to have been from suicide, were handled by local staff.

The audit on community service deaths found that only 25% of the incidents examined were notified in accordance with legislative requirements and HSE rules. The audit team had to rely on circumstantial evidence to determine compliance with notification rules in a number of cases, the audit report says.

Another audit, on deaths in approved mental healthcare centres, identified a failure to investigate whether care or service delivery problems could be linked to the deaths.

HSE rules stipulate that all unexplained deaths should be notified to the designated persons locally within the HSE as well as the relevant statutory agencies, and investigated locally using recommended systems analysis.

In the audit of unexplained deaths in community mental health services, it was found that 10 of 21 incidents examined were not investigated or reviewed. Where reviews were reported to have taken place, they varied from the formal to the informal, the audit says.

These review reports tended to be brief with little evidence of systematic examination of events or a 'structured process of reflection', the audit states.

The audit, which was carried out on likely suicide deaths in community services between October 2013 and January 2014, also found that the quality of data and supporting documentary evidence in relation to the deaths made available to the audit team for inspection was below what could have reasonably have been expected.

The audited incidents where patients died in community services as a result of suspected suicide occurred in 2010 and 2011.

The other HSE audit looked into the handling of 12 incidents of death likely to have been from suicide that took place in approved mental health treatment centres in 2010 and 2011. It criticised the way the incidents were dealt with and investigated by local staff.

The audit, carried out from March to May last year, said in general, care or service delivery problems were not highlighted in the investigation of these deaths in accordance with guidelines.

While there was some attempt by some local investigation teams to identify contributory factors, they were not linked to care/service delivery problems, the audit said. It added that where recommendations were made on foot of the investigations they were not linked to contributory factors.

The audit of these deaths said the only one of eight investigations it looked at in detail was fully consistent with systems analysis methodology. The quality of local reports into the deaths varied considerably, the audit stated.

It said while 11 of the 12 deaths in mental health centres were notified in accordance with regulations, the audit team had to rely on circumstantial evidence to determine compliance in some cases. Conclusive validation was not possible in these cases due to a lack of supporting documentation, the audit noted.

The audit of the community mental health service deaths noted that a small number of services where deaths took place did examine areas for improvement and made recommendations that could mitigate the likelihood of similar incidents recurring in future.

The audit into these deaths concluded that based on information it had gathered, it cannot provide assurance that incidents of sudden, unexplained deaths of persons in community mental health services are notified in accordance with HSE policy and procedures. Not could it provide assurance that incidents of this nature are investigated using systems analysis methodology.

The audit of the deaths in mental health centres said it cannot provide assurance that the incidents of sudden, unexplained deaths in these centres are investigated using recommended systems analysis methodology. It acknowledged that local HSE services in some cases made recommendations for service improvements.

The HSE drew up 18 recommendations for service improvements on foot of the two audits.

The audits did not investigate all sudden unexplained deaths in community mental health services or mental health centres in 2010 and 2011.

RTE's This Week programme recently revealed that nine consultant psychiatrists in Carlow/Kilkenny and South Tipperary said they had no confidence in the service as they believed it was unsafe, following nine patient fatalities in mental health services in these regions between 2011 and 2013.

Junior health minister Kathleen Lynch denied she had ignored the doctors' concerns and said she had raised them with HSE management. She said there had been no resource issues involved with the mental health service in the south-east.

The consultants had written to the Minister expressing their concerns in June 2013, questioning the safety of the governance of the mental health services in which they worked. They claimed their safety concerns had been ignored by the HSE.

 

[Posted: Tue 24/06/2014]

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