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