Investigating mental health under PSRIF

HSSIB’s latest work explores how patient safety incidents in mental health are being investigated under the Patient Safety Investigations Response Framework highlighting both the shift to system based learning and the challenges of applying it in complex care settings.

The safety watchdog’s report sets out the focus of three investigations covering incidents involving:

• Attempted suicide while under the care of community services
• A person who self-harms while in inpatient mental health care
• A person who experiences a physical health problem while in an inpatient mental health care who then requires admission to an acute hospital 

HSSIB has published one of the three investigation reports covering attempted suicide while under the care of community services.

HHSIB explain that, although suicide has been the focus of extensive national work, it has persisted as a safety risk and themes from incidents and complaints have remained the same over time. They felt that greater insight into the challenges faced at an organisational level would be helpful.  In light of that they identified an opportunity to model approaches to Patient Safety Incident Investigations (PSIIs) under PSIRF.

So, this investigation used the PSIRF template and tools.
Reading the history you will see:

• the referral lacked information about previous mental health history
• the electronic health record systems that the GP and community mental health services (CMHS) used were not interoperable
• communication needs were not fully taken into account
• lack of consistent staff
• DNAs
• discharge from community mental health team (CMHT)
• limited resources / immense pressure / increase in demand / more acuity
• long term sickness and burnout

The investigation identified four areas of improvement which the mental health trust could develop safety actions to address:

1. Making information about service users easily available and accessible across providers to support effective initial engagement and decision making.
2. Early exploration of adjustments that individual service users might need to engage in the triage and referral processes.
3. Staff knowledge and insight into how community mental health services can support service users who may require prescription medication and who use drugs and/or alcohol.
4. Organisational support for protected time, resources and assistance for staff to mitigate and respond to the distress and demands they experience in their role.

We will keep readers updated as HSSIB publishes the remaining two reports.

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