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Content ArticleSuicide is a leading cause of maternal death during the perinatal period, which includes pregnancy and the year after birth. While maternal suicide is a relatively rare event with a prevalence of 3.84 per 100,000 live births in the UK, the impact of maternal suicide is profound and long-lasting. Many more women will attempt suicide during the perinatal period, with a worldwide estimated prevalence of 680 per 100,000 in pregnancy and 210 per 100,000 in the year after birth. This qualitative study aimed to explore the experiences of women and birthing people who had a perinatal suicide attempt and to understand the context and contributing factors surrounding their perinatal suicide attempt. The researchers spoke to women with lived experience of perinatal mental illness. Their results highlighted three key themes: Trauma and Adversities which captures the traumatic events and life adversities with which participants started their pregnancy journeys. Disillusionment with Motherhood which brings together a range of sub-themes highlighting various challenges related to pregnancy, birth and motherhood resulting in a decline in women’s mental health. Entrapment and Despair which presents a range of factors that lead to a significant deterioration of women’s mental health, marked by feelings of failure, hopelessness and losing control. The authors called for further research into these factors which could lead to earlier detection of suicide risk, improving care and potentially prevent future maternal suicides.
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Content Article
This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Magda talks to us about her role as Family Liaison Officer Team Lead, how PSIRF has changed the way her Trust involves patients and families after patient safety incidents and the importance of placing patient and family perspectives at the heart of learning responses. -
News Article
Three staff disciplined over death at ‘culture of impunity’ trust
Patient Safety Learning posted a news article in News
Three staff have been put on “improvement plans” after a patient’s death which a coroner said nurses had been dishonest about, HSJ has learnt. North East London Foundation Trust was heavily criticised over the death of Winbourne Charles at an inquest last year. Coroner Graeme Irvine said staff “had not told the truth” about how Mr Charles came to take his own life in an inpatient unit at Goodmayes Hospital, in east London. Two witnesses refused to give evidence, citing a rule that they could not be compelled to incriminate themselves. Mr Irvine recorded a verdict of “suicide, contributed to by neglect, to which failures in medical intervention contributed and to which failures to respond to an obvious risk of self-harm contributed”. His prevention of future deaths report also noted “observation records appeared to have been created utilising a ‘cut and paste’ function” while there were “factually inaccurate entries” stating Mr Charles “was alive and well” up to two days after his death. In comments reported by the Barking and Dagenham Post last year, Mr Irvine said: “I think witnesses who have given evidence to me in this inquest have not told the truth. “It seems to me that this remarked upon a culture of impunity and that, unless someone sees there are consequences to their actions, nothing is going to change.” Read full story (paywalled) Source: HSJ, 14 June 2024 -
Content ArticleOn 11 April 2021 an investigation into the death of Winbourne Gregory Charles, aged 58, was carried out. Winbourne was admitted into hospital under section 2 of the Mental Health Act 1983 in November 2020 following an attempt to take his own life. In December 2020 on a diagnosis of depressive illness incorporating psychotic symptoms, Mr Charles was made subject to an order under section 3 of the Mental Health Act 1983. On 10 April 2021 Mr Charles was found unresponsive, suspended on the mental health ward. The Court returned a conclusion of: “Suicide, contributed to by neglect, to which failures in medical intervention contributed and to which failures to respond to an obvious risk of self-harm contributed.” Mr Charles’ medical cause of death was determined as 1a Suspension.
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Content ArticleDespite not being indicated for lactation in the UK, the anti-sickness medicine domperidone is increasingly being prescribed or bought illegally to aid lactation, but its side-effects can include anxiety, depression and suicidal thoughts. In this account for The Guardian, Rose Stokes describes her experience of being prescribed domperidone after the birth of her son. When her milk production didn't increase and with her mental health rapidly deteriorating, Rose bought her own supply of the drug online and through a private doctor and ended up taking more than five times the NHS maximum dose. When her mental state continued to worsen, she decided to suddenly stop taking domperidone which left her suicidal. She describes receiving no guidance on the mental health risks associated with the medication or sudden withdrawal.
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Content ArticleSuicide and non-fatal self-harm represent key patient safety events in mental healthcare services. However, examples of optimal practice that help to keep patients safe also often important learning for organisations and healthcare professionals. This study in BMC Psychiatry aimed to explore clinicians’ views of what constitutes good practice in mental healthcare services in the context of suicide prevention. The study highlighted clinicians’ views on good practice specific to mental health services that focus on enhancing patient safety via prevention of self-harm and suicide. The authors concluded that clinicians possess important understanding of optimal practice, but there are few opportunities to share such insight on a broader scale. A further challenge is to implement optimal practice into routine, daily care to improve patient safety and reduce suicide risk.
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News Article
Trust scraps suicides review
Patient-Safety-Learning posted a news article in News
A trust has announced it is scrapping a major suicides review, prompting concerns about the “devastating” impact the surprise move could have on some grieving families. The concerns from a whistleblower—and a family member who has reportedly expressed their “upset and shock”—come despite the provider’s insistence they had taken relatives’ views into account when reaching their decision. Cambridgeshire and Peterborough Foundation Trust originally announced plans for the review of over 60 cases in July last year—a move which followed allegations that a patient’s record was tampered with after they had died by suicide in the trust’s care. A chair was appointed to lead the review just last month. But in a short statement on its website, the trust said it had now taken the decision “not to proceed with [the review] as originally intended [after] speaking with several families and loved ones with lived experience” of the suicide cases, which date back to 2017. The review had been “planned with the best of intentions [but] it has become clear… that the review would not answer the individual and highly personal questions some families might have,” the trust said. Read full story (paywalled) Source: HSJ, 13 May 2024 -
Content ArticleThis investigation by the Health Services Safety Investigations Body (HSSIB) considers improvements that can be made to patient safety in relation to the use of continuous observation with adult patients in acute hospital wards who are at risk of self-harm. For its reference case, it looks at the case of a patient who self-harmed when receiving care at a high dependency unit while two members of staff were continuously observing her.
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Content Article
Why Bother Trying, the least inspirational poem ever…
Patient_Safety_Learning posted an article in Mental health
The following account and poem has been kindly shared with Patient Safety Learning by Tom Bell. -
News ArticleA bereaved father whose vulnerable son died after managing to escape from the Priory has called for a criminal inquiry into the mental health care group after the deaths of four more patients. Richard Caseby, who lost his son Matthew, has campaigned for three years against the privately run group after an inquest found his son’s death was contributed to by neglect. The 23-year-old was able to abscond from the hospital over a fence which had previously been identified as a risk. He was hit by a train just hours later. Now the Priory, one of the UK’s largest mental health providers, faces new scrutiny as coroners are set to examine the death of 20-year-old Amina Ismail, who died while at the Cheadle Royal Hospital in Stockport. Ms Ismail died in September 2023, a year after three other young women died at the same unit - Beth Matthews, 26, Lauren Bridges, aged 20, and 30-year-old Deseree Fitzpatrick. Mr Caseby, a former newspaper editor, told The Independent: “The Priory is a fundamentally dangerous company, one that persistently refuses to learn from its mistakes and neglect. The roll call of death and disgrace at its hospitals just gets longer.” Read full story Source: Independent, 25 April 2024
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News Article
Trust appoints chair to lead independent suicides review
Patient Safety Learning posted a news article in News
A trust has appointed a chair to lead an independent review into dozens of suicides that was sparked by allegations of record tampering. Following questions from HSJ about the review’s chair and terms of reference, Cambridgeshire and Peterborough Foundation Trust said Ellen Wilkinson, a former medical director at Cornwall Partnership FT and its current chief clinical information officer, would chair the review. The trust, which is looking for a substantive CEO following Anna Hills’ departure earlier this year, said the review “will not examine individual patient deaths but will take a thematic approach and look at the learnings we can take from these tragic incidents”. The trust told HSJ the terms of reference for the review of more than 60 cases of patients who died by suicide since 2017 were still being finalised. The decision not to investigate individual cases has been criticised by the whistleblower whose concerns prompted the review in the first place, as HSJ reported in October. While an employee of the trust, Des McVey, a consultant nurse and psychotherapist, carried out an investigation in July 2021 into the case of 33-year-old Charles Ndhlovu, who died by suicide in 2017. Mr McVey told HSJ his review found Mr Ndhlovu’s patient record had been tampered with and “his care plans were created on the day after his death” – a conclusion he stands by. Read full story (paywalled) Source: HSJ, 3 April 2024 -
News ArticleA senior mental health nurse suffered “degrading and humiliating” treatment while she languished for 10 days on an unsuitable NHS ward during a mental health crisis, The Independent has been told. Rachel Luby, 36, was admitted to Basildon Hospital A&E in Essex on 5 January this year after attempting to take an overdose of over-the-counter medicine following a traumatic assault. This, she claimed, was the start of weeks of horrific care she endured while waiting for a mental health bed. It culminated in her being restrained and forced into a caged van “like an animal”. She revealed her story after The Independent reported on a warning from top emergency doctors that self-harming and suicidal patients who go to A&E are not being treated with compassion because staff are overwhelmed. Ms Luby, an award-winning nurse, said she waited more than a week and a half in a general hospital before she was moved to a bed on a mental health ward. Ms Luby was able to leave the ward and find medication to overdose again, despite staff allegedly assessing her as a risk. In a second incident, she went to the bathroom and attempted to take her own life. She told The Independent: “I feel that this is something I will not recover from. I will not ever reach out for help in the future. “If this is the treatment that I’m getting as a nurse, then what the heck is happening to those that don’t have the voice or education that I have? It horrifies me to think what is happening to people that are far more vulnerable than me.” Read full story Source: The Independent, 27 March 2024
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News ArticleA&E staff are unable to properly look after the most vulnerable mental health patients or treat them with compassion because emergency departments are so overwhelmed, top medics have warned. An exclusive report shared with The Independent shows more than 40% of patients who needed emergency care due to self-harm or suicide attempts received no compassionate care while in A&E, according to their medical records. The data, collated by the Royal College of Emergency Medicine (RCEM), prompted a warning from top doctor Dr Adrian Boyle that mental health patients are spending far too long in A&E – where they are cared for by staff who are not specifically trained for their needs – before being moved to an appropriate ward. Dr Boyle, who is president of the RCEM, said there had been some progress in improving care for a “historically disadvantaged” group, but added: “Patients with mental health problems are still spending too long in our emergency departments, with an average length of stay of nearly 10 hours and this has not really improved. “An emergency department is frequently noisy and agitating, the lights never go off and cannot be described as an environment that promotes recovery.” When a patient goes to A&E after a self-harm attempt, they should receive an assessment by a clinician into the type of self-harm, reasons for it, future plans or further suicidal thoughts. The college said it indicates a “significant gap” in the NHS’ ability to provide holistic care for mental health patients with complex needs and warned “urgent” improvements are needed. Read full story Source: The Independent, 25 March 2024
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Content ArticleThe Joint Commission has released a simplified breakdown of eight patient safety goals for US hospitals in 2024.
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Content ArticleSerious incident management and organisational learning are international patient safety priorities. However, little is known about the quality of suicide investigations and the potential for organisational learning. Suicide risk assessment is acknowledged as a complex phenomenon, particularly in the context of adult community mental health services. Root cause analysis (RCA) is the dominant investigative approach, although the evidence base underpinning RCA is contested, with little attention paid to the patient in context and their cumulative risk over time. This study reviewed research in this area and found that recent literature proposes a Safety-II approach in response to the limitations of RCA.
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Content ArticleNicholas Gerasimidis had a history of mental illness manifesting as obsessive compulsive disorder (OCD) and anxiety. In 2022, his condition deteriorated. His GP referred him twice to the Community Mental Health Team but the referrals were rejected with medication being prescribed instead, together with advice to contact Talking Therapies. He was taken on to CMHT workload after being assessed by the Psychiatric Liaison Team in Royal Cornwall Hospital in November 2022. The preferred course of treatment was psychological treatment in the form of Cognitive Behavioural Therapy with Exposure Response Prevention. There was a waiting list of a year. In May 2023, Mr Gerasimidis became worse. It was felt an informal admission to hospital was required but a bed was not available. He was found hanged at his home address on 3 June 2023.
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Content ArticleThis annual report published by the National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH) contains findings relating to people aged 10 and above who died by suicide between 2011 and 2021 across all of the UK. View an infographic outlining the report's key findings.
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Content ArticleThere is currently a lack of research addressing the impact of patient suicide on GPs. This qualitative study in BMJ Open aimed to examine the personal and professional impact of patient suicide, as well as the availability of support and why GPs did or did not use it. The authors found that GPs are impacted both personally and professionally when they lose a patient to suicide, but may not access formal help due to commonly held idealised notions of a ‘good’ GP who is regarded as being unshakable. Fear of professional repercussions also plays a major role in deterring help-seeking. A systemic culture shift which allows GPs to seek support when their physical or mental health requires it is needed, and this may help prevent stress, burnout and early retirement.
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Content ArticlePrimary care appointments may provide an opportunity to identify patients at higher risk of suicide. This study in the British Journal of General Practice aimed to explore primary care consultation patterns in the five years before suicide to identify suicide high-risk groups and common reasons for seeing a healthcare professional. The authors found that frequent consultations (more than once per month in the final year) were associated with increased suicide risk. The associated rise in suicide risk was seen across all sociodemographic groups as well as in those with and without psychiatric comorbidities. However, specific groups were more influenced by the effect of high-frequency consultation, including females, patients experiencing less socioeconomic deprivation and those with psychiatric conditions. The commonest reasons that patients who went on to commit suicide requested consultations in the year before their death, were medication review, depression and pain.
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News Article
Suicidal patient, 24, died hours after being discharged from scandal-hit hospital
Patient Safety Learning posted a news article in News
A suicidal man died hours after being discharged from a scandal-hit hospital which is at the centre of a probe into the care of Nottingham triple killer Valdo Calocane. Daniel Tucker was released from a mental health ward at Highbury Hospital in Nottingham last year and died shortly afterwards, having taken a toxic substance he had purchased online. An inquest into his death last week found there were multiple failings by Nottinghamshire Healthcare Foundation Trust in the lead-up to Tucker’s death, with no appropriate care plan or risk assessment in place for him before or after his discharge. The 10-day hearing heard he had been discharged from the hospital on 22 April, despite having shared suicidal intentions with staff just days before. The jury concluded that failures by staff to ensure an appropriate plan for him contributed to his death. It comes after health secretary Victoria Atkins ordered the Care Quality Commission to carry out an inquiry into Nottinghamshire Healthcare. The probe will look at the handling of Calocane, who had been discharged from Highbury Hospital and was a patient under the trust’s community crisis services when he stabbed three people to death in a brutal knife rampage. Read full story Source: The Independent, 18 February 2024 -
Content ArticleOn 29 December 2022, Shahzadi Khan was detained under section 2 of the Mental Health Act due to her mental state and the risks she presented. She was found to have had a manic episode with psychotic symptoms. Due to a lack of beds, she was placed in a privately-run mental health hospital in Norfolk. She remained there until her discharge to the family home on 26 January 2023. She was commenced on Olanzapine and Zopiclone for her mental health whilst an inpatient. Her diagnosis on discharge was mania with psychotic symptoms. She was to remain on olanzapine in the community. Her placement out of area contributed to disjointed and inadequate discharge planning to support her in the community and was exacerbated by poor communication between the team managing out of area placements and the local team. As a consequence, the aftercare planning did not take place in accordance with S117 Mental Health Act. This was exacerbated by a failure by all health professionals involved in her care within the mental health trust to recognise that she needed to be referred on to the Trafford Shared Care pathway. A referral would have ensured she received support and care for at least 12 weeks when she returned to the community. There is no clear reason for this failure. She was seen by the Home-Based Treatment Team (HBTT) on 28 January and 2 February, then discharged back to her GP. Within a week of that discharge from HBTT, which meant she had been left with no mental health support, she had deteriorated significantly. On 9 February her GP sent her to hospital for emergency assessment due to her presentation. She was discharged home to be seen by the Home- Based Treatment Team on 11th February. She was seen by that team on 11, 12, and 13 February. There was still no recognition of the fact that the Trafford policy was not being followed. She had indicated her lack of compliance with olanzapine, suicidal thoughts and her behaviour on 13th February was erratic. On 14 February 2023 she took a fatal overdose of prescribed zopiclone at her home address.
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News Article
NHS apologises after hospital doctor took own life
Patient Safety Learning posted a news article in News
The doctor in charge of medical training for NHS England has apologised unreservedly to the family of a medic who took her own life. Dr Vaish Kumar, a junior doctor, left a suicide note blaming her death entirely on the hospital where she worked, her family revealed last year. Dr Kumar, 35, was wrongly told she needed to do a further six months of training before starting a new role. It meant she was forced to stay at Queen Elizabeth Hospital (QE) in Birmingham, where she had been belittled by colleagues, an inquest heard. In a letter to Dr Kumar's family, seen by the BBC, NHS bosses admitted she did not need to do the extra training. Dr Navina Evans, chief workforce and training education officer for England, told the family in the letter: "I wish to unreservedly apologise for these mistakes and for the impact they would have had. "As an organisation we are determined to learn... not only across the Midlands but across England as a whole." Read full story Source: BBC News, 13 February 2024 -
Content Article
Doctors in Distress website
Patient-Safety-Learning posted an article in Suggest a useful website
Doctors in Distress is a UK-based independent charity that promotes and protects the mental health of all healthcare workers and prevents suicides in the medical profession. It was set up in 2018 by Amandip Sidhu following the suicide of his brother Jagdip, a consultant cardiologist, with the aim of providing support for healthcare staff facing burnout and mental health difficulties. The charity runs free online support groups and webinars for healthcare professionals and students. Previous webinars can be viewed on the Doctors in Distress YouTube channel. -
News Article
Patients at risk of suicide and harm over unsafe hospital discharges
Patient-Safety-Learning posted a news article in News
Mental health services are failing to keep patients safe from suicide and harm after leaving hospital, the Parliamentary and Health Service Ombudsman (PHSO) has warned. It also identified failings around planning and communication when patients are discharged, and has urged the Government to strengthen the Mental Health Act. The warning comes after the Department for Health and Social Care was forced to announce a Care Quality Commission (CQC) rapid review into mental health services in Nottingham following the killings of students Grace O’Malley-Kumar and Barnaby Webber, both 19, and school caretaker Ian Coates, 65, in June last year, by Valdo Calocane. Knifeman Calocane had paranoid schizophrenia and had been a regular patient of Highbury Hospital with mental health problems. In a report last week, The Independent revealed separate investigations into Highbury Hospital which have led to the suspension of more than 30 staff over allegations of falsifying records and harming patients. The latest report by the Parliamentary and Health Service Ombudsman (PHSO), following a report in 2018, looked at more than 100 complaints between 2020 and 2023 where it had identified failings in mental health care. Lucy Schonegevel, director of policy and practice at the charity Rethink Mental Illness, said: “Someone being discharged from a mental health service, potentially into unsafe housing, financial insecurity or distanced from family and friends, is likely to face the prospect with anxiety and a sense of dread rather than positivity. Mistakes or oversights during this process can have devastating consequences. This report puts a welcome spotlight on how services can improve the support they offer people going through the transition back into the community, by improving communication and the ways in which different teams work together to provide essential care.” Read full story Read PHSO report Discharge from mental health care: making it safe and patient-centred (PHSO, 1 February 2024) Source: Independent (1 February 2024) -
Content Article
In this report the Parliamentary and Health Service Ombudsman (PHSO) looks at patient safety concerns relating to the care and discharge of mental health patients. Its findings are based on the analysis of more than 100 complaints that the Ombudsman has investigated between April 2020 and September 2023 where it found failings in care that involved mental health care.
