NHS Resolution has today published its report following a year-long review into claims arising from actual or attempted suicide. The themes arising are unlikely to cause any surprises, however, the wide reaching recommendations to address those recurrent themes should be welcomed. The report is vital reading for all those who work in the mental health field, and also staff involved in managing inquests and dealing with serious incidents, as well as trust board members. There is a wealth of good practice highlighted throughout the report which all trusts will be able to learn from.

The investigation focussed on NHS Resolution claims and therefore does not include claims made against independent sector providers. However, the themes identified and recommendations made will touch upon all healthcare providers.

We are delighted that the author of the report, Dr Alice Oates, will be joining us in our London Office on Tuesday 11 September (registration at 09.00) to speak to us about the findings of her report. You can register to attend on our event page.

Themes

Clinical

The report has identified five areas of clinical care which are both persistent and proposed areas for improvement:

  1. Substance misuse
  2. Communication (in particular intra-agency working)
  3. Risk assessments (frequency and quality)
  4. Observations
  5. Prison healthcare

Non-clinical

In addition to the clinical areas, the report identified a further four areas of concern which were prevalent throughout the review:

  1. Lack of family involvement and staff support through the investigation and inquest process
  2. Quality of root cause analysis investigations undertaken as part of the serious incident (SI) investigation
  3. Recommendations arising from the SI investigation were often ineffective
  4. PFD reports (reports to prevent future deaths) from coroners issued during inquests were inconsistent and had poor mechanisms to ensure effective and sustainable change

Recommendations arising out of the report

  1. A referral to specialist substance misuse services to be considered for all individuals presenting with an active diagnosis of substance misuse. If a referral is not made, the rationale for this should be clearly documented.
  2. A systemic and systematic approach to communication ensuring that important information is shared with appropriate parties to best support that individual.
  3. Risk assessments to occur as part of a wider needs assessment or individual wellbeing. Risk assessments should include high quality clinical assessments, with input from the individual, family and clinical team. Training should be provided to ensure the highest quality risk assessments.
  4. All relevant staff (to include nursing staff, HCAs and medical staff 'prescribing' observation levels) to undergo specific training in therapeutic observation when they are inducted into a trust or changing wards. This should include agency/bank staff and students.
  5. On-going review of learning from litigation of deaths in custody through sharing between NHS Resolution, Her Majesty's Inspectorate of Prisons and the CQC. Learning to continue to inform the Prison Safety Plan and National Partnership Agreement action plan.
  6. Consideration should be given by DHSC, HSIB, NHS Improvement, HEE and other relevant bodies to a standardised and accredited training programme for all staff conducting SI investigations.
  7. SI investigations should not be closed until the family/carers have been actively involved throughout the investigation process.
  8. Trust boards should ensure those involved in the inquest process have adequate support throughout the process (to include being provided with written information at the outset of an investigation) and to recognise when staff have been involved in more than one inquest to provide pastoral support.
  9. The chief coroner should address the inconsistencies of the PFD process nationally to include additional training to be given to all coroners and senior monitoring of the PFD process.

With the same concerns being raised throughout the country, it can only be hoped that national recognition of these themes and ways to address them will serve to reduce this repetition.

We will be providing a more detailed analysis of the report following tomorrow's event with Dr Alice Oates, which will include the highlights of the discussion with the delegates.

Originally published 10 September 2018

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