SUICIDE PREVENTION POLICY

Transcription

1 SUICIDE PREVENTION POLICY DOCUMENT CONTROL: Version: 1 Ratified by: Clinical Assurance Sub Group Date ratified: 25 October 2011 Name of originator/author: Patient Safety Lead Name of responsible Clinical Assurance Sub Group committee/individual: Date issued: 02 November 2011 Review date: October 2014 Target Audience All Clinical Staff

2 CONTENTS SECTION PAGE NO 1. INTRODUCTION 3 2. PURPOSE 3 3. SCOPE 4 4. RESPONSIBILITIES, ACCOUNTABILITIES AND DUTIES 7 5. PROCEDURE/ IMPLEMENTATION TRAINING IMPLICATIONS MONITORING ARRANGEMENTS EQUALITY IMPACT ASSESMENT LINKS TO OTHER TRUST PROCEDURAL DOCUMENTS REFERENCES APPENDICES 18 Page 2 of 57

3 1. INTRODUCTION 1.1 This Suicide Prevention Policy is a Trust wide policy that applies to all clinical staff and supports National Suicide Prevention Strategy in England (2002) and the Trust Risk Management Framework and Patient Safety Strategy ( ). The Policy aims to promote good practice in suicide prevention strategies including the assessment, formulation and management of people at risk of suicide. 1.2 In England, one person dies every two hours as a result of suicide (DoH, 2011). Suicide prevention is a government health priority. Every case of suicide represents an individual tragedy and a loss to society. It has a devastating effect on families as well as survivors, economically, psychologically and spiritually (DoH, 2002). The Trust also places high priority on suicide prevention and has developed this Trust wide policy to provide a framework as part of its suicide prevention strategy. 1.3 In 1999, the Department of Health published the white paper, Saving Lives: Our Healthier Nation, which set the reduction in suicide rate at 20% by The National Service Framework for Mental Health (1999), standard seven took this into account. The National Suicide Prevention Strategy in England also supports this target and outlined goals and actions that are needed to achieve this reduction. It states that every year in England, about 5,000 people will take their own lives. The risk factor increases in the population that suffer from severe and enduring mental illness hence effective risk management and continuity of care is essential (NIMHE, 2005). 1.4 While progress has been made in achieving a reduction in the number of suicides by people in contact with mental health services, health care professionals need to review thoroughly their clinical practices and underlying attitudes (NIMHE, 2007). A significant number of suicides occur during a period of inpatient care or shortly after discharge; therefore managing risk effectively and ensuring good continuity of mental health care are essential. 1.5 The National Suicide Prevention Strategy for England takes into account the fact that there is no single approach to reducing suicides and states that a broad strategic inter-agency approach is required. It is important that suicide prevention initiatives are evidence-based. 1.6 In the event of a suicide the Trust Policies namely Policy for The Care of In-patients Who are Identified as Posing a Significant Risk to Themselves or Others, Policy for the management of Serious Incidents, Policy for the Investigation of Incidents, Complaints and Claims including Analysis and Improvement and Being Open: Communicating Openly and Honestly with Service Users and Their Carers Following a Patient Safety Incident or Related Complaint or Claim gives clear guidance to help staff remember the important stages and processes to follow in the management of reported Cases of Incidents and Serious Incidents in respect of all areas of Trust services. 2. PURPOSE 2.1 The Trust is aware that service users/patients should expect that their clinical risk will be appropriately assessed and managed to aid their recovery within a robust framework of consistent high standard of risk assessment and management which promotes appropriate risk taking. The purpose of this policy therefore is to: Reduce suicides rate in the Trust care delivery localities by ensuring a coordinated approach to Risk Assessment, Management and Therapeutic Risk Taking, using evidence based treatment and care, whilst ensuring that services Page 3 of 57

4 are relevant and appropriate to meet the varying degree of risk people may experience. To give guidance to ensure that suicide prevention is integral to the Trust wider clinical strategy in delivering high quality care to the Service Users in promoting their wellbeing. To ensure that the environment of care is safe by carrying out the Annual environmental suicide and ligature point risk assessment and audit using the Trust approved tools in order to meet the specific needs of people identified as at higher risk of suicide (Appendix G). 2.2 The Trust objectives are underpinned by the National Suicide Prevention Strategy for England (Department of Health 2002): and include: To promote good practice in suicide prevention strategies that is evidence based. To support the Trust Suicide Prevention Strategy, reflecting the need for multi- Disciplinary, Agency and Partnership working. To ensure that all areas of the trust are proactively engaged in suicide prevention activities and that data concerning suicide and serious untoward incidents is subject to regular audit with action plans to address identified Care and Service Delivery Problems (CDP/SDP) and to monitor for changes and improvements to embed lessons learnt into practice. To provide a framework to enable staff to effectively assess, formulate and develop management plans for people at risk of suicide whether it is within inpatients or community settings. To provide guidance to staff regarding identified high risk groups and suicide prevention strategies that will bring about: - Reducing the risk in high risk groups (See appendices D and F) - Promoting mental well being in our Service User population and - Reducing the availability and lethality of suicide methods. 2.3 The Trust will achieve these through the Principles of Best Practice in Managing Risk (DOH 2007) (Appendix C). 3. SCOPE 3.1 This Trust wide policy applies to all clinical staff working within the services of the Trust and adopts the 12 Points to a Safer Service Suicide Prevention Strategy from Safety First (DoH, 2001). These points are to support effective clinical practice through a sound Risk Assessment. The recommendations for Suicide Prevention by the five year report of the National Confidential Inquiry into Suicide and Homicide of people with Mental Illness are stated below: 1. Staff training in the management of risk, both suicide and violence every 3 years. 2. All patients with severe mental illness and a history of self-harm or violence to receive the most intensive level of care. 3. Individual care plans to specify action to be taken if the patient is noncompliant with medication or fail to engage. 4. Prompt access to services for people in crisis and for their families Page 4 of 57

5 5. Assertive outreach teams to prevent loss of contact with vulnerable and high risk patients. 6. Atypical anti-psychotic (second generation anti-psychotic) medication to be available for all patients with severe mental illness who are non compliant with typical (first generation anti-psychotic) drugs because of side effects. 7. Strategy for dual diagnosis covering training on the management of substance misuse, joint working with the substance misuse services, and staff specific responsibility to develop the local service. 8. In-patient wards to remove or cover all likely ligature points, including all non collapsible curtain rails. 9. Follow-up within 7 days of discharge from hospital for every one with severe mental illness or a history of self-harm in the previous 3 months. 10. Patients with a history of self-harm in the last 3 months to receive supplies of medication covering no more than two weeks. 11. Local arrangements for information sharing with criminal justice agencies. 12. Policy ensuring post incident multidisciplinary case review and information to be given to families of involved patients. Appendix B. 3.2 Definitions 1. Clinical Risk Assessment: According to Best Practice in Managing Risk (2007), Clinical Risk Assessment involves working with the service user/patients to help estimate each of these aspects namely: information about their history of violence, self-harm or selfneglect, their relationships and any recent losses or problems, employment and any recent difficulties, housing issues, their family and the support that is available, and their more general social contacts. Steve Morgan (2000) defined it as a gathering of information and analysis of the potential outcomes of identified behaviours. Identifying specific risk factors of relevance to an individual, and the context in which they may occur. This process requires linking historical information to current circumstances, to anticipate possible future change. He also states that Clinical Risk Assessment is a dynamic and ongoing process that should be reviewed on a regular basis, especially after significant events and prior to changes in the service user s (patient s) care arrangements. 2. Clinical Risk Management Clinical Risk Management involves the development of one or more flexible strategies that is aimed at preventing a negative event from occurring or minimising the harm caused. Risk Management must also include a set of action plans, the allocation of each aspect of the plan to an identified profession and a data review. (Best Practice in Managing Risk, 2007). It is also the process within the care planning framework that ensures that risks and vulnerabilities of the service user/patient are formulated, appropriate and that timely interventions are planned to manage the outcomes of the clinical risk assessment. The risk management process will include a statement of plans, and an allocation of individual responsibilities, for translating collective decisions into actions. This Page 5 of 57

6 process should name all the relevant people involved in the treatment and support, including the individual service user and appropriate informal carers. It should also clearly identify the dates for reviewing the assessment and management plans (Morgan, 2000). 3. Risk Formulation In the document Refocusing the Care Programme Approach; Policy and Positive Practice Guidance (DoH, 2008), Clinical Risk Formulation is described as a process in which the practitioner decides how the risk might be triggered or become acute. It identifies and describes predisposing, precipitating, perpetuating and protective factors, as well as how these interact to produce risk. The formulation should be agreed with the service user/patient and others involved in their care in advance and should take account of information relating to their history and presentation. It should lead to an individualised risk management plan as detailed within the Care Programme Approach principles. 4. Unexpected Death This is a death that is not expected due to a terminal condition or physical illness. 5. Serious Incidents (SIs) A Serious Incident (SI) requiring investigation is defined as an incident that occurred in relation to NHS-funded services and care resulting in one of the following: Unexpected or avoidable death of one or more patients, staff, visitors or members of the public Serious harm to one or more patients, staff, visitors or members of the public or where the outcome requires life-saving intervention, major surgical/medical intervention, permanent harm or will shorten life expectancy or result in prolonged pain or psychological harm (this includes incidents graded under the NPSA definition of severe harm) A scenario that prevents or threatens to prevent a provider organisation s ability to continue to deliver healthcare services, for example, actual or potential loss of personal/organisational information, damage to property, reputation or the environment, or IT failure Allegations of abuse Adverse media coverage or public concern about the organisation or the wider NHS One of the core set of 25 Never Events for 2011/12 6. Patient Risk Factors and Risk Assessment: Useful tools in the management of suicide and Self-harm include an accurate Risk Assessment, a clear clinical (e.g. Nursing, medical etc) Care Plan and a well defined Clinical Management Plan. According to Moore (1996), risk assessment will consider four basic components namely: 1. What is the behaviour to be predicted? 2. What is the probability of that behaviour occurring? 3. What is the likely cost of the behaviour? 4. What steps can be taken to reduce the possibility and or cost of the behaviour? A key principle and best predictor of future behaviour and risk is previous behaviour. Staff must therefore ensure that they have all the relevant Page 6 of 57

7 information in order to effectively assess risk. The Trust has core approved list of clinical risk assessment tools and for the details of these please see Clinical Risk Assessment and Management Policy. Business Divisions have additional tools that take account of their specialty and needs of their client group. For indicators of a service users predisposition for suicide, please see Appendix D. Additional resource is found in appendix F. The Trust promotes the multidisciplinary team working approach to risk assessment and where ever possible all risk assessments for patients who present with significant risk should be carried out by two members of staff preferably from different professional backgrounds. 4. RESPONSIBILITIES, ACCOUNTABILITIES AND DUTIES 4.1 The Trust recognises its responsibilities to implement in full its duties in respect of the prevention of suicide by safe and proper means. All areas of the Trust services should be working on suicide prevention and data concerning suicide and serious untoward incident should be subject to regular audit. The Trust Business Divisions have the responsibility to ensure that relevant plan for the maintenance of safe environment of care is in place, updated and regularly being reviewed. 4.2 Chief Executive The Trust delegates to the Chief Executive overall responsibility for the implementation of this policy across the Trust, and in turn this responsibility is delegated to the Directors and Senior Managers of the Trust. 4.3 Chief Operating Officer The Chief Operating Officer is the director with lead responsibility for this policy and its implementation. 4.4 Director of Estates and Facilities Director of Estates and Facilities will: Take action to make Trust buildings and facilities and changes to existing buildings/facilities fit for purpose by eliminating hazards such as ligature points from designs to the areas that service user/patients would have access. Work with Service Managers/ Unit Managers to eliminate hazards such as ligature points and non collapsible rails from Trust facilities where patients have access. 4.4 Responsibilities of Directors and Senior Managers Directors and Senior Managers will: Make arrangements for the effective implementation and monitoring of the policy. Produce risk assessments in their areas of responsibility as required under the Management of Health and Safety at Work Regulations 1999, where ligature points are identified as a hazard. The risk assessment should include environmental factors such as ligature points as well as individual vulnerability assessments. Where risk assessment identifies training as a measure to support effective implementation of the policy, agree with the relevant training lead the timely delivery of suitable training. Make arrangements for the effective implementation and monitoring of the Trust Page 7 of 57

8 Incident Reporting Policy, promoting a positive reporting and learning culture to facilitate continuous safety improvement with regard to suicide prevention. Influence the design of buildings via the Director of Estates and Facilities so that full account can be taken of known environmental factors associated with proactive risk management and elimination of non collapsible curtain rails from all Trust sites. 4.5 Patient Safety Lead: The Patient Safety Lead will: Promote awareness of known effective measures within the Trust to support implementation of evidence based best practice. This will involve the training in the use of NPSA Suicide Prevention Tool Kit by the Trust managers. Provide advice and support to Directors and Senior Managers to facilitate effective implementation and monitoring of the policy. Produce management reports which provide thematic and trend analysis of suicides and incident data, to inform practice development and organisational learning. Work alongside clinical leads in the production of Serious Incident investigation reports with action plans to address any identified Care and Service delivery issues. Work with Assistant Directors to learn from incidents within their Business Divisions and share the learning Trust wide. 4.6 Service Managers, Unit Managers and Modern Matrons Service Managers, Unit Managers and Modern Matrons will: Have operational responsibility for the implementation of this policy within own areas of management accountability. Take action to make the care environment safe by carrying out the mandatory annual Environmental Suicide and Ligature Point Risk Assessment Audit and facilitate any necessary remedial action. Any risk assessment is only valid for a point in time or for as long as the risk factors remain unchanged and therefore all staff should be alert to indentifying new risks and repeat the assessment when changes are made to the environment. Facilitate relevant managers/ Team Leaders to effectively use the NPSA Suicide Prevention Tool Kit 2009 to promote the safety of service users/patients Provide for the training of their staff in the applicable mandatory training to their area of service and Clinical Risk Assessment tool in use. Facilitate and support their staff to use and apply the 12 point Suicide Prevention Strategy (Appendix B) listed in this policy in their work. Carry out the completion of risk assessments as under senior managers above. Communicate lessons learned from incidents to the Organisational Learning Forum (OLF) for Trust wide sharing. 4.7 Team Leaders and Ward Managers are responsible for: Supporting all clinical staff in the Trust clinical services to attend the appropriate Page 8 of 57

9 training as set out in their organisational training needs analysis. Implementation of the systems and processes that are in place to monitor and prevent suicide within this policy. Facilitating the process where all clinical practitioners/ Care Coordinators/Lead Professionals are reviewing their caseload on a regular basis within a supervisory framework. Monitoring that accurate record keeping within Trust standards is maintained in collaboration with the service user/patient throughout their journey through the care pathway. 4.8 Clinical Staff are responsible for: Being aware of the content of this policy and application of the prescribed standards in practice. Implementing the policy standards and procedures. Maintaining their individual competence in suicide prevention strategies, including Clinical Risk Assessment and Clinical Risk Management and attending training as required by their role. Be aware of service users/ patients at increased risk of suicide and to develop and implement care plans appropriate to their needs and risks. Routinely use approved Risk Assessment Tool to identify and support the service users that are vulnerable to suicide as part of the care pathway. 5. PROCEDURE/ IMPLEMENTATION 5.1 Care Programme Approach (CPA) The Care Programme Approach (CPA) was introduced in England in It established a joint Health and Social Care approach to the care of people with mental health problems referred to specialist mental health services. It required Health Authorities in collaboration with Social Services Departments to put in place appropriate arrangements for the care and treatment of mentally ill people in the community. The CPA aims to facilitate closer and integrated working, enabling a co-coordinated approach to care delivery and the recovery process. The four main elements of the CPA process are: 1. Systematic arrangements for assessing the health and social needs of people accepted into specialist mental health services. 2. The formation of a care plan, which identifies the health and social care required from a variety of providers. 3. The appointment of a care co-coordinator to keep in close touch with the service user/patient and to monitor and co-ordinate care and 4. Regular review and, where necessary, agreed changes to the care. Current guidance on CPA is given in Refocusing the Care Programme Approach (DoH 2008) and the Trust Care programme approach policy. One of the criteria for identifying where the new CPA is needed are if the service user/patient has: Page 9 of 57

10 Current or potential risk(s) including: Suicide, self harm, harm to others (including history of offending) Relapse history requiring urgent response Self neglect or non concordance with treatment plan Vulnerable adult; adult/child protection 5.2 Clinical Risk Assessment and Clinical Risk Management Clinical Risk Assessment and Clinical Risk Management are not a once only activities but rather ongoing dynamic processes that are reviewed regularly. It involves working with the service user/patient (and/or their carers if appropriate) to help to estimate each of the aspects of risk (i.e. violence, self-harm/suicide or self-neglect) occurring, how likely it is to occur, how soon and how severe it would be if it did. The assessment process will be evidence based and will include information about the service user s history of violence, self-harm or self-neglect, their relationships, their strengths, any recent difficulties, losses or problems, employment, housing issues, their family and the support that is available and any other issues that could be relevant. It will also involve identifying whether the clinical benefit justifies the level of risk, and the appropriateness of positive risk taking (Appendix A). It is good practice that service users/patients, their families and carers are involved in all stages of the Clinical Risk Assessment and Management process and are fully informed of outcomes and changes to care provision. This may not be feasible in all cases and it will be reviewed on an individual basis by the multi-disciplinary team and giving consideration to the wishes of the service user/patient. 5.3 Clinical risk assessment tool These are forms or formats specifically designed to inform systematic clinical risk management decision making and practice. Tools can contribute a part of an overall view of the risk presented by a particular individual at a particular time. Some tools have built-in prompts for thinking about the management of any risks that are identified while others do not. The Trust has approved tools for use by staff and for these, please refer to the Clinical Risk and Management Policy. Some Business Divisions have specialist risk assessment tools in place to meet the needs of their client groups. Tools should only be used as part of a risk clinical assessment conducted with a service user/patient and combined with other information on many aspects of the service user s/patients life and current situation, need and presentation. 5.4 Clinical Risk Formulation This is the analysis and evaluation of the full risk assessment information and risk evidence base, which will inform the development of the risk management plan. This formulation will include an understanding of what the potential risks are, how likely they are, when they might be present, what the triggers are, what indicators, how often and how serious they are. The process of formulation has three key aims; to define and describe the problem, to explain why and how the problem has occurred and to summarise the problem maintaining factors (what keeps the problem ongoing). All professionals involved in Page 10 of 57

11 care of a service user/patient may not be familiar with formulation compared to psychology colleagues. Both the terminology and methodology are alien to some health professionals, which may lead to this element of the risk assessment process being compromised. In this respect, assessment fails to inform management effectively. To overcome this, clinical risk formulation should be Multi Disciplinary Team (MDT) driven and the process to include at least two members of different MDT professions. For example, medical/nursing, nursing/psychology etc. 5.5 Risk Assessment Processes This is a systematic way of: 1. Identifying hazards and risks 2. Deciding what harm could result, to who or what and how 3. Reviewing if these hazards/risks are adequately managed. 4. Taking action to manage, control or limit the hazards or risks 5. Identifying whether there are any benefits that justify the level of risk 6. Reviewing the effectiveness of the assessment and action plan 7. Monitoring for changes within the environment and the client group and taking action to mitigate identified risks 8. Recording this process to inform Risk Management 5.6 Risk Management Planning This is a systematic application of policies, procedures and practice to: 1. Risk assessment based on the identification and evaluation of hazards 2. Implementation of measures to control or manage the risk and 3. Regular monitoring, review and repackaging of care as necessary. This process could be recorded and monitored using a Business Division Risk Register in order to ensure that control measures are in place and that identified risks are being mitigated. All service users/patients will be risk assessed in order to identify any current risks and to develop a risk management plan when they are: i. on admission or when they make contact with the service ii. at key turning points during their care, such as a change of circumstances or mental state, discharge and iii. when changes are made to the environment It is important to consider the full range of risks in the context of his or her environment and circumstances (psychological, social, family, and welfare circumstances), including those associated with being a user of mental health and learning disability services e.g. social inclusion and mental health promotion. Some of these will include Risk to: Self harm Self neglect Violence to self and others Page 11 of 57

12 Risk of abuse, exploitation, physical ill health, poor living conditions, the effects of poverty, discrimination, homelessness, isolation, social exclusion and the need for mental health promotion. The Risk Management Plan will be informed by the risk domain across: a) Static risk factors historical risk factors generally not subject to change, such as things that have happened in the past. (Although static these can have dynamic components, such as anniversaries and triggers.) b) Dynamic risk factors more volatile risk factors that are subject to change, such as alcohol and drug use, medication concordance, mental state, current relationship issues and relapse. c) Factors that influence risk, which include: Historical risk information How recent and severe any risk has been. Any known patterns or triggers to risk behaviour Any current plans or intent related to risk behaviour Any risk or relapse indicators Unwanted side effects from treatment Compliance and engagement issues, which may relate to the acceptability of treatment or care proposals Effects of poor diet Poor social networks Being a carer as well as suffering mental health problems Stigma Local community issues (e.g. difficult neighbours) Offending behaviours and patterns, including recidivism (habitually returning to crime) Service users/patients could have (or may be able to develop) strengths, skills and resources that are important protective factors that can be used in recovery and risk management plans. This may include both personal strengths and any support networks. It can also include identifying where skills and strengths could be developed, or how unhelpful or maladaptive behaviours could be reduced. Working in collaboration with Service Users/patients and their Carers could have an important contribution to the risk management process. 5.7 The Risk Management Plan The clinical risk management plan is a documented plan that is clearly based on the findings and formulation of a risk assessment that includes identified action plans to manage the risk of harm, and may include positive risk-taking (see appendix A). Clinical risk management plan involves: Developing flexible strategies, aimed at preventing any negative event from occurring or, if this is not possible, minimising the harm caused. Considering what will limit or control the risks most effectively Matching the clinical intervention to the service user s needs, with the expectation of reducing risk as well as reducing distress and despair. Including the service user s strengths. Include informed decisions to take positive risks. Taking account of how critical risk factors need to be managed over time (a risk assessment is undertaken at a point in time). Page 12 of 57

13 Wherever possible, decision-making should be agreed made within a multidisciplinary setting and involve the service user/patient and carers. The risk management plan will be clearly documented and will include: A summary of all identified risks Formulations of the situations in which identified risks may occur How these risks will be managed How the service user s strengths contribute to the management of risk How the service user s strengths will be promoted through the development of important life skills e.g. problem-solving, stress management. How unhelpful or maladaptive behaviours will be reduced. Each aspect of the plan allocated to an identified person, profession or team. An identified lead practitioner (e.g. key worker, care coordinator or case manager) who will: o work with the service user to improve effective risk management o ensure the plan is recorded and communicated o ensure the plan is appropriately reviewed and updated Any known triggers of an increase in risk to self or others Any known signals or indicators of an increase in risk to others or self. Awareness of the potential for service user s disengagement with care and whether that might signal an increase in risk to others or self. Actions to be taken by the service user/patient (and/or carer if appropriate) and by practitioners in response to crisis A date for review Guidance on the reasons for earlier review 5.8 Recording risk assessment and risk management plans The Trust Policy for Health Record Keeping standards and Health Records management applies. A good quality and clear documentation serves a number of purposes, including communication with others, a record of the care provided at a point in time and the reasons for this and potentially provides a source of evidence in the face of scrutiny e.g. an investigation when something goes wrong. All considerations and decisions relating to risk will be clearly recorded in the service user/patient main case records (with copies to others as necessary). This will usually be in the electronic service user record, Maracis. The content of the records will include: 1. Level of patient/ service user, carer and professional involvement in the risk assessment and management process including: Service user/patient consent to information sharing and involvement Actual involvement Reasons for non-involvement or refusal to engage in the process Any dissenting views or disagreements 2. Risk assessment information Completion of a risk assessment tool or - Presenting risks and risk factors - Historical risk information A detailed risk assessment records - such as the second part of Page 13 of 57

14 5.9 Environmental risks the Sainsbury risk assessment tool 3. Risk formulation Formulations Decision-making processes and outcomes Records of who was involved Any dissenting views. The views of service users/patients and, where appropriate, their carers Any lack of collaboration (or obstacles to collaboration) by service users/patients or carers. This will also be documented in the care plan where appropriate. 4. The risk management plan and actions The plan (as described above Positive risk taking Accessibility of the information to others e.g. the service user, carer, other agencies. 5. Progress notes Clinical risk assessment and management is supported by the assessment and management of environmental risks, such as ligature point s audit. The tools for such audit are included in this policy (see Appendix G) Discharge Process from Trust Services All discharge/transfer care planning should take place within the framework of the Care Programme Approach (CPA). See Care Programme Approach Policy. Care coordination responsibilities will continue while a service user is in hospital. A Positive Outlook: a good practice guide to improve discharge from in-patient health care (CSIP/NIMHE, 2007) emphasises a whole systems approach to care planning and the need for effective liaison between in-patient and community teams. The Trust recognises the contribution that effective discharge/transfer care planning makes to high quality service provision, continuity of care and the recovery journey. Hospital discharge is not the point of discharge from care, but a transfer in the location of delivery of care. It acknowledges both the value and complexity of co-coordinating this process effectively with the involvement of service users/patients, Carers and a range of staff groups and organisations. The standards for discharge from hospital inpatient care specified within Preventing Suicide: a toolkit for Mental Health Services (NIMHE, 2003, Appendix E), are included in the Trust policy for the Discharge/Transfer of Service Users from Inpatient Services, and are also reflected in the Trust Care Programme Approach (CPA) Policy Learning and Sharing Lessons The vast majority of NHS care is safe, but mistakes do happen, sometimes with tragic consequences. We can only prevent these problems if we learn from what goes wrong (Medical Error (NPSA, 2005). Learning from experience is critical to the delivery of safe and effective services. To Page 14 of 57

15 avoid repeating mistakes, the Trust needs to recognise and learn from incidents and to ensure that the lessons learned are communicated and that plans for improvement are formulated, acted on and followed up. The sharing of lessons learnt from one service to other areas of the Trust will help ensure that any system failures discovered during investigations are adopted by the Trust as a whole and pockets of good practice are not isolated. Within its integrated governance arrangements, the Trust has in place: a number of interrelated policies, committees/groups; posts with lead responsibilities and, a Practice Development Programme, all of which support the organisational learning from experience. Following an adverse health care event e.g. suicide or attempted suicide, the service/ unit manager will feed in the lessons learnt from the incident to the Organisational Learning Forum (OLF) to envisage a Trust wide learning and sharing Level 1 Observation While in receipt of Trust services as an inpatient, Service Users/patients who are identified as being a suicide risk should be assessed and placed on the level of observation that is required to manage or mitigate the risk. In cases where there is an immediate or high risk of suicide, the Service User/patient should be nursed on Level 1 Observation until such a time the risk is significantly reduced or managed. For the details of nursing Service Users/patients on levels of observation in other to appropriately meet their need/s, please refer to the Trust Policy for The Care of Inpatients Who are Identified as Posing a Significant Risk to Themselves or Others. 6. TRAINING IMPLICATIONS There is no specific training programme that is required for the use of this policy and the appended audit tools (Appendix G). The Trust will create awareness of these Environmental Suicide and Ligature Point Audit Tools through staff weekly bulletin to all clinicians and other relevant staff and publish it on it s website for easy access to staff. The audit tools have explanatory information and guidance on their use. Service/ Unit Managers will support their staff teams in understanding and using the tools. Where required, the Trust Patient Safety Lead can be contacted for additional support. Service Managers will inform all clinical practitioners delivering clinical services of this policy and made them aware of the policy and its contents. They will identify those employees that require specific training within their services and take the necessary action for them to attend the appropriate training. Where a specific Risk Assessment Tool is in use within a Business Division, the Assistant Director will be required to have a strategy in place for staff training in the use of such Risk Assessment tool. Page 15 of 57

16 7. MONITORING ARRANGEMENTS Area for Monitoring How Who by Reported to Frequency All clinical environments that service users/patients have access to. Staff skilled in the assessment and formulation of risk and risk management Staff to use the audit tool contained in this policy to identify and take remedial action to manage any ligature point to promote a safe environment for service users/ patients. Staff trained in the use of Risk Assessment tools Service/ Unit Managers supported by their Ward managers, Team Leaders and colleagues from other areas or support staff. Electronic Staff Register. Ward managers and Team leaders Assistant Director of the service. Trust Patient Safety Lead. Clinical Effectiveness Group. Assistant Director of the service. Head of Learning and Development. The audit is to be carried out annually and when: Changes are made to the environment or There is a change to the patient group being cared for within the environment which presents a potential increase to the level of risk. Annually considered as part of PDR process Risk Management sub-group. The Trust through its Organisational Learning Group (OLG) and Trust Quality Council (TQC) monitor and analyse trends and themes in incidents including suicide to envisage improvement. Page 16 of 57

17 8. EQUALITY IMPACT ASSESSMENT TEMPLATE The completed Equality Impact Assessment for this Policy has been published on the Equality and Diversity webpage of the RDaSH website click here 8.1 Privacy, Dignity and Respect Privacy, Dignity and Respect The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi s review of the NHS, identifies the need to organise care around the individual, not just clinically but in terms of dignity and respect. Indicate how this will be met This will be met through individualised care planning. As a consequence the Trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity and respect, (when appropriate this should also include how same sex accommodation is provided). 9. LINKS TO OTHER TRUST PROCEDURAL DOCUMENTS Policy for the management of Serious Incidents (SIs). Policy for the Investigation of Incidents, Complaints and Claims, including Analysis and Improvement. Clinical Risk Assessment and Management policy. Policy for the Prevention of Self-harm in secondary care. Policy for The Care of In-patients Who are Identified as Posing a Significant Risk to Themselves or Others. Being Open: Communicating Openly and Honestly with Service Users and their Carers following a Patient Safety Incident or related Complaint or Claim. Policy for Health Record Keeping Standards and Health Records Management. Policy for the Discharge/Transfer of Service Users from In-Patient Services. Care Programme Approach policy. Admission and Discharge policy for Assessment and Treatment Unit - learning disabilities. Trust Risk Management Framework and Patient Safety Strategy ( ). 10. REFERENCES Bryony Moore (1996) Risk Assessment: Practitioner's Guide to Predicting Harmful Behaviour. Care Services Improvement Partnership National Institute for Mental Health in England (2007) A Positive Outlook: a good practice guide to improve discharge from impatient healthcare. Page 17 of 57

18 Department of Health (1999) Saving lives: Our Healthier Nation. Department of Health (2001) SAFETY FIRST: Five-Year Report of the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. Department of Health (2002) National Suicide Prevention Strategy for England Department of Health (2007) Best Practice in Managing Risk, National Risk Management Programme. Department of Health (2008) Refocusing the Care Programme Approach: Policy and Positive Practice Guidance. Department of Health (2011) Consultation on preventing suicide in England: A crossgovernment outcomes strategy to save lives. National Institute for Mental Health in England (2003) Preventing Suicide: A toolkit for Mental Health Services. National Patient Safety Agency (2011) In-patient suicide using non-collapsible rails National Reporting and Learning System (NRLS). Scottish Government Social Research (2008) Risk and Protective Factors for Suicide and Suicidal Behaviour: A Literature Review. Steve Morgan (2000) Clinical Risk Management: A Clinical Tool and Practitioner Manual, the Sainsbury Centre for Mental Health. The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (2011) Annual Report: England, Wales, and Scotland 11. APENDICES Appendix A - Positive Risk Management Appendix B - Twelve Points to Safer Care Appendix C - 16 Best Practice Points for Effective Risk Management Appendix D - Suicide Indicator Appendix E - The standards for discharge from hospital inpatient care specified within Preventing Suicide: a toolkit for Mental Health Services (NIMHE, 2003) Appendix F - Scottish Government Social Research (2008) Risk and Protective Factors for Suicide and Suicidal Behaviour: A Literature Review. Appendix G - Environmental Suicide and Ligature Point Risk Assessment and Audit Tool. Page 18 of 57

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20 APPENDIX A Positive Risk Management (From Best Practice in Managing Risk) The governing principle behind good approaches to choice and risk is that people have the right to live their lives to the full as long as that does not stop others from doing the same. Fear of supporting people to take reasonable risks in their daily lives can prevent them from doing the things that most people take for granted. What needs to be considered is the consequence of an action and the likelihood of any harm from it. By taking account of the benefits in terms of independence, wellbeing and choice, it should be possible for a person to have a support plan which enables them to manage identified risks and to live their lives in ways which best suit them. Department of Health, Independence, choice and risk: a guide to best practice in supported decision making, DH, London, May 2007 Positive risk management means being aware that risk can never be completely eliminated and that risk management plans inevitably have to include decisions that carry some risk. This should be explicit in the decision-making process and wherever possible openly discussed with the service user. Another way of thinking about good decision-making is to see it as supported decision-making. Positive risk management includes: working with the service user to identify what is likely to work; paying attention to the views of carers and others around the service user when deciding a plan of action; weighing up the potential benefits and harms of choosing one action over another; being willing to take a decision that involves an element of risk because the potential positive benefits outweigh the risk; being clear to all involved about the potential benefits and the potential risks; developing plans and actions that support the positive potentials and priorities stated by the service user, and minimise the risks to the service user or others; ensuring that the service user, carer and others who might be affected are fully informed of the decision, the reasons for it and the associated plans; using available resources and support to achieve a balance between a focus on achieving the desired outcomes and minimising the potential harmful outcome. Page 20 of 57

21 APPENDIX B Twelve points to a safer service (Developed from the work of the National Confidential Inquiry 3) Staff training in the management of risk every 3 years All patients with severe mental illness and a history of self-harm or violence to receive the most intensive level of care under the Care Programme Approach Individual care plans to specify action to be taken if a patient is non-compliant or fails to attend Prompt access to services for people in crisis and for their families Assertive outreach teams to prevent loss of contact with vulnerable and high-risk patients Atypical anti-psychotic medication to be available for all patients with severe mental illness who are non-compliant with typical drugs because of side-effects Local strategies for dual diagnosis covering training on the management of substance misuse, joint working with substance misuse services, and staff with specific responsibility to develop the local service In-patient wards to remove or cover all likely ligature points Follow-up within 7 days of discharge from hospital for everyone with severe mental illness or a history of self-harm in the previous 3 months Patients with a history of self-harm in the last 3 months to receive supplies of medication covering no more than 2 weeks Local arrangements for information-sharing with criminal justice agencies Policy ensuring post-incident multi-disciplinary case review and information to be given to families of involved patients Page 21 of 57

22 APPENDIX C 16 best practice points for effective risk management (Best Practice in Managing Risk, Department of Health, National Risk Management Programme, 14 June 2007) 1. Best practice involves making decisions based on knowledge of the research evidence, knowledge of the individual service user and their social context, knowledge of the service user s own experience, and clinical judgment. Fundamentals 2. Positive risk management as part of a carefully constructed plan is a required competence for all mental health practitioners. 3. Risk management should be conducted in a spirit of collaboration and based on a relationship between the service user and their carers that is as trusting as possible. 4. Risk management must be built on a recognition of the service user s strengths and should emphasise recovery. 5. Risk management requires an organisational strategy as well as efforts by the individual practitioner. Basic ideas in risk management 6. Risk management involves developing flexible strategies aimed at preventing any negative event from occurring or, if this is not possible, minimising the harm caused. 7. Risk management should take into account that risk can be both general and specific, and that good management can reduce and prevent harm. 8. Knowledge and understanding of mental health legislation is an important component of risk management. 9. The risk management plan should include a summary of all risks identified, formulations of the situations in which identified risks may occur, and actions to be taken by practitioners and the service user in response to crisis. 10. Where suitable tools are available, risk management should be based on assessment using the structured clinical judgement approach. 11. Risk assessment is integral to deciding on the most appropriate level of risk management and the right kind of intervention for a service user. Working with service users and carers 12. All staff involved in risk management must be capable of demonstrating sensitivity and competence in relation to diversity in race, faith, age, gender, disability and sexual orientation. 13. Risk management must always be based on awareness of the capacity for the service user s risk level to change over time, and a recognition that each service user requires a consistent and individualised approach. Individual practice and team working Page 22 of 57

23 14. Risk management plans should be developed by multidisciplinary and multiagency teams operating in an open, democratic and transparent culture that embraces reflective practice. 15. All staff involved in risk management should receive relevant training, which should be updated at least every three years. 16. A risk management plan is only as good as the time and effort put into communicating its findings to others. Page 23 of 57

24 APPENDIX D SUICIDE INDICATOR Steve Morgan (2000), the Sainsbury Centre for Mental Health 2000, Clinical Risk Management When assessing a person s risk of suicide the practitioner should consider both previous and most recent suicide attempts. This includes serious (e.g. suffocation, overdose, hanging, etc.) and less serious attempts (e.g. wrist scratching, or anything intended as a cry for help ). Do not consider accidental self-injury or any other unrelated injury. Detail the method used, and the considered seriousness of the attempt. When considering the severity of an attempt, look at the context in which it was made (e.g. if the person attempted to hang themselves and were only discovered by chance, this is considered more severe than someone who takes a small overdose and then presents themselves to an A&E department). The more severe, the greater the perceived risk. Previous attempts on their life: When was the attempt made? The more recent, the greater the perceived risk. Have there been several attempts? The more frequent attempts have been made the greater the perceived risk. Consider length of time between attempts - the shorter the period the greater the perceived risk. Consider previous methods are they similar in nature, is there a pattern? Do previous methods show seriousness of attempt (e.g. only found by accident on previous occasions or did they plan to be found)? Is there a gradual escalation in seriousness of method, or is it the same? Are there triggers to the behaviour in the previous attempts (e.g. does the person attempt to harm themselves in given situations, at certain times of the year, such as anniversaries)? If there is a pattern the perceived risk is increased. If there is a potential to learn from previous experience the possibility arises of yielding information about riskmitigating or protective factors. Previous use of violent methods: All forms of self-harm or attempted suicide can be considered as violent, but the intensity of the violent action can vary, and the method used may indicate the level of intent. The more violent the action, the more serious the perceived risk. The violent nature of the attempted self-harm or suicide should consider both the previous and current attempts made. Violent forms of self-harm or suicide include the use of firearms, knives, rope/other ligatures, drowning, jumping off buildings or in front of moving vehicles/trains, suffocation and inhalation of gases, fire, chemicals, drugs, alcohol and other hazards. Misuse of drugs and/or alcohol: When considering whether drugs, alcohol or other substances had a major part to play in the attempted suicide consider both the previous and current attempts made. The taking of drugs or other substances, particularly nonprescription and illegal drugs should be considered. What was the intended purpose of taking them? Is there a resulting change in behaviour (e.g. aggressive, withdrawn, lowering of mood, elation) which may indicate an increased perception of the risk of suicide? Major psychiatric diagnoses: Diagnoses of depression, schizophrenia and manic depression are indicated as more prevalent in the incidences of suicide. Depressive symptoms, psychotic experiences, and evidence of thought disorders, whilst not indicating suicidal intent in isolation, are found to be contributory factors. Expressing suicidal ideas: Expression of suicidal ideas should include any fleeting or substantial thoughts made by the person about ending their life, although there may have been no attempts at self-harm. Previous and current thoughts should be explored. Does Page 24 of 57