Reducing Risk: Mental health team discussion framework May 2015 Contents Introduction... 3 How to use the framework... 4 Improvement area 1: Unscheduled absence and managing time off the ward... 5 Improvement area 2: Discharge and other transitions in care... 8 Improvement area 3: Mental health and drug and alcohol teams joint working... 11 Improvement area 4: Overdose reducing access to means of suicide... 14 Improvement area 5: Not taking medication and associated relapse... 17 Improvement area 6: Hospital-based care keeping the environment safe... 19 Improvement area 7: Hospital and community recording and sharing information and managing risk... 22 Improvement area 8: Patient and staff engagement... 26 Improvement area 9: Involving family members and carers... 29 Improvement area 10: Training and making it safe to learn... 32 Appendix 1: Learning from suicide reviews team culture checklist... 34 2
Reducing Risk: Mental health team discussion framework May 2015 Introduction In 2013, the National Confidential Inquiry into Suicide and Homicide (NCISH) published a safer mental health services toolkit. It is intended to be used as a basis for self-assessment by mental health services in England and Wales. In early 2014, the Scottish Government asked Healthcare Improvement Scotland s Suicide Reporting and Learning System (SRLS) to develop a similar document for use in Scotland. We collaborated with our colleagues from the SRLS Community of Practice, the Scottish Patient Safety Programme in Mental Health (SPSP-MH), the Mental Welfare Commission for Scotland and Scottish Government to produce this framework. When a suicide takes place, NHS boards need to understand what happened and learn from any lessons identified. The lessons learnt are important to improve services and help staff recognise where risk exists. Suicide reviews are the way that NHS boards, and their mental health services, analyse what happened and recognise where anything can be done to make things safer for other people at risk. We understand that NHS boards can call these reviews different things, for example adverse events review, critical incident reviews, significant event analysis. In this framework, we will refer to these reviews as suicide reviews. All NHS boards are required to report to the SRLS team any suspected suicide of a person who has been in touch with mental health services 12 months prior to death. The SRLS aims to assist NHS boards to improve the way that suicide reviews are carried out and reduce risk. These reviews produce many detailed learning points and recommendations that provide strong themes and messages about how we can improve the way we work together. The framework is largely based on the information we receive from these suicide reviews, supplemented by the NCISH toolkit. The purpose of this framework is to help your mental health multidisciplinary teams and managers develop a habit of coming together to think about risk and how to reduce it in the work that they do. The framework does not give specific guidance on risk assessment and management. It has been designed to promote discussion between members of your multidisciplinary team, to make sure there is a common understanding of knowledge, practice and attitudes towards the way that individual patient care is organised and managed. Staff from different disciplines, staff with different roles, staff from different agencies and service managers all have a variety of skills and perspectives that are essential in providing safe and effective care. It is important that these different perspectives are shared to help towards providing safer services. Risk reduction is everyone s responsibility. Please use this framework to give a structure to your multidisciplinary discussions about the care and treatment you provide. 3
Reducing Risk: Mental health team discussion framework May 2015 How to use the framework Mental health care is based on a relationship between the person seeking help towards recovery and the many staff whose job it is to support and provide care and treatment. People with mental health problems are admitted to hospital for a variety of reasons. For a significant number, the admission will be associated with risks arising from their mental health, including suicidal thinking and behaviour. Suicidal thinking and behaviour are complex manifestations of many factors in a person s life, including mental illness and distress arising from relationships and other social factors. Helping people in such circumstances requires a structured approach to assessment and care and is likely to involve a number of professional disciplines and agencies. To work effectively, the different people involved in the person s recovery need to understand each other s roles and perspectives in relation to assessing and managing risk. The purpose of this framework is to help facilitate discussion between your multidisciplinary team and share perspectives on the care your team provides. Suicide reviews from around Scotland have highlighted that: team members may not always completely understand each others roles in relation to responding to risk sharing information about risk makes for better assessments and care, and clear clinical leadership makes for better understanding of responsibilities, better communication and better multidisciplinary care. This framework is divided into 10 improvement areas that can be used to form the basis of a multidisciplinary discussion about how your team works. The improvement areas pose a number of questions to get your discussion going and to: find out if your team members share views on how you work highlight any areas of uncertainty identify things that could be improved, and find out if your service has a balanced view on managing risk in the care you provide. We recommend that you record the outcome of the discussions to allow you to revisit each area at agreed intervals to maintain a shared and agreed approach to each improvement area. While this discussion framework has been developed for multidisciplinary mental health teams, you might find it beneficial to involve other agencies in your discussions to develop ways of gaining the views and concerns of the service user. This may be through discussion with individual service users, patient representative bodies and advocacy services. Involving service managers in the discussion with the multidisciplinary team is likely to give a wider perspective on how the service is working and assist in developing improvement strategies. Time is precious in multidisciplinary meetings, but taking even 15 minutes to discuss one of these topic areas can provide an opportunity to reflect on the way your team works together. 4
Improvement area 1: Unscheduled absence and managing time off the ward There are measures in place to prevent at risk patients leaving without the knowledge of staff. There is a standard response/protocol for at risk patients who leave hospital without the knowledge/permission of staff. There is careful preparation and support for patients leaving the ward on pass or suspension of detention. What we know from the review reports you send us Effective monitoring of ward entry and exit points can help to keep vulnerable patients safer. Observation practices should include a general awareness of the whereabouts of all patients and recognise the risks involved when depending on timed checks for those at immediate risk of suicide. Safety briefings help to make sure all staff are alerted to any patient at risk of unplanned absence and to environmental and situational risks. Patients are helped by being sufficiently prepared for time off ward and being out of the hospital, for example discussing: any potential risks they face strategies for dealing with a crisis, and the importance of time limits, arranging phone check-in times and providing written crisis information. A current and easy to use missing person s procedure that has been developed in conjunction with local representatives of Police Scotland helps to speed up the response to vulnerable and at risk patients leaving hospital without previous arrangement with staff. 5
Improvement area 1: Questions for multidisciplinary team discussion Discussion questions Do all members of your team know how to use your service s protocol for managing at risk patients leaving hospital without pre-arrangement with staff? How are agreed risks managed what are your measures in place to prevent patients leaving without staff knowledge? Are there effective observation practices where all patients whereabouts are known to staff? Is your team involved in safety briefings and do they make you aware of potential risks? 6
Discussion questions Does your team discuss arrangements for time out of hospital, as detailed above, with patients? Does your service have an agreed missing person s procedure and is it known by your team? Has Police Scotland been involved in preparing your missing person s procedure? 7
Improvement area 2: Discharge and other transitions in care There is multidisciplinary planning, which includes appropriate family and carer involvement, prior to discharge or significant service transition, involving all relevant staff. The plan of care is communicated to all relevant agencies (particularly primary care) before the planned discharge or transition takes place. What we know from the review reports you send us Review reports we receive identify the importance of patients and family members having clear information on care arrangements, recovery plans, relapse/crisis identification and response to rapid changes in mental state and associated increased levels of risk. The reports make recommendations on the availability of simple and clear information on who to contact for help and in what circumstances. Discharge from hospital, and other significant transitions of care, are high risk and require careful and co-ordinated management. 8
Improvement area 2: Questions for multidisciplinary team discussion Discussion questions Is there a system to make sure that planning meetings are held prior to a patient s discharge or transition which include the patient and family members or carers? If so, do these meetings routinely involve all relevant staff? This can include hospital-based staff, community staff and/or other agencies. Is there a system to make sure that staff who have not attended the multidisciplinary team meeting are kept up to date with relevant information and care and treatment decisions? 9
Discussion questions Is there a system to make sure that the plan of care is communicated to all relevant agencies, such as primary care? Does the patient have clear information on their care arrangements, how they can communicate with staff and what to do when there is deterioration in condition or a crisis? Do family members or carers have clear information on the patient s care arrangements, early warning signs and what to do when there is deterioration in condition or a crisis? 10
Improvement area 3: Mental health and drug and alcohol teams joint working There is effective joint working between mental health services and drug and alcohol teams (including shared care pathways, referral and training). There is a specific management protocol or written policy on the management of patients who are being supported by mental health services and drug and alcohol teams. What we know from the review reports you send us The reports we receive provide evidence of the importance of effective joint working between mental health services and drug and alcohol teams. The main issues identified in suicide reviews are as follows. The absence of shared care pathways can lead to confusion and inconsistencies in care. Communication between mental health services, drug and alcohol services, primary care and general acute care, such as A&E, can be patchy for shared care planning and crisis management. Classification of, and response to, urgent referrals can lead to confusion about need and timescales for rapid interventions. Inconsistent notification of did not attends (DNAs) and discharges from mental health services or drug and alcohol services can lead to patients unintentionally disengaging with services. There are gaps in training for staff in working with patients who have co-existing mental health and drug and alcohol problems. The root of these problems is often identified in reports as a lack of clarity of who has responsibility for overall clinical leadership. 11
Improvement area 3: Questions for multidisciplinary team discussion Discussion questions Does your service have a specific policy on the management of patients with co-existing mental health and drug and alcohol problems and does it make sure the patient s care, treatment and recovery needs are met by the different services involved? Do all these patients have a shared care pathway? Do mental health services and drug and alcohol services carry out joint assessments? In what ways could communication about referrals and patient care be improved between mental health services, drug and alcohol services, primary and acute care (or any other relevant services)? 12
Discussion questions Is there a system to make sure that discharges, or drop outs, from any part of a patient s care delivery are communicated to the others involved in the patient s care? Are there clear lines of clinical leadership and responsibility for all patients in your service who are engaged with multiple services? Have all staff working with patients with co-existing mental health and drug and alcohol problems had appropriate training? 13
Improvement area 4: Overdose reducing access to means of suicide There is evidence of risk assessment and the appropriate management of medication throughout the patient s care, treatment and recovery journey. What we know from the review reports you send us In both planned and impulsive suicides, the availability of means has been recognised as significant in a number of reviews, such as prescription and over the counter medication. The reduction of easy access to the means of suicide is likely to reduce the risk of completion. While reports we receive recognise that a determined person will be able to access potentially dangerous medication with little difficulty, the recommendations of review reports highlight the following. When helping people at risk (and their family members and carers), it is beneficial to develop strategies to keep their homes free of hazardous drugs by appropriate prescribing, dispensing and storage. Overdose risk, either by prescribed or over the counter medications, should be discussed as part of the risk assessment and care planning process for all individuals and with particular emphasis where the risk assessment (clinical risk screen) notes previous history of overdose or self-harming behaviour. There is benefit in having a standard procedure or protocol for prescribing tricyclic antidepressants which take into account the toxicity of these drugs in overdose. Risk assessments should take account of the patient s access to potentially toxic non-psychiatric medication. It is beneficial to have a standard procedure for advising patients about the safe disposal of unwanted medications and for assisting patients who may have difficulties in managing disposal unassisted. 14
Improvement area 4: Questions for multidisciplinary team discussion Discussion questions Is overdose risk, either by prescribed or over the counter medications, discussed as part of the risk assessment and care planning process for all patients (including systems for safe prescription on discharge from hospital and community)? Do risk assessments take into account access to potentially toxic non-psychiatric prescription medication? Is there a system to make sure that primary care routinely communicates to the mental health team about medication changes and details of non-psychiatric medication the patient is prescribed? 15
Discussion questions Does your service have a standard procedure for advising patients and their carers on the safe disposal of unwanted medication? Does your team assist patients who may have difficulties in managing disposal of unnecessary medications? 16
Improvement area 5: Not taking medication and associated relapse There is a specific written policy on patients who are not taking medication as prescribed. What we know from the review reports you send us Suicide review reports we receive identify non-concordance with medication and apparent associated relapse as a significant factor in a number of suicides. The factors identified in reports include: initial poor engagement with services insufficient patient education about their condition and it s treatment non-attendance with services symptomatic improvement leading to the patient stopping treatment unpleasant side effects, and mental state interfering with ability to consistently take the medication. Recommendations made in such cases include: improving patient education about medication and side effects creating clearer protocols (for non-concordance with medication and non or erratic attendance with services) considering the use of medication dispensing boxes, particularly where there is cognitive impairment, and improving personal contact and use of reminders, such as telephone calls, texting and emails. 17
Improvement area 5: Questions for multidisciplinary team discussion Discussion questions Does your service have a written, clear policy on patients who are not taking medication as prescribed which is used by your team? Does your team provide patient education about their treatment, medication and possible side effects? Does your team assess whether the use of medication dispensing boxes would be appropriate? Does your team provide patients with reminders in their preferred form, for example texts, telephone calls or emails? 18
Improvement area 6: Hospital-based care keeping the environment safe All acute mental health facilities consider if the physical environment is in keeping with their clinical function and whether that environment reduces the risk of suicide or self-harm by their client group. This includes: the removal of non-collapsible curtain rails and low-lying ligature points the control of unsupervised access by people at risk to potentially dangerous items, such as ligatures, sharp items and impermeable plastic bags staff carrying out regular environmental checks, working to agreed standards of safety, and effective care planning remembering the prevention of harm while preserving individual patient dignity and the promotion of recovery. What we know from the review reports you send us Review reports that we receive indicate that all suicides that took place in an acute setting involved ligatures or suffocation. Recommendations from these reports highlight the following. Checks of potential ligature points should include an assessment of where the ligature point is situated in terms of its level of visibility. Access to potential ligatures points should be carefully controlled for at risk patients and be specified in individual care plans. Enhanced levels of observation should include special attention to the safety of the patient s environment where the observation is being carried out. Ligature points in areas that have a lower level of supervision present the most risk. The use of impermeable plastic bag liners in rubbish bins in unsupervised areas should be avoided. 19
Improvement area 6: Questions for multidisciplinary team discussion Discussion questions Does your ward have functioning collapsible curtain rails? Does your ward have low-lying ligature points? Does your team have a system to carry out regular and effective checks on the safety of the environment for people at risk of self-harm? 20
Discussion questions Does your team have a shared view on balancing safety with patients dignity and rights? Have areas where enhanced observation is going to be carried out been assessed for safety? Does your ward use impermeable plastic bag liners in rubbish bins in unsupervised areas? 21
Improvement area 7: Hospital and community recording and sharing information and managing risk All information about your patient s care, treatment and risk management is recorded and shared effectively by hospital and community services. What we know from the review reports you send us For people with complex needs who require multi-agency contact, it is essential that an overview of their care is maintained. The quality of record-keeping is a professional responsibility of all those involved in care and treatment. However, the involvement of different disciplines, clinical teams and other agencies with a variety of record-keeping systems can present challenges to recording and sharing assessments, history and the provision of care and support. In addition, within individual services, there can be more than one system of record-keeping, typically a combination of electronic systems and written notes that may be used in different ways by different disciplines. The cornerstone of effective communication between those involved in helping a patient towards recovery is a clear record system that is accessible to all those involved in care. 22
Improvement area 7: Questions for multidisciplinary team discussion Discussion questions Does your team know in how many places your patient s relevant care and treatment information is recorded? Does your team know of any formal information-sharing protocols between agencies (including health, local authority, police, prison service and third sector services)? Does the process and recording of risk assessment, formulation and care planning effectively manage the patient s individual identified risks and provide a clear picture of their condition and associated risks? Is there a system for effective communication between hospital wards and community mental health teams to make sure appropriate sharing of patient information around treatment plans, day passes, risk management and discharge plans? 23
Discussion questions When there has been a significant change in a patient s condition and risk factors, is there a system to communicate relevant information to all those staff involved in care and support? Is there a system in place to inform the referrer (for example primary care) of patients who do not attend appointments with mental health services? Are joint assessments with staff from other parts of the patient s care carried out at the same time? Does your team have a standard process for immediately contacting primary care about their patients who have been seen on an emergency basis? 24
Discussion questions Is all the information relevant to the patient s care accessible to all appropriate staff when required? 25
Improvement area 8: Patient and staff engagement The questions for multidisciplinary discussion in this section originate from issues about observation identified in suicide reviews we have received to date. At the time of writing this discussion framework, the national good practice statement, that NHS boards patient observation and engagement policies have been based on, is in the process of being updated. The update will better reflect current person-centred recovery-based care. The aim of this new approach is to better promote patient engagement at times of high risk. Patient and staff engagement needs to be based on assessment and individual safety plans developed in partnership with the patient, family members or carers and the multidisciplinary team. Patient and staff engagement must also sit within current developments in risk assessment and safety planning. In summary, it will promote an approach to intensive patient and staff engagement that is: supportive of the patient s recovery and does no unnecessary harm to them a clear and understood part of the care, operation and culture of the clinical area fully integrated in the patient s overall care plan carried out with the patient, as far as possible, and not something that is done to them not a form of de facto detention when the patient does not consent, or unable to consent, to any restrictions placed on them then the relevant legislations are used to protect their rights carried out only when necessary and there is no effective, less restrictive, alternative not highly visible in a way that carries a risk of stigmatising the patient concerned undertaken by staff with the necessary knowledge, skills and information who are confident and supported by management in positive risk taking, and based on the principles of the Mental Health (Care and Treatment) (Scotland) Act 2003 and complies with the requirements of human rights legislation. When the new guidance has been published, we will update this section to reflect these developments. However, in the meantime the questions in this section will continue to use the terms used in the suicide reviews that we have received to date. 26
Improvement area 8: Questions for multidisciplinary team discussion Discussion questions Do all members of your team have a clear understanding of the current local policy on observation, in particular who can initiate and reduce enhanced levels of observation? Is there a clear timescale for the multidisciplinary review of patients who are on enhanced observation? Is there a system to make sure that all staff carrying out enhanced observation are competent in the necessary skills to keep the patient safe? Is there a system of regular checks to make sure that the environment where the enhanced observation will be taking place is safe for the circumstances of the particular patient? 27
Discussion questions Does your service have a policy for the removal of potentially dangerous items from patients on enhanced observation? Is there a system for all patients on enhanced observation to be discussed at handovers and safety briefings to make sure that all staff are aware of, and can contribute to, risk assessment? Is the enhanced observation discussed with the patient to allow their perspective to be taken into account? 28
Improvement area 9: Involving family members and carers There is standard practice in your service to make sure that family members and carers are involved in the patient s care, or it is recorded where this is not practicable. What we know from the review reports you send us There is a consistent theme in review reports we receive that involving family members and carers is important to the provision of good and safe care. Reports highlight that where there has been good involvement of family members in care prior to a completed suicide, this has helped the family understand what has happened. Conversely, when family members feel that any concerns they had prior to a completed suicide were not heard or acted upon by mental health services, they are likely to be angry and disappointed with the service. Other issues highlighted include family members feeling that they were excluded from decision-making and that they did not receive information about treatment, appointments and discharge. Learning points also highlight the importance of family members receiving information about side effects of any medication and what to do in a crisis or where they suspect deterioration. Examples from review report recommendations include the following. Use of the Care Programme Approach in complex cases to make sure that family members and carers are aware of the patient s care plan, particularly when they are a significant provider of support. If there is conflict in a family, or other difficulties exist, a meeting should be offered to the patient and family members. If there are reasons why family members are not involved in the care planning process, this should be clearly stated in the records. When family members express concerns about their relative, efforts must be made to re-engage and reassess the patient. Information about patient passes and discharge should be given to family members and carers involved in the patient s care and support. Make sure family members know who to raise any concerns with and that information provided by them is available to the care team. It is important that family members receive clear explanations around treatment expectations, side effects and changes, with a clear record kept of information shared. An introduction to the service for family members and carers which includes information about the care pathway and details about what different staff do and how they can be contacted. Staff are carer aware and confident in their interactions with family members and carers. Do not allow issues of confidentiality to become a barrier to communication with family members and carers. It is important to have a clear policy for staff on confidentiality and sharing information. 29
Improvement area 9: Questions for multidisciplinary team discussion Discussion questions How does your team help engage with family members and carers and do you understand the importance of their involvement in the care and treatment provided? How does your team try to make family members and carers feel welcome when they are in contact with the service? Is written information about the service you provide made available to family members and carers? Are information packs available to family members and carers that give more in-depth information about mental ill-health conditions, confidentiality and patient and carer rights? 30
Discussion questions Are family members and carers appropriately involved in care and treatment decisions? Is there a system to make sure that the patient s family members and carers know who to contact to discuss care and any concerns they may have? 31
Improvement area 10: Training and making it safe to learn Working through each of the improvement areas in this framework will encourage your team to reflect on any training needs in relation to the issues identified in your discussions. What we know from the review reports you send us Not all staff have received training in suicide risk assessment, management and prevention. Reports have highlighted the importance and potential benefit of multidisciplinary training in suicide prevention and risk management. There are some indications that different disciplines can have different thresholds to intervention. Not all staff are aware of how to access learning from suicide reviews to increase their knowledge and develop skills. 32
Discussion questions Do all staff in your team have access to suicide risk assessment and prevention training? Are attitudes towards suicide risk and thresholds for action consistent across your team and other agencies involved in your patients care? Is your suicide risk assessment and prevention training multidisciplinary? How do staff access the learning points from suicide reviews to increase their knowledge and inform their skills development? 33
Appendix 1: Learning from suicide reviews team culture checklist For the purposes of this framework, culture means the ideas, customs and social behaviours of the people who make up the organisation of care. While leaders who set the tone and managers making decisions have a major influence on culture, operational staff also have a responsibility to set the culture in the way they respond and act towards each other in their day-to-day work. We often make assumptions about what other people think. As team members, leaders and managers we may believe that the people we work with think the same way that we do about the culture of the organisation. Try using this checklist to see if you have a culture that promotes open discussion and learning from suicide reviews. Use this checklist to identify any barriers to open discussion within your team. Discussion questions One of your team s patients/clients has completed suicide, do you and your team feel able and safe to discuss what happened? Do you and your team know the process and key objectives of a suicide review? 34
Discussion questions Do you feel that your opinion is valued when you are involved in a suicide review? Do you think you and your team respect and value the opinion of your colleagues involved in a suicide review? Do you and your team respect and value the contribution of family members and carers? Does your team value learning from situations where things have gone wrong? Is the approach how to fix it or who is to blame? 35
Discussion questions Do you and your team take a considered approach to understanding the circumstances of a suicide and not jump to conclusions? Do you and your team work to make improvements even in difficult circumstances? Think about your own support. Where in your organisation would you get support in dealing with your own emotional and professional responses to a suicide? 36