Quality and Safety Notifications under the Mental Health Act 2001 Effective July 2015 Revised 28 July 2016 This document replaces the document entitled Data Requirements under Rules and Codes of Practice issued by the Mental Health Commission
Contents 1. Introduction... 3 2. Notification Requirements... 3 3. Reference Documents... 17 List of Tables Table 1: Notifications: Children, CAMHS Bed Occupancy, Deaths, Summary Incident Reports, ECT, Seclusion, Mechanical Restraint and Physical Restraint.... 4 Table 2: List of Serious Reportable Events (SREs) (HSE, 2015)... 8 Updated July 2016 2
1. Introduction The principal functions of the Mental Health Commission is to promote, encourage and foster the establishment and maintenance of high standards and good practices in the delivery of mental health services and to take all reasonable steps to protect the interests of persons detained in approved centres under the Mental Health Act (the 2001 Act ). Approved centres and other mental health services shall be required to submit quality and safety notifications as defined by the Mental Health Commission, as per the Mental Health Act 2001. All notifications shall be reviewed to ensure ongoing quality and safety of care to the residents within an approved centre and service users in receipt of other mental health services. The notifications shall assist in providing a risk profile of the approved centres. Where the required notifications are not received, the Standards and Quality Assurance Division shall send the Registered Proprietor (or nominee) a formal email outlining that the required notifications are overdue. 2. Notification Requirements This section identifies the notification requirements for approved centres and other mental health services. Table 1 outlines the notification requirements regarding admission of children, bed occupancy in CAMHS, notification of deaths, summary incident reports, the administration of Electro-convulsive Therapy (ECT) and the use of seclusion, mechanical means of bodily restraint and physical restraint. Table 2 includes a list of Serious Reportable Events (SREs) which shall be notified to the Mental Health Commission. All submissions shall be made electronically to: mentalhealthdata@mhcirl.ie All notification forms and guidance in relation to their completion are available on the Mental Health Commission s website http://www.mhcirl.ie/for_h_prof/forms/ Updated July 2016 3
Table 1: Notifications: Children, CAMHS Bed Occupancy, Deaths, Summary Incident Reports, ECT, Seclusion, Mechanical Restraint and Physical Restraint. Notification Requirements Data: Child Admission Data Adult units in Approved Centres are required to notify the Commission of the admission of a child. Adult units in Approved Centres are required to notify the Commission of the discharge of a child. Child units in Approved Centres are required to submit admission and discharge data. Child units in Approved Centres operated by the HSE are required to submit admission and discharge data in relation to agreed arrangements in place. Bed Occupancy for CAMHS Child units in approved centres are required to send a bed occupancy report. Death Notification Approved centres are required, under Article 14(4) of the Mental Health Act 2001 (Approved Centres) Regulations 2006 to notify the Commission of all deaths, including sudden, unexplained deaths, of any resident of an approved centre. Timeframe: Within 72hrs of the child s admission Within 72hrs of the child s discharge Monthly No later than the seventh day of the following month e.g. January admission and discharge report to be returned by 07 February. Monthly No later than the seventh day of the following month e.g. January admission and discharge report to be returned by 07 February. Monthly No later than the seventh day of the following month e.g. January admission and discharge report to be returned by 07 February. Within 48 hours of the date of occurrence Updated July 2016 4
Notification Requirements Data: Death Notification All mental health services are required to notify the Commission of all sudden and unexplained deaths of any person availing of/in receipt of a mental health service or recently discharged (within four weeks of the date of occurrence) from a mental health service and not in receipt of a mental health service. Timeframe: Within 7 days of the date of occurrence (or as soon as possible once the service becomes aware of the death) Incident Reporting Approved Centres are required to return incident summary reports including but not limited to: 6 monthly basis January to June data no later Number than 31 st August Incident Category/Classifications July to December data no later Severity of Injury/Risk Rating than 28 th February Approved centres may use the MHC template or an extract from their own incident management system e.g. NIMS. Rules Governing the Use of Electro-convulsive Therapy and Code of Practice Governing the Use of Electroconvulsive Therapy for Voluntary Patients Data on the administration of ECT Approved centres must record all programmes of ECT in the associated ECT Register and return an annual report to the MHC Annually No later than 31 st January of subsequent year Form 16 ECT without consent Where a Form 16 ECT without consent Involuntary Patient (Adult) is completed, a copy of the form should be returned to Within 5 working days of the form being completed the Commission. Rules governing the use of Seclusion and Mechanical Means of Bodily Restraint Data on the use of Seclusion Approved centres must record all episodes of seclusion in the associated Seclusion Register and return an annual report to the MHC. Annually No later than 31 st January of subsequent year Updated July 2016 5
Notification Requirements Data: Notification of Seclusion exceeding 72 hours Rule 6.3: If a decision is made by the consultant psychiatrist responsible for the care and treatment of the patient concerned, or the duty consultant psychiatrist acting on his or her behalf, to continue to seclude a patient for a total period exceeding 72 hours. Notification of seven or more Seclusion orders in seven days Rule 6.4: If a patient has seven or more seclusion orders over a period of seven consecutive days. Timeframe: Within 5 working days of the event Within 5 working days of the event Data on the use of Mechanical Means of Bodily Restraint to Prevent Immediate Threat to self or others Approved centres must record all uses of Mechanical Means of Bodily Restraint to Prevent Immediate Threat to self or others in the associated Mechanical Means of Bodily Restraint Register and return an annual report to the MHC. Code of Practice on the use of Physical Restraint in Approved Centres Annually No later than 31 st January of subsequent year Data on the use of Physical Restraint Approved centres must record all uses of Physical Restraint and return an annual report to the MHC. Annually No later than 31 st January of subsequent year Updated July 2016 6
Serious Reportable Events (SRE) Approved centres are required to notify the Mental Health Commission of Serious Reportable Events (SREs), identified in table 2, involving any resident of an approved centre. Any SRE resulting in the death of a resident should continue to be notified in line with current death notification requirements, as specified in the Mental Health Act 2001 (Approved Centres) Regulations 2006, identified in Table 1 above. Section 7.4 of the death notification form Has the death been reported as a Serious Reportable Event? should be completed as Yes. There is no requirement to complete a separate SRE notification if a death notification has been submitted to the Mental Health Commission. Any SREs that did not result in the death of a resident should be notified to the Mental Health Commission, within 48 hours of the date of occurrence, using the Mental Health Commission prescribed SRE notification form. The registered proprietor should nominate a person who shall be responsible for notification of SREs to the Mental Health Commission. Updated July 2016 7
Table 2: List of Serious Reportable Events (SREs) (HSE, 2015) Updated July 2016 8
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3. Reference Documents Department of Health (2001), Mental Health Act 2001. (Dublin Stationery Office). Department of Health (2006), Mental Health Act 2001 (Approved Centres) Regulations 2006. (Dublin Stationery Office) Health Service Executive (2015), Serious Reportable Events. HSE Implementation Guidance Document. (Dublin). Mental Health Commission (2008), Code of Practice for Mental Health Services on Notification of Deaths and Summary Incident Reporting. (Dublin) Mental Health Commission (2016), Code of Practice on the Use of Electro-Convulsive Therapy for Voluntary Patients. (Dublin). Mental Health Commission (2009), Code of Practice on the Use of Physical Restraint in Approved Centres. (Dublin). Mental Health Commission (2016), Rules Governing the Rules Governing the Use of Electro- Convulsive Therapy. (Dublin). Mental Health Commission (2009), Rules Governing the Use of Seclusion and Mechanical Means of Bodily Restraint. (Dublin). Updated July 2016 17