‘Situational awareness’ (SA) is one of the major tenets of safety in high-risk situations such as aviation, policing and medicine. As the name suggests, it means having an accurate understanding of our surroundings or situation – where we are, what happened, what is happening, what is changing and what could happen. Good SA requires:
- Gathering relevant information
- Making sense of the collected data
- Thinking ahead about possible outcomes
Let’s look at the areas where SA could have been better in my son’s care.
- He was under the care of his GP who saw him 2 days before Day 0. Neither did he talk to him about suicidal thoughts, nor did he get him to fill out a PHQ-9 that would tell him about his overall mental state.
- I told the GP that he was really depressed and I would like him to be referred to Psychiatry services but he decided to increase the dose of his antidepressants instead. We know that antidepressants may worsen depression and cause suicidal ideology.
- Nobody suggested that he maintain a ‘Mood Chart’ so that the trends in his mental state could be known better.
- The patient is a young male with recently diagnosed Bipolar illness who is not on Lithium which is the drug of choice and has proven anti-suicidal effects in such patients.
Making sense of collected data
- Given that not much data was collected and my assessment of the situation was not given much attention, there was nothing much to work on.
- NICE guidelines suggest that if a patient is depressed for 6-8 weeks, they should be referred to specialist services and he fell in that category but this action was not taken despite being suggested.
- It was not picked up that this patient needed specialist care for various reasons that were known : young male patient with recently diagnosed Bipolar illness, severely depressed for 6 weeks, prematurely discharged by Psychiatric services due to extraneous factors without any expert follow-up or monitoring in place.
- He was on medications that might increase his risk of suicide.
Thinking ahead about possible outcomes
- Young males are at the highest risk of suicide. So, that was a very real possible outcome that was not anticipated.
- His illness had been diagnosed only 10 weeks prior so it was very early in its course and hence unstable.
- The depression had been preceded by a manic phase and that puts him in a high-risk bracket.
- He had shown some signs of improvement over the previous weekend that also put him at higher risk.
- No discussion took place with me as his sole carer about his care at home, signs of crisis and when I should think of taking him to Emergency services.
So, our Situational Awareness was poor. Not surprisingly, so was the outcome.