Findings of National Confidential Inquiry into suicides and homicides by people with Mental Illness – 20 year review published in 2016 :
Key elements of safer care in Mental health services
- Safer wards: Removal of ligature points /Reduced absconding / Skilled in-patient observation
- Early follow-up on discharge from hospital to community
- No ‘out of area’ admissions for acutely ill patients
- 24 hour crisis resolution/home treatment teams
- Community outreach teams to support patients who may lose contact with conventional services
- Specialised services for alcohol and drug misuse and “dual diagnosis”
- Multidisciplinary review of patient suicides, with input from family
- Implementing NICE guidance on depression and self-harm
- Personalised risk management, without routine checklists
- Low turnover of non-medical staff
Key elements of safer care in the wider health system:
- Psychosocial assessment of self-harm patients
- Safer prescribing of opiates and antidepressants
- Diagnosis and treatment of mental health problems especially depression in primary care
- Additional measures for men with mental ill-health, including services online and in non-clinical settings
There is strong evidence for all of the above.
5 items from the first list (MH Services) were missing for Saagar.
4 were not applicable. One, I am not sure of(rate of staff turnover).
All 4 items on the second list were missing for Saagar. The ‘wider’ health system did him more harm than good.
Can we turn this evidence into action before hundreds more die? Please.