Welsh Government Inquiry into Suicide Prevention
Call for Evidence December 2017
Submission by ABMU Health Board
Sentinel Incident Review Group
The Mental Health and Learning Disabilities Delivery Unit has a monthly Sentinel Incident Group (SIG) meeting chaired by the Medical Director of the service. The aim of the group, which is drawn from across the Delivery Unit together with the Health Board’s Serious Incident and Patient Feedback Teams, is to review critical incident reports and ensure that appropriate actions are taken if any failings are identified. Critical incident reviews are commissioned following the unexpected death of a patient who has had contact with secondary care mental health services in the previous 12 months. The reviews are chaired by a Consultant Psychiatrist unconnected with the patient’s care and follow a root cause analysis process.
In addition to reviewing individual clinical incident review reports, the group also produces an annual report summarising lessons which have been learnt through the year which are categorised into themes. This report also considers the work generated from the National Confidential Inquiry hosted by Manchester University into confirmed deaths by suicide.
Following the publication of the National Confidential Inquiry report in October 2017 and drawing on themes from the work of SIG, areas for development have been identified, including:
· Audit programmes including an audit on all adult acute admission units against the NICE guideline (NG53) Transition of Inpatients to Community, together with the ongoing audit of care and treatment planning
· Redesign of the current three places of safety and renewal of the Section 136 policy, particularly in relation to the implications of the new Policing and Crime Act 2017 which places further restrictions on the use of police cells as a place of safety.
· Implementation of the MAZARS report following the Southern Healthcare Inquiry which includes the rollout of a pilot project in the Neath Port Talbot locality relating to the completion of mortality reviews and the involvement of families in the review process.
· Participation in the Welsh Government’s Fatal Drug Poisoning Consensus Seminar programme which highlights the recent increasing number of suspected drug related deaths in Wales. This programme also includes a key message from the National Confidential Inquiry in relation to the need to effectively manage opiate prescribing.
Single Point of Access
A single point of access for all referrals was adopted in Old Age
Psychiatry in Bridgend in 2003. The model was published in 2007
(Colgate R and Jones S). Further collaboration with academic
nursing colleagues from Melbourne Australia led to the United
Kingdom mental health triage scale in 2015 which was quickly
adopted by General Adult Psychiatry services in Bridgend and more
recently in Swansea.
The triage scale allows a modern mental health service to achieve
reconfiguration to identify those patients who need urgent
assessment accurately and consistently both in the working week and
out of hours. Suicidal ideas and intent are accorded priority
usually within four hours (category B) or where clinically
appropriate within 24 hours (category C). (Also published as Sands
N et al 2016.)
The triage process concentrates upon patient need rather than
requiring a diagnosis. Governance and reliability are especially
strong where services have been able to identify a dedicated
referral coordinator who is able to allocate a priority based on
individual patient need, separate from (the term dislocated is
used) the immediate availability of staff or service pressures.
Mental Health Crisis Services
Each of the 3 localities within the Mental Health and Learning Disabilities Delivery Unit of the Health Board has a mental health crisis service comprising acute inpatient admission crisis resolution and home treatment, together with recovery unit services. The recent reduction in suicides among people leaving hospital may suggest that the crisis resolution and home treatment teams are now better able to support people to prepare for discharge and when they return home. The demand however for crisis team assessments has been substantially increased each year since their inception in Wales in 2006. Each of the 3 crisis teams within the ABMU Health Board has the challenge of balancing the provision of patient assessments with the need to provide home treatment and discharge planning services.
As part of the Health Board’s response to the Mental Health Crisis Concordat, frontline police officers have been asked to contact local crisis teams at the point when they are considering applying a Section 136 detention. Work is currently ongoing to closely monitor these requests for advice to help ensure the most appropriate use of this power.
Early and Effective Intervention within the Inpatient setting
Recent funding from the Welsh Government has enabled the establishment of psychology input into the inpatient wards to enable holistic care and treatment planning for individuals under the Mental Health Measure. This has ensured that inpatients who have attempted suicide or engaged in self harm have access to qualified psychological risk assessment and specialist psychological intervention according to their needs in addition to input provided by other multidisciplinary team members. As a consequence to the establishment of psychology, regular CBT and mindfulness groups have also been set up on wards to help individuals develop problem solving and coping mechanisms to mitigate risk and prevent future episodes.
The establishment of a psychosocial care pathway on the community for older individuals experiencing mental health issues and carers of people with dementia has also enabled a rolling programme of CBT, mindfulness, carers CBT and positive psychology groups on the community to help individuals develop coping mechanisms, problem solving strategies and social connections to hopefully mitigate the risk of suicide and self-harm for attendees.
Initiatives around Psychiatric Liaison
The Morriston Hospital Psychiatric Liaison team provides a service to the Emergency Department. Referrals to the Liaison service are made by the triage nurse so that waiting times in ED for patients with mental health issues are reduced.
The Liaison service in Morriston Hospital is planning to start a follow up clinic in the new year for those individuals who have been seen and assessed by Liaison in the Emergency Department following self harm and where the person does not require a referral to either primary or secondary mental health services. It would be offered to those individuals who Liaison feel would benefit from brief solution focused interventions, coping skills type interventions and would be offered for a maximum of 3 sessions with either the psychologist or a mental health nurse. Psychiatrist input would be offered to commence medication if appropriate.
Management of young people (16-17) presenting following self-harm to the A&E departments at Morriston Hospital, Swansea and Princess of Wales Hospital, Bridgend
When young people present to Accident and Emergency departments within the ABMU Health Board, they receive the necessary medical treatment for any physical health which may involve admission to the hospital. When they are determined to be medically fit, there is sometimes a considerable delay in securing the necessary CAMHS assessment. Those under the age of 16 can be admitted to a paediatric ward on each of the general hospital sites to facilitate the mental health assessment in an appropriate environment. For those between the ages of 16 and 17, there is just a single bed identified on the adult acute assessment mental health Ward F, Neath Port Talbot Hospital. Patients are only normally transferred into this single bed once the CAMHS assessment has been completed within the Accident and Emergency Department. Accident and Emergency departments report the challenge of having to safeguard the young person within their department whilst the assessment process is completed and arrangements are made for admission to a mental health unit if necessary. This can take many hours and often requires special 1:1 observations for which the departments are not staffed.
Morriston Hospital bereavement group
A bereavement service was established in the A&E department at Morriston Hospital which aimed to provide help and support to the family, carers and friends of individuals who had deceased within the department. This involved the offer of a meeting with a nurse representative from the department and a clinical psychologist from the psychiatric liaison service 6 weeks after the death. These meetings have provided helpful support in providing answers to questions and signposting to bereavement counselling. This scheme has recently been rolled out throughout the hospital.
Self-harm prevention initiatives in the regional Burns and Plastic Surgery service, Morriston Hospital
The regional burns and plastic surgery service based at Morriston Hospital provides care to many patients who have sustained injury as a result of deliberate self harm. The regional burns unit has been working proactively with the prison service over prevention and early intervention initiatives. The plastic surgery unit would also like to develop this work in addition to the existing arrangements which are in place for the safeguarding of individual prolific self harmers.
Dechrau Newydd
Dechrau Newydd is a community-based complex needs team providing specialist therapy to secondary care clients, with a presentation indicative of a personality disorder. The team offer Dialectical Behaviour Therapy (DBT) to clients who have a recent history (last six months) of self-harm and/or suicidal behaviour. DBT consists of a weekly group in which clients learn skills in four domains: mindfulness, distress tolerance, emotional regulation and interpersonal effectiveness. Clients also attend a weekly one to one session with a therapist, and have access to a coaching line Monday- Friday 9-5pm.
All DBT clients have a formulation and agreed targets to address suicidal behaviour and self-harm. When clients have learned sufficient skills, they devise a crisis plan with their therapist which highlights the skills they find the most useful in crisis, and this is shared with the Community Mental Health Teams. Clients are encouraged to use the coaching telephone line when they have urges to self-harm, so that therapists can offer support and encouragement to utilise skills to cope ‘in the moment’. Outside office hours, clients are encouraged to contact the Community Crisis Teams for this support.
Initiatives around Primary Care
The 3 locality based Local Primary Mental Health Support Services (LPMHSS) within the Health Board were set up under Part 1 of the Mental Health Measure to work with clients with mild to moderate common mental health problems. The teams however also have contact with clients who have variable levels of suicidal/self-harm ideation and intent. In order to help manage such risks, the teams provide education and advice, receive appropriate training (for example STORM), use scoring tools such as Corenet to measure levels of risk when providing mental health assessments and interventions, work closely with GP surgeries, constantly review risk through the therapeutic process and signpost to third sector services, as appropriate.
Preventing Suicide in Public Places
The Health Board helped coordinate the regional collaborative Suicide and Self Harm Prevention Workshop which was held with partners on 22nd November 2017. The aim of the workshop was to help pull together the regional collaborative prevention plan which is required by the Welsh Government as part of the Talk to Me 2 strategy by February 2018. During the event, there was discussion on the need for a more strategic approach to preventing suicide in public places. As a result, the Health Board will be aiming to develop a group with partners to help address environmental risks within the community. This will involve representation from such organisations as Network Rail, the police and Local Authority.
Improving Community Resilience and Social Connectedness
Talk to Me 2 (2015) indicates that a major protective factor in the case of suicidal behaviour is for an individual to have a strong sense of community connection and the ability to harness social and cultural and spiritual beliefs to support the self. The locality is planning the resurrection of an ABM-wide Mental Health and Spirituality Special Interest group (MHSSIG). The remit of the group will be to explore and facilitate the relationship between statutory services and faith communities to help raise mental health and suicide awareness in those ‘harder to reach’ communities including asylum seekers, refugees and the Muslim community. The plan is to hold a NPT conference on Mental Health and Spirituality entitled ‘Breaking down the Barriers’ to enable service providers, faith communities and individuals to come together to consider how to address the issue of mental health and suicide going forward at this time of austerity and to also consider how best to target socially deprived areas of the patch.