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Learning from Experience: Reflections on Adverse Incidents in Mental Health Practice

This practitioner’s reflection explores the crucial insights gained from the analysis of adverse incidents in mental health settings. It discusses key findings from national inquiries, focusing on inpatient suicides and safety concerns. The piece emphasizes the importance of reflective practice, effective training, and the implementation of actionable plans in preventing avoidable deaths. With data indicating high rates of preventable incidents and emphasizing communication with caregivers, this reflection aims to foster a culture of safety and improve mental health care delivery.

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Learning from Experience: Reflections on Adverse Incidents in Mental Health Practice

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  1. Dare to Share Learning from experience: a practitioner’s reflection

  2. Dare to Share • Facts and Figures • Experience of Adverse Incidents • Observations/ Reflections • Questions

  3. Facts and Figures • National Confidential Inquiry • Safety First Document 2001 • Avoidable Deaths Document 2006

  4. Inpatient suicides: trends over time

  5. Inpatient suicides: trends over time 1997 1295 222 (17) 2004 1396 155 (11)

  6. Facts and Figures • Some success with “priority groups” • Inpatients • Non-compliance • But……..

  7. Facts and Figures • 1300 p.a (NCI April 2000-Dec 2004) • No real change in post-discharge period • 49% in contact week before death • 19% in contact 24hrs before death • 86% thought low risk at last contact

  8. Facts and Figures • 233 (18%) p.a “preventable” (NCI) • For inpatients 28% “preventable” • AWOL, non-routine obs, MHA 41% “preventable” • Should wards be 100%?

  9. Experience of Adverse Incidents • 1. Training Course • 2. Panel member on PIR • 3. Reflective practice reviews • 4. Implementation Action Plans • 5. Interviewed by PIR panel

  10. Training Course • Intensive • Hard Work • Grounding in Root Cause Analysis (RCA) • Contribute to PIR

  11. PIR • Development • Resource intensive • Detailed investigation • Problem of hindsight • Individual versus process issues • Some basic deficiencies • Importance of documentation

  12. PIR • Section 17 leave not clear • No explanation of changes to obs levels • Communication with others • Information/concerns of carers/relatives

  13. Action Plans • Recommendations from PIR • AMH action plan • Problems with recommendations • Danger of too many • Practicality of implementation

  14. Patient Suicide • Age 51 • Known since 1998 • History of schizophrenia • Long inpatient stay • Died in Nursing Home

  15. Aware of vulnerability • Keep accurate up-to-date records • Positive Risk Management

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