Suicide by Mental Healthin-Patients Under Observation

Suicide by mental healthin-patients under observation

Flynn S, Nyathi T,Tham SG, Williams A, Windfuhr K,Kapur N,Appleby L, Shaw J.

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ABSTRACT

Background

Observations in psychiatric in-patient settings are used to reduce suicide, self-harm, violence and absconding risk. The study aims were to describe the characteristics of in-patients who died by suicide under observation and examine their service-related antecedents.

Methods

A national consecutive case series inEngland and Wales (2006-2012).

Results

There were 113 suicides by in-patients under observation, an average of 16 per year. Most were under intermittent observation. Five deaths occurred while patients were under constant observation. Patient deaths were linked with the use of less experienced staff or staff unfamiliar with the patient, deviationfrom procedures and absconding.

Conclusions

We identified key elements of observationthat could improve safety, including only usingexperienced and skilled staff for the intervention and using observation levels determined by clinical need not resources.

BACKGROUND

There were over 5100 registered suicides in England and Wales in 2013 (Office for National Statistics, 2015).Recent data from the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (NCISH)showed28% of suicide deaths in England were by patients in contact with mental health services 12 months before their death(23%in Wales).In England and Wales in-patient suicides accounted for an average of 124deaths per year, 9% of patient deaths (NCISH, 2015a).Patients are admitted to acute in-patient care at a time of crisis, and observation is an intervention used to reduce the risk of serious adverse incidents such as suicide (Manna, 2010).NCISH previously found22% of in-patient suicides occurred while the patient was under intermittent observation (i.e. being checked every 5-25 minutes), and 3% occurred while the patient was under constant observation (i.e. within eyesight or within arms-length) (NCISH, 2015b).Concern has previously been raised that there is a lack of empirical evidence for the effectiveness of formal observation in preventing harm to patients or in providing therapeutic benefit (Green & Grindel, 1996). Theinternational literature is inconclusive (Green & Grindel, 1996; Cutliffe & Barker, 2002),and dated as reviews have shown (Manna, 2010; Stewart et al. 2012)The current literature is generally limited by methodological shortcomings, predominately focusing on constant or ‘special observations’ (Duffy, 1995),qualitative studies (MacKay et al. 2005; Bowers et al. 2000), case reports, small case series designs (Gournay & Bowers, 2000; Whitehead & Mason, 2006; Kettles & Paterson, 2007),and opinion-based articles (Bowles et al. 2002).In this current research we usedunique data from NCISH to examine a national consecutive case series of in-patient suicide while under observation in England and Wales. We aimedto describe the demographic and clinical characteristics of mental health in-patients who died by suicide under observation and examine the service-related antecedents in relation toclinical care and safety.

METHOD

Research design

We examined a national consecutive case seriesofmental health in-patients who died by suicide whilst under observation in England and Wales. Westudieddeaths that occurred between 1st January 2006 and 31st December 2012. The data werepart of a larger mix method study of in-patient suicide under observation in the UK, which included qualitative analysis from an online survey and focus groups (NCISH, 2015b).

Case ascertainment

Data on suicide and open verdicts were obtained from the Office for National Statistics (ONS).By contacting NHS trustsandindependent hospitalsin the deceased’s district of residence, we identified whether any of the individual’s hadcontact with mental health services within 12 months of their death. If recent contact was confirmed, a questionnaire was sent to the consultant psychiatrist responsible for the patient’s care. The questionnaire comprised of sections requestingsocio-demographic information, information on the last in-patient admissionand details of clinical care received at the time of death.NCISH have used this methodology since 1996 and have generated a unique internationally recognised UK-wide database of all suicides, homicides and Sudden Unexplained Deaths by people in contact with mental health services. In addition to this data, Serious Untoward Incident (SUI) reports were requested from NHS trustsandindependent hospitals where the incidents occurred. SUI reportsprovided a detailed account of the organisation’s internal investigation, often using root cause analysis,the reports included recommendations for improving patient safety.The method of data collection for NCISH has been described in detail elsewhere (NCISH, 2015a).

Definitions

Observation levels were defined in accordance with published guidance from the National Institute for Health and Clinical Excellence (NICE, 2005).The four levelswerelevel 1:low-level general observation; level 2:intermittent observation (15-30 minute checks); level 3:continuous within eyesight and level 4:continuous observation within arm’s length of one staff member. For this study, we used the term ‘under observation’ to describe all ‘non-general’ observation levels (i.e. levels 2, 3 and 4).The guidance enables individual health and social care providers to develop their own policiesfor observation practice including; how often observation levels should be reviewed; who can instigate and change observation levels;directions for staff undertaking observations; how the experiences of patients are considered and recording and documenting these decisions.

We definedan in-patient mental health ward as a therapeutic environment where patients are admitted for assessment and treatment. They are usually same-sex accommodation with communal areas and individual bedrooms.

Statistical analysis

The main findings are presented as proportions with 95% confidence intervals (CIs). All proportions are provided as valid percentages i.e. the denominator in all estimates is the number of valid cases. If an item of information was not known for a case (i.e. data were missing) the case was removed from the analysis of that item. In these cases the denominator is provided for clarity. Stata 12 software was used in the analysis.

Ethical approval

Approvals were sought and received from the University of Manchester Research Ethics committee (19/12/2013); NRES Committee North West (09/05/2014); Health Research Authority (amendment to existing approval) (03/01/2014); and Research Management and Governance approvals from individual NHS Trusts. NCISH is registered under the Data Protection Act, 1998.

RESULTS

Characteristics of patients under observation at the time of their suicide

In England and Wales between 2006 and 2012, 8,592 patients had been in contact with mental health services within 12 months before taking their own lives, 26% of deaths by suicide in the general population. There were 715 in-patient suicides during this period, 8% of all patient suicides. At the time of their death, 113 (16%) in-patients were under observation, an average of 16 deaths per year (figure 1).

(Insert figure 1).

The following results are based on the 113 in-patient suicides that occurred while under observation.Sixty-five percentof the patients were male. The median age of patients was 40 years (range 19-83). The majority had a history of self-harm. Over a third were detained under mental health legislation at the time of their death.Most had serious mental illness (affective disorderorschizophreniaand other delusional disorders). Almost half had a secondary diagnosis, most commonly affective disorder (13/54, 24%), alcohol dependence/misuse (12/54 22%) and drug dependence/misuse (11/54, 20%).The most common method of suicide was hanging(63, 56%) (table 1). Of the56 deaths by hanging on the ward, the most commonly used ligatures were sheets and towels (16, 32%) and belts (15, 30%).One hundred and eight patients (96%) were under intermittent observation (65% of these were male) and 5 (4%) were under constant observation (60% were male).

(Insert table 1).

Clinical care and patient safety prior to suicide

Breach of policy and procedure

We received 78 Serious Untoward Incident (SUI) reportsrelating to the in-patient deaths, a 69% response rate. Of those with SUI reports, we found that suicide under observation occurred when observation was implemented poorly(46/76, 61%).For example, in 11/50cases (22%), the observations were carried out later than the timescheduled. The planned observation was oftendisrupted due to ward distractions (16/69, 23%) such as responding to other disturbed patients (6/77, 8%).Twenty-six deaths (33%) occurred during busy periods on the ward (e.g. 7-9am, 1-3pm and 7-9pm) when staff had multiple duties to attend to. Furthermore, one SUI stated night-time observation was not carried out in accordance with Trust policy as staff did not want to disturb the patient’s sleep by entering their bedroom. Of all the 113 incidents, poor ward design was said to have hindered the observation in 17 cases (15%).

Staff experience, familiarity with the patient and staffing levels

Twenty-seven deaths (27/48, 56%) occurred when observation was by less senior staff (i.e. student nurses / nursing or healthcare assistants) or by staff who were likely to be unfamiliar with the patient (e.g. bank/agency staff). Also, there were examples of poor documentation(11/42, 26%), with no information on the patient’s presentationor how staff engaged with the patient. In 19/77 (25%) casesstaffing levels on the ward were found to be below the required level at the time the death.

Location of the suicide

Patient safety was put at risk when patients left the ward. We found 40(35%) suicides occurred when the patient had left the ward either with or without agreement, in most cases patients who left the ward had absconded(34/38, 89%) (Table 1).However, those who left with agreement were permitted to leavethe ward either escorted or unescorted e.g. for cigarette breaks, to attend to their laundry or to attendother appointments.Of the patients who died on the ward, two-thirds took their own life in their bedroom (table 1).

Constant observation

In 5 cases (4%)the suicide occurred while the patient was under constant observation. In 1 case, the patient was within eyesight but not being continuously observed because the patient was thought to be sleeping. Two deathsoccurred after the patient had absconded from the ward, one of whom escaped while being escorted outside to retrieve laundry.

DISCUSSION

This study examined a consecutive case-series of patient suicide deaths while under observation on an in-patient ward. Our findings show that on average,16 patients per year took their own life while under observation, including constant observation.In over halfthe cases,observations were not carried outas required.Previous studies have shown that some staff made their own judgement when undertaking observation, and tended to modify practice, not adhering to the observation policy (Duffy, 1995; Langenbach et al. 1999; Neilson & Brennan, 2001; MacKay et al. 2005; Kettles & Paterson, 2007; Vråle & Steen, 2008; ).Duffy (1995)reportedthat staff modified observation practice considerably, departing from what was prescribed and recorded in care plans. Individual judgment and flexibility were used when conducting the observation, particularly around escorting patients on bathroom breaks (Duffy, 1995).Bowerset al. (2000)also reported a variation in observation practicewithnursesamending procedure on an ad hoc basis. A numberof researchers have identified non-compliance with existing procedures as a factor that can increase risk (Porter et al. 1998; Bowers et al. 2000).

Another important finding ofthe current study was that less experienced staff members had been assigned the role of observation at the time of death. Previous research has shown a variation in the use of qualified and unqualified personnel for the intervention (Green & Grindel, 1996; Bowers et al. 2000). In a study of observation policies from 27 in-patient units in England and Wales, Bowers et al (2000) reported a disparity across trusts as to which staff memberswere authorised to observe patients. There was no consensus as to whether agency, bank staff or nursing assistants should be used.Similarly, student nurses were permitted to assume the roleat all levels of observation in 24% of trusts and some levels in 43%. Therefore, it not uncommon practice for the most inexperiencedor least trained members of staff or staff who were not familiar with the patients to be assigned this skilled nursing intervention, the rationale for this being limited staff and financial resources. We also found staffing levels in a quarter of cases were below the optimum level. Gournayand Bowers (2000) whoexamined 31 cases of suicide and serious self-harm on in-patient wards noted the difficulties in maintaining adequate levels of nursing coverand appropriate skill mix due to the changing requirements of patients including the need to provide observations. Bowers et al.(2008) in a study self-harm and observation on 136 wards found a reduction in the rate of self-harm when qualified nursing staffwere on duty, and the reverse effect, an increase in rates,whenstudent nurses or unqualified nurses were on shift.

Deaths on wards still occurred despite patients being under observation in a controlled setting. The most common method was hanging. These deaths are often from low-lying ligature points such as doors and windows using sheets and towels as ligatures. In a recent study Hunt et al. (2012) concluded that increasing awareness of the methods of suicide used by in-patients, the removal of potential ligature points and restricting access to potential ligatures for high risk patients may help to reduce risk.

We found the most common location for in-patient suicides werepatients’ bedrooms. Conducting observations by entering a bedroom is common practice however we foundevidence of staff being reluctant to enter private spaces, particularly when patients were sleeping. Theimplementation ofnew technology to monitor vital signs would avoid disturbing patients at night. A contactless camera system has been trialled by Oxford University in custody suites and in Broadmoor high security hospital. The system is less intrusive than conventional intermittent observations and monitorschanges in respiration, heart rate and movement, automatically alerting staff to safety issues (Hodson, 2016).

We found a third of patients died while off the ward, in most cases the patient had absconded. Staff members need to be aware of the action to be taken if the patient absconds both from the ward and whilst on escorted leave.Hunt et al. (2010) in a study of in-patient suicide following absconding suggested two major suicide prevention measures, improving the patients experience by making wards more therapeutic and less intimidating and having tighter controls of ward exits. Technology such as electronic monitoring has also been trialled in forensic setting to enhance risk management and help locate patients who abscond (Tully et al. 2014).

In this study, 5 deaths occurred while patients were under constant observation. The patientsshowed a determination to either abscond or deliberately evade the view of observer. It is particularly important therefore,for those undertaking constant observation to be experienced and know the patient well to ensure changes in mental state can be recognised early.

Limitations

The findings should be considered in the context of the following methodological shortcomings. First, we are unable to quantify the number of lives saved due to observation, as the study was not designed to measurethe effectiveness of observation in preventing suicide. Second, this was a descriptive studywhich examined the circumstances preceding the suicide.Without a comparison group we cannot determine causality or drawaetiological conclusions.Third, data provided by clinicians and NHS trusts in the questionnaire and SUI reports may be subject to bias due to their awareness of the outcome. Fourth, the SUI reports were not standardised or written for research purposes, thereforewhile the information contained was valuable,the reportsvaried in their content and quality.

Implications for clinical practice

Although the number of in-patient suicides has fallen over the past decade (NCISH, 2015a), reducing the number of deaths by patients admitted to acute care remains a priority for mental health services. Consequently, our findings have important implications for clinical practice.We have identifiedkey areas for service improvement. Improving systems to ensure proper implementation of protocols could reduce human error and prevent adverse events. Observation policies have previously been shown to be well defineddocuments; however non-adherence to procedure has been associated with adverse events.The use of checklists in other healthcare settings i.e. anaesthetics and surgery haveincreased adherence to procedures and reduced the risk of serious incidents (Haynes et al. 2000).Systematic safety checks are commonplace in other high risk industries such as aviation and aeronautics (Helmreich, 2000; HalesPronovost, 2006).Researchers from Stockholm have developed a 28 item Suicidal Patient Observation Chart (SPOC) which identifies the most important observation items to be documented in constant observations (Björkdahlet al. 2011).

Less ambiguity and better communicationwithin the multidisciplinary team, particularly with staff new to the ward or unfamiliar with the patient could also help improve adherence to policies. This is particularly pertinent during handover periods.

The observation component of a risk management plan should follow clear protocols, which should be adhered to, recorded and monitored with the inclusion of aclear rationale for the commencement of observation and a clear guidance for when the observation should stop. Observation is an acute clinical intervention and as such, significant deviation from the observationplan should be recorded and reviewed by senior staff, including breaches of policy that did not result in harm to the patient. Serious breaches of protocol should be investigated under SUI procedures.

We found staffing levels to have been below the required level in a quarter of cases. Staffing levels can also be a deterrent to going on or coming off observation, the availability of staff should not prevent a patient being placed under observation, this decision should be based on clinical need. Patients at the highest risk of harming themselves are often placed under constant observation. This level of observation can be challenging and difficult for patients and staff,therefore clearer guidance is required for to ensure staff can remain vigilant whilst ensuring the patients’ dignity is respected.

Undertaking regular risk assessment andcarefully monitoring the patient’s mental state while under observation should inform decision making when clinicians are considering changing observation levels or ending the intervention. This is a skilled acute clinical intervention and consequently, only staff members who haveexperience and skills in engaging with seriously unwell and distressed patients should undertake this intervention.