Report on adverse events of mental health patients

Report focuses on serious adverse events involving patients of mental health and addictions services
Media release
Embargoed to 12 noon, Thursday 26 September 2013

District health boards (DHBs) have reported 177 serious adverse events involving patients of mental health and addictions services in the year to 30 June 2013.

Most events – 87 percent – took place in the community. There were a total of 134 suspected suicides, of which two occurred in inpatient facilities. In 2011/2012, nine suspected suicides occurred in inpatient facilities.

Ninety-two percent of mental health and addictions service users access only community services, with the remaining 8 percent receiving a mixture of community and inpatient services.

The report’s release comes as health quality and improvement experts and health professionals focus on patient safety, at the Asia Pacific (APAC) Forum in Auckland. APAC is hosted by Ko Awatea and the Institute of Healthcare Improvement and supported by the Commission.

The adverse events are summarised in the report District health board mental health and addictions services: Serious adverse events reported to the Health Quality & Safety Commission 1 July 2012 to 30 June 2013 released today.  The report is available on the Commission’s website: www.hqsc.govt.nz.

It is the Commission’s first report to look specifically at mental health reportable events. Events that occurred at inpatient facilities, while the person was on leave from an inpatient facility and when a person went missing from an inpatient facility were previously included in the annual reporting of serious and sentinel events. Events that occurred in the community while the person was an outpatient were not reported by the Commission last year.

“This report is the Commission’s first step towards engaging with the challenging problem of harm to patients of mental health and addictions services,” says Dr Janice Wilson, Chief Executive of the Commission.

She says DHB reporting is voluntary but the Commission strongly encourages it so the sector can learn from these very sad events.

Dr Rees Tapsell, Director of Clinical Services, Waikato DHB and Executive Clinical Director at the Midland Regional Forensic Psychiatric Service, says the report contains valuable information for clinicians.

“We have a highly professional and dedicated health workforce but harm does occur.  Not all of it can be prevented but some of it can be.  It’s the responsibility of all of us working in health to provide the safest care possible.”

Death by suspected suicide was the most frequently reported event.  The way suspected suicides are reported has changed from last year, which required the event to have occurred within seven days of a person’s contact with a mental health and addictions service. This has been extended to within 28 days of contact with a service, and as a result more cases of death by suspected suicide are likely to be reported in coming years.

The Commission and Ministry of Health have agreed in principle to a two-year mortality review trial to improve knowledge about the factors contributing to suicide, patterns of suicidal behaviour, and for better identification of key points to intervene to prevent suicide.  A small group of experts from different sectors will review the contributing factors and possible intervention points leading to a suicide, with the aim of preventing them in future.  A report of their findings and recommendations will be published at the end of the trial.

MentalHealthSAE__Report_Final.pdf 

Mental Health Serious Adverse Events Report
Questions and Answers
Embargoed to 12 noon, Thursday 26 September 2013

What is this report about?

The report, District health board mental health and addictions services: Serious adverse events reported to the Health Quality & Safety Commission 1 July 2012 to 30 June 2013, looks at the harm to patients of mental health and addictions services which occurred over a one-year period.

It is the Commission’s first report to look specifically at mental health reportable events. Events that occurred at inpatient facilities, while the person was on leave from an inpatient facility and when a person went missing from an inpatient facility were previously included in the annual serious and sentinel events report. Events that occurred in the community while the person was an outpatient were not reported by the Commission last year.

This year, the Commission has produced a separate report on mental health and addiction adverse events. This report complements other reporting on mental health events from the Ministry of Health and other organisations.

What are the main findings?

District health boards (DHBs) have reported 177 serious adverse events involving patients of mental health and addiction services in the year from 1 July 2012 to 30 June 2013. These included:

• 134 cases of death by suspected suicide
• 17 cases of serious self-harm (includes events reported as attempted suicides)
• 17 cases of serious adverse behaviour (includes allegations of assault by a patient on a staff member, another patient or other person, and allegations of criminal acts)
• 5 cases of people going missing from an inpatient facility (no harm)
• 4 other events resulting in patient harm.

Patient harm occurred in the following locations or circumstances:

• in the community, when the person was an outpatient
• at inpatient facilities
• while the person was on approved leave from an inpatient facility
• when the person went missing from an inpatient facility

A total of 17 events involved patients who had gone missing from an inpatient facility without approved leave. Five of these events did not result in any subsequent harm but harm occurred in the remaining 12 events – either death by suspected suicide, serious self-harm, or serious adverse behaviour.

DHB reporting does not currently identify whether the patients were voluntary patients who could choose to leave, or were subject to a formal restriction under the Mental Health (Compulsory Assessment and Treatment) Act 1992, or the Criminal Procedure (Mentally Impaired Persons) Act 2003.

Have suspected suicides by mental health and addition services users increased?

It is not straightforward to compare the figures in this report with those used in previous years. For example, the way death by suspected suicide is reported has changed this year. In past years, the event had to have happened within seven days of a person’s contact with a mental health and addictions service. This has been extended to within 28 days of contact with a service, and as a result more cases of death by suspected suicide are likely to be reported in this year and coming years.

Figures in the other categories are very small, and caution is needed when interpreting them.

Suspected suicides 2012/13 and 2011/12

Could these deaths and instances of harm been prevented?

Serious mental illness is a significant risk factor for self-harm and suicide. International evidence shows that despite the best efforts of family, friends, other social agencies and mental health staff, tragically, some people will commit suicide.

Mental health and addictions services are dealing with some of New Zealand’s most vulnerable people. In some cases, these people are very unwell and end up acting in ways that result in harm or death. It is not always possible to prevent that happening.

However, health professionals have a duty to do everything in their power to keep patients safe while they are receiving treatment. If someone dies or is harmed, the DHB involved will look at what happened to see if anything could have been done differently. This reporting is part of that process of review and reflection. It’s about learning from things that went wrong and improving the way health care is delivered.

How do the various district health boards (DHBs) compare with each other? And how do the figures compare with previous years?

This report is not designed to provide a comparison between DHBs, although a list of events by DHB is provided within the document. DHBs deal with the diverse needs of their populations and these may differ considerably across regions.

For a more detailed explanation of a particular DHB’s reporting of, and experience of mental health and addictions adverse events, you will need to contact that DHB.

ENDS

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