A proper assessment of patients of a mental health service where 13 people died by apparent suicide in less than two years would have made staff more alert to the risk of them taking their own lives, a report has found.
While a review of the patient safety culture and governance within Carlow/Kilkenny and South Tipperary mental health services concluded that the number of deaths by apparent suicide was not out of sync with figures in the UK, it also found staff training for risk assessment was either “insufficient, or else it wasn’t being carried out at all”.
Between January 2012 and March 2014, 13 patients died by apparent suicide, three in the Department of Psychiatry, St Luke’s Hospital, Kilkenny; two within 24 hours of discharge from the Department of Psychiatry; four while the patient was under the care of the home-based treatment team; one died while in a crisis house; and three died while under the care of the community mental health services.
In addition, four serious incidents involving patients took place, one of which resulted in the death of a patient’s family member; one in which a patient suffered serious burns while in the Department of Psychiatry; one in which a patient had two serious episodes of self-harm within a short timeframe; and one in which a patient carried out a serious physical assault on a member of the public.
The review found a ligature anchor point was used by a patient to take their own life despite the findings of a previous audit of ligature anchor points following two similar suicides.
In the case of one resident who died by apparent suicide, there was no record of a medical assessment on admission to the Department of Psychiatry. Three patients who fell in the Department of Psychiatry did not have an X-ray for periods ranging from two to 10 days, despite complaints of pain in two cases.
The review, carried out by the Inspector of Mental Health Services at the behest of the Mental Health Commission, found the system for information-sharing following incidents “did not function well and did not support a safety culture”. It also found “deep disharmony” between senior management and psychiatrists which had undermined clinical governance at the time of the review in early 2014.
The commission’s report is the second examination of the services — a HSE review of the governance structures within Carlow/Kilkenny/South Tipperary mental health services, published last year, made similar findings.
However, the commission took the approach of a “targeted intervention” so that instead of just a review of the facts with recommendations, an implementation plan was drawn up with follow-up inspection to verify required actions were taken. Of 19 recommendations, 12 have been implemented while implementation of the remaining seven is under way.
Commission chair John Saunders said he believes the service had “changed dramatically” in the wake of the two reports and that he was happy to reassure patients that it is now safe.
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