Mental health inpatients under observation due to risk of suicide are being placed in more danger by trusts relying on inexperienced staff and agency nurses, according to a major report.
The latest report from National Confidential Inquiry into Suicide and Homicide by People with Mental Illness found that 18 inpatients a year died by suicide while under observation.
Observation usually meant checks every 10-15 minutes, but in 9% the patient was supposed to be under constant observation, said the report by researchers from the University of Manchester.
“We found that where deaths occurred, responsibility had often been given to less experienced members of staff”
They examined the details of all suicides in the UK over seven years under observation. They also conducted an online survey for patients and staff to report their experience of observation.
They found half of deaths examined occurred when checks were carried out by less experienced staff or agency staff who were unfamiliar with the patient.
Deaths occurred when staff were distracted by ward disruptions, during busy periods, or when the ward was poorly designed, noted the report.
One nurse, who participated in the focus group, said: “Very few nurses really understood what an observation meant. They thought it meant go away, see someone, come back and sign the sheet.”
The researchers called for suicide under observation to be considered a “never event” in England and Wales – or as a serious adverse event in Northern Ireland and Scotland – and subject to independent investigation.
Inquiry director Professor Louis Appleby, who also leads the National Suicide Prevention Strategy for England, said the current observation approach was “not working safely enough”.
“This is an important part of keeping patients safe, but we found that where deaths occurred, responsibility had often been given to less experienced members of staff,” he said.
“Observation is a skilled task, not an add-on that can be delegated to anyone available,” he added.
Inquiry co-author Professor Jenny Shaw said observation should be viewed as an opportunity to engage with patients, as part of a comprehensive care plan.
“New models for observation need to be developed and tested to cut the number of deaths,” she said.
“Effective handover processes need to be in place to ensure that all staff are made completely aware of their patients’ treatment needs”
The Royal College of Nursing said the report “shines a light” on an area of practice often overlooked but that was crucial in saving the lives of mental health patients.
Peter Carter, chief executive and general secretary of the RCN, said: “Those under observation are some of the most vulnerable patients under nurses’ care and deserve staff that are specifically trained for this role.”
He said the report highlighted a serious consequence of a “depleted workforce”, citing recent RCN research suggesting 3,300 posts in mental health nursing had been cut since 2010.
“The NHS needs not only sufficient numbers of nurses, but also a workforce with the right balance of skills, who are fully prepared to meet the complex needs of mental health patients,” said Dr Carter.
“Continuity of care is also key,” he said. “Agency nurses are fully qualified, professional staff, however effective handover processes need to be in place to ensure that all staff are made completely aware of their patients’ treatment needs.”