{"id":1580,"date":"2018-05-29T13:35:40","date_gmt":"2018-05-29T12:35:40","guid":{"rendered":"https:\/\/sites.manchester.ac.uk\/ncish\/?page_id=1580"},"modified":"2025-02-03T14:29:41","modified_gmt":"2025-02-03T14:29:41","slug":"in-patient-suicide-under-observation","status":"publish","type":"page","link":"https:\/\/sites.manchester.ac.uk\/ncish\/reports\/in-patient-suicide-under-observation\/","title":{"rendered":"In-patient suicide under observation"},"content":{"rendered":"

[et_pb_section bb_built=”1″ admin_label=”section” fullwidth=”on” locked=”on” next_background_color=”#000000″ global_module=”322″][et_pb_fullwidth_menu global_parent=”322″ _builder_version=”3.0.106″ menu_id=”7″ submenu_direction=”downwards” fullwidth_menu=”off” background_layout=”dark” module_class=”main-navigation” parent_locked=”on” \/][\/et_pb_section][et_pb_section bb_built=”1″ fullwidth=”off” specialty=”off” transparent_background=”off” allow_player_pause=”off” inner_shadow=”off” parallax=”off” parallax_method=”on” make_fullwidth=”off” use_custom_width=”off” width_unit=”on” make_equal=”off” use_custom_gutter=”off” custom_padding=”0px||0px|” custom_css_main_element=”padding-top:0px” module_class=”header-image-section” prev_background_color=”#ffffff” next_background_color=”#ffffff”][et_pb_row allow_player_pause=”off” parallax=”off” parallax_method=”on” parallax_1=”off” parallax_method_1=”off” make_fullwidth=”off” use_custom_width=”off” width_unit=”on” use_custom_gutter=”off” make_equal=”off” custom_margin=”||0px|” custom_padding=”||0px|” module_class=”header-image” background_position=”top_left” background_repeat=”repeat” background_size=”initial”][et_pb_column type=”4_4″][et_pb_image src=”https:\/\/sites.manchester.ac.uk\/ncish\/wp-content\/uploads\/sites\/31\/2018\/06\/in-patient-suicide-report-2015.jpg” show_in_lightbox=”off” url_new_window=”off” use_overlay=”off” align=”left” always_center_on_mobile=”on” use_border_color=”off” force_fullwidth=”off” custom_margin=”0px|||” animation_direction=”left” show_bottom_space=”off” border_color_all=”#ffffff” _builder_version=”3.7″ \/][\/et_pb_column][\/et_pb_row][\/et_pb_section][et_pb_section bb_built=”1″ fullwidth=”off” specialty=”off” transparent_background=”off” allow_player_pause=”off” inner_shadow=”off” parallax=”off” parallax_method=”on” make_fullwidth=”off” use_custom_width=”off” width_unit=”on” make_equal=”off” use_custom_gutter=”off” custom_padding=”||0px|” prev_background_color=”#ffffff” next_background_color=”#ffffff”][et_pb_row allow_player_pause=”off” parallax=”off” parallax_method=”on” parallax_1=”off” parallax_method_1=”off” make_fullwidth=”off” use_custom_width=”off” width_unit=”on” use_custom_gutter=”off” make_equal=”off” custom_margin=”||0px|” custom_padding=”||0px|” module_class=”breadcrumbs-row” background_position=”top_left” background_repeat=”repeat” background_size=”initial”][et_pb_column type=”4_4″][et_pb_text background_layout=”light” text_orientation=”left” use_border_color=”off” border_color=”#ffffff” border_style=”solid” module_class=”breadcrumbs” custom_css_main_element=”border-bottom: 1px solid #ececed;” module_alignment=”left” background_position=”top_left” background_repeat=”repeat” background_size=”initial”] NCISH<\/a><\/span><\/span> [\/et_pb_text][\/et_pb_column][\/et_pb_row][\/et_pb_section][et_pb_section bb_built=”1″ fullwidth=”off” specialty=”on” transparent_background=”off” allow_player_pause=”off” inner_shadow=”off” parallax=”off” parallax_method=”on” parallax_1=”off” parallax_method_1=”off” parallax_2=”off” parallax_method_2=”off” make_fullwidth=”off” use_custom_width=”off” width_unit=”on” make_equal=”off” use_custom_gutter=”on” gutter_width=”2″ prev_background_color=”#ffffff” next_background_color=”#1d1d1d”][et_pb_column type=”1_3″][et_pb_sidebar area=”et_pb_widget_area_1″ orientation=”left” remove_border=”on” background_layout=”light” module_id=”left-nav-menu” show_border=”off” \/][\/et_pb_column][et_pb_column type=”2_3″ specialty_columns=”2″][et_pb_row_inner admin_label=”Row”][et_pb_column_inner type=”4_4″ saved_specialty_column_type=”2_3″][et_pb_text admin_label=”Text: Title and intro” background_layout=”light” text_orientation=”left” use_border_color=”off” border_color=”#ffffff” border_style=”solid” border_color_all=”#ffffff” border_style_all=”solid” module_alignment=”left” _builder_version=”3.3.1″]<\/p>\n

In-patient suicide under observation<\/h1>\n

Date of publication: March 2015<\/p>\n

This investigation by the National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH) examined suicides that had occurred in psychiatric in-patient care while the patient was under observation.<\/p>\n

We looked at service-related factors related to the deaths, and asked patients and staff for their opinions on the effectiveness of and potential alternatives to observation.<\/p>\n

[\/et_pb_text][et_pb_text admin_label=”Text: Key messages title” background_layout=”light” text_orientation=”left” use_border_color=”off” border_color=”#ffffff” border_style=”solid” border_color_all=”#ffffff” border_style_all=”solid” module_alignment=”left” _builder_version=”3.3.1″]<\/p>\n

Key messages<\/h2>\n

[\/et_pb_text][et_pb_accordion admin_label=”Accordion: Key messages” use_border_color=”off” border_color_all=”#ffffff” _builder_version=”3.8.1″][et_pb_accordion_item _builder_version=”3.8.1″ title=”New models of observation are needed”]<\/p>\n

The current observation approach (especially intermittent observation) is not working safely enough. There was on average of 18 suicides by in-patients under observation per year in the UK over a \u00a0seven year study period. 91% of deaths under observation occurred under level 2 (intermittent) observation. New models need to be developed and evaluated.<\/p>\n

\"The<\/p>\n

[\/et_pb_accordion_item][et_pb_accordion_item _builder_version=”3.8.1″ title=”An opportunity for engagement”]<\/p>\n

\"IconThe observation component of a care plan should not be stand-alone; time with a patient is an opportunity for engagement within a comprehensive risk management plan.<\/p>\n

[\/et_pb_accordion_item][et_pb_accordion_item _builder_version=”3.8.1″ title=”Observation is an acute intervention”]<\/p>\n

Observation should be seen as an acute intervention; there should be a record of breaches and the transition to general observation should be planned. A balance of observation and active engagement should be agreed with the patient where possible. As an acute intervention, observation is a skilled task for staff of appropriate seniority.<\/p>\n

\"The<\/p>\n

[\/et_pb_accordion_item][et_pb_accordion_item _builder_version=”3.8.1″ title=”Proper implementation of protocols”]<\/p>\n

Deaths under observation tended to occur when policies or procedures (including times between observations) were not followed. The observation component of a risk management plan should follow clear protocols \u2013 which should be adhered to, recorded, and monitored \u2013 including actions to take if the patient absconds.<\/p>\n

\"The<\/p>\n

[\/et_pb_accordion_item][et_pb_accordion_item _builder_version=”3.8.1″ title=”Suicide under observation an NHS \u2018never event\u2019?”]<\/p>\n

\"ASuicide under observation (intermittent or constant) should be considered an NHS \u2018never event\u2019<\/a> in England and Wales (or as a serious adverse event in Northern Ireland and Scotland) and should be subject to independent investigation.<\/p>\n

 <\/p>\n

[\/et_pb_accordion_item][et_pb_accordion_item _builder_version=”3.8.1″ title=”Breaches of protocol”]<\/p>\n

All serious breaches of protocol in the care of patients under constant observation (for example, leading to self-harm and absconding, not only where there is a fatal outcome) should be investigated under NHS incident procedures.<\/p>\n

\"The<\/p>\n

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Find out more<\/h2>\n

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\n\t\t\t\t\t\"Download\n\t\t\t\t<\/div>
\n\t\t\t\t\tDownload full report (PDF)\n\t\t\t\t<\/div>
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\n\t\t\t\t\tWatch a video of the key findings\n\t\t\t\t<\/div>
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\n\t\t\t\t\t\"\"\n\t\t\t\t<\/div>
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\n\t\t\t\t\t\"Publication\n\t\t\t\t<\/div>
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Contact Us<\/h4>\n

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Find Us<\/h4>\n

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NCISH<\/a><\/span><\/span> In-patient suicide under observation Date of publication: March 2015 This investigation by the National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH) examined suicides that had occurred in psychiatric in-patient care while the patient was under observation. We looked at service-related factors related to the deaths, and asked patients and staff for […]<\/p>\n","protected":false},"author":11,"featured_media":0,"parent":1479,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_et_pb_use_builder":"on","_et_pb_old_content":"","_et_gb_content_width":"","_exactmetrics_skip_tracking":false,"footnotes":""},"class_list":["post-1580","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/sites.manchester.ac.uk\/ncish\/wp-json\/wp\/v2\/pages\/1580","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/sites.manchester.ac.uk\/ncish\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/sites.manchester.ac.uk\/ncish\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/sites.manchester.ac.uk\/ncish\/wp-json\/wp\/v2\/users\/11"}],"replies":[{"embeddable":true,"href":"https:\/\/sites.manchester.ac.uk\/ncish\/wp-json\/wp\/v2\/comments?post=1580"}],"version-history":[{"count":14,"href":"https:\/\/sites.manchester.ac.uk\/ncish\/wp-json\/wp\/v2\/pages\/1580\/revisions"}],"predecessor-version":[{"id":1939,"href":"https:\/\/sites.manchester.ac.uk\/ncish\/wp-json\/wp\/v2\/pages\/1580\/revisions\/1939"}],"up":[{"embeddable":true,"href":"https:\/\/sites.manchester.ac.uk\/ncish\/wp-json\/wp\/v2\/pages\/1479"}],"wp:attachment":[{"href":"https:\/\/sites.manchester.ac.uk\/ncish\/wp-json\/wp\/v2\/media?parent=1580"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}