All organisations providing mental health care should have a procedure in place to review critical incidents. What is presented here clearly has a health bias. It is hoped that it can follow a template for others to modify and adapt for their own circumstances.
ALL MENTAL HEALTH SERVICE PROVIDERS
POLICY DOCUMENT - THE CONDUCT OF CRITICAL INCIDENT REVIEWS
1.1 Critical Incidents are defined as follows:
a. Death of a resident in-patient or out-patient which is sudden or unexpected or where suicide is the most likely cause.
b. Homicide allegedly committed by a resident, in-patient or out-patient.
c. "Incidents", including those which might have resulted in suicide or homicide, episodes where there is evidence of serious intent of self-harm or violence to others or which led to injury or disability.
d. An event where an important policy, procedure, or practice was not followed by staff leading to a detriment or potential detriment of care - so called "near misses".
Reasons for Review
1.2 There are a number of reasons why it is essential that the circumstances of such incidents are reviewed by service managers, any clinical staff or others, including those service users involved. Most importantly any factors which could have prevented the incident should be identified so that steps can be taken to reduce future risk. "Near miss" events may not have had an obvious catastrophic outcome, but luck should play no part in service delivery; the effect on others may be considerable. It is equally essential that the impact on staff members and individuals using the service of the incident is identified and that appropriate support is made available. The Review should also allow the needs of others, for example, relatives or carers of the individual, to be identified and met.
1.3 A Critical Incident Review is not part of the disciplinary procedure. Any matter involving discipline should be dealt with separately altogether (see paragraph 5).
If any member of staff is made aware of a Critical Incident as defined above he/she should report this immediately to their line manager who, in turn, will make this information available to the service manager for mental health and the lead clinician. Trusts should establish a system for the confidential reporting of incidents.
2.1 The line manager will be responsible for arranging immediate support for the immediate patient group and any members of staff involved in the incident and for ensuring that all relevant persons are informed. If there is any possibility that the event may be of interest to the media the on call general services' manager should be contacted.
2.3 On being advised of a Critical Incident the lead clinician in discussion with senior medical and nursing colleague will initiate a Review. The Review will be carried out by a senior member of staff from another part of the organisation. All available information will be taken into account as well as face-to-face contact with staff, workers from other agencies, individuals involved (accompanied by an advocate if necessary) and relatives/carers. Contact may be in a meeting or in one-to-one interviews. The purpose of the Review is to establish matters of fact, not to attribute blame or responsibility.
2.4 All patient records from all disciplines and including care plans must be passed onto the lead clinician immediately after the incident for safe keeping; they then will be passed onto the person carrying out the review.
2.5 The patient's RMO will inform the Procurator Fiscal of any sudden or unexpected death which falls within the categories listed in Deaths in Hospital MEL(1996)33.
2.6 The patient's RMO will notify the Mental Welfare Commission of the Incident and advise them that a follow-up report will be made available.
2.7 When the Review is complete a report should be made available to all relevant staff which must include the patient's General Practitioner. While the method and extent of the distribution should take account of the potential sensitivity of the information contained in the report, secrecy is not an option. The author of the report should convene a meeting of all those to whom it had been sent to discuss the contents and consider any implications. In particular, the Review should determine whether any aspect of patient care contributed to the incident and whether any recommendation should be made with regard to current clinical practice or policy.
2.8 A final report should then be prepared by the person leading the Review. This report should be forwarded to the Mental Welfare Commission and to the Medical Director of the Trust for consideration by the Clinical Governance Board.
3.1 Any member of staff made aware of a Critical Incident must report this to their line manager immediately.
3.2 If the line manager judges that there is any likelihood of media interest the on call general services manager must be advised immediately. The on call nurse manager and consultant psychiatrist should be informed immediately and the lead clinician and service manager advised of the Incident as soon as possible.
3.3 A Review should be completed within 4 weeks of the Critical Incident and the Multidisciplinary Meeting to consider its content should be completed within 6 weeks.
3.4 It is essential that the Review should involve affected patients, or carers, admitting an independent advocate if requested.
3.5 Wherever possible the Final Report should be available within 8 weeks.
4.1 The report should include the following factors, whatever the nature of the incident:
a. A brief background of the service users involved, including a brief psychiatric history, any relevant personal details, a description of the assessment of the individual's needs, the risk assessment and the diagnosis.
b. The care plan for the service user involved at the time of the incident, including an assessment of its relevance and the extent to which the planned care had been delivered to the user (and where relevant to other users of the Service).
c. Significant events in the period before the Critical Incident.
d. The service user's liability to detention under the Mental Health (Scotland) Act and, if voluntary, whether detention should have been considered.
e. If the service user was in hospital comment on the level of observation.
f. Where available the detailed circumstances of the incident.
g. Actions proposed by the Procurator Fiscal and any comments from the Mental Welfare Commission.
h. Significant outcomes of the review with particular comments on any evidence of substandard care or recommendations to be made with regard to changes in practice, training or communication or working environment, together with a timescale.
i. Possible contribution of substance or alcohol abuse.
4.2 Where the incident has involved suicide or other sudden death reference should be made to subsequent contact with the service user's family, and what support has been offered.
4.3 Whether appropriate expressions of regret and apologies have been made to the service user(s) and carers.