Modelling PSIRF investigations in community mental health services

The report is intended to support NHS organisations and local investigation staff by providing examples of how PSIRF tools, guidance and templates can be applied in practice. Stakeholders told us that seeing investigations carried out using PSIRF would help to increase confidence in undertaking and learning from patient safety incidents across the healthcare system.

This report differs from our usual format. It uses the Patient Safety Incident Investigation (PSII) report template, reflecting the approach NHS organisations are expected to take under PSIRF.

Supporting the use of PSIRF in practice

To inform the investigation, we engaged with a range of stakeholders, including clinicians and national leads to understand the challenges associated with learning from patient safety incidents in mental health settings. Although suicide prevention has been the focus of extensive national work, it remains a persistent safety risk, with themes from incidents and complaints remaining largely unchanged over time.

Evidence from intelligence gathered suggests that greater insight into challenges faced at an organisational level when a service user has sadly attempted suicide or taken their life would be helpful. Our investigation focused on an attempted suicide in a community mental health setting, and was a valuable exercise in demonstrating how PSIRF tools and approaches can be used effectively to explore complex patient cases and patient safety issues.

Learning in community mental health settings

The individual case in the report was that of a 42-year-old male who had a complex mental health history and also documented drug and alcohol use. The attempt to end his own life occurred following a period of ongoing contact with primary care and community mental health services, with multiple missed appointments and change in mental health medication. Following the attempt at ending his life, he spent several weeks in hospital before being discharged home, where he continues to receive support from community mental health services.

Our report makes findings specific to the incident. However, patient safety incident investigations undertaken under PSIRF are designed to explain how healthcare systems and processes contribute to patient safety incidents. They do not seek to assign blame or determine individual culpability. Instead, they examine system factors such as service design, workload, information flow, resources, and organisational context

The report lays out four areas for improvement which the mental health trust could develop safety actions to address. Whilst aimed at the specific trust, the areas for improvement could be applicable to other organisations. The four areas of improvement focus on:

• The sharing, availability and accessibility of information across providers.
• The importance of the early exploration of reasonable adjustments for individual service users.
• Managing risk when service users who may require prescription medication and who use drugs and/or alcohol.
• Organisational support for staff to enable them to respond to the distress and demands of their role.

Supporting future learning

By using the PSII report template and PSIRF tools throughout this investigation, our aim is to provide a practical resource for NHS organisations and investigation teams. The report shows how PSIRF can be applied in mental health and community care settings and how learning can be identified to support safer care. This investigation forms part of HSSIB’s wider work to support the effective implementation of PSIRF across the NHS and to strengthen system-based approaches to learning from patient safety incidents.