Written Question · S4W-20760 · Session 4
What the standard review process is in cases of suspected suicide in NHS mental health wards; how many reviews have been carried out in eac…
The question
To ask the Scottish Government what the standard review process is in cases of suspected suicide in NHS mental health wards; how many reviews have been carried out in each of the last 10 years, broken down by NHS board, and whether these results are made publicly available.
The answer
Review process:
Across mental health services in Scotland, suicide review policies have been gradually integrated into NHS board adverse event policies which are part of the wider adverse event management. All NHS boards categorise every adverse event to determine the level of review required. The categorisation is partly based on the level of harm caused by the incident. Suicide is usually considered a high-level category which will prompt a full review.
All NHS boards’ mental health services carry out individual suicide reviews that examine the circumstances of suicides of patients under their care with the aim of making mental health services safer. Healthcare Improvement Scotland provides a unique resource through the Suicide Reporting and Learning System which analyses these reviews to promote learning and improvement strategies throughout Scotland. The primary aims of this process are to learn any lessons that help to improve services, to reduce risk and to improve the actual process of suicide reviews.
The current Healthcare Improvement Scotland arrangements, for health boards to report their reviews of completed suicides of people in contact with mental health services in Scotland, dates from the end of 2008. Prior to this the only reporting requirement was to the Mental Welfare Commission for Scotland but their reporting criteria did not capture all completed suicides.
In-patient suicides by health board
Statistics for suicides in NHS mental health wards are not available. Healthcare Improvement Scotland does not publish in-patient suicides by health board for the following reasons:
The numbers are very small and there is a high risk of the unintended disclosure of the identity of individuals, particularly in the smaller health boards. This would constitute a breach of confidentiality and the risk of great distress for the relatives of the people who have died.
Suicide is a multi-faceted and multi-factorial phenomenon. Suicidal risk can be increased by mental illness, social circumstances, addictions, life events and many other factors. The nature of mental health services and the communities they serve vary greatly across Scotland. Publishing completed suicides by health board could lead to unjustified comparisons of health board performance in relation to what is a highly complex and sensitive subject.
The primary purpose of reviewing the circumstances of the suicides of people in contact with mental health services is to identify areas of improvement and to share learning that can help reduce the risk of suicide. This requires a culture of openness and sharing which is not well served by using suicide statistics as a mental health services performance indicator.
Across mental health services in Scotland, suicide review policies have been gradually integrated into NHS board adverse event policies which are part of the wider adverse event management. All NHS boards categorise every adverse event to determine the level of review required. The categorisation is partly based on the level of harm caused by the incident. Suicide is usually considered a high-level category which will prompt a full review.
All NHS boards’ mental health services carry out individual suicide reviews that examine the circumstances of suicides of patients under their care with the aim of making mental health services safer. Healthcare Improvement Scotland provides a unique resource through the Suicide Reporting and Learning System which analyses these reviews to promote learning and improvement strategies throughout Scotland. The primary aims of this process are to learn any lessons that help to improve services, to reduce risk and to improve the actual process of suicide reviews.
The current Healthcare Improvement Scotland arrangements, for health boards to report their reviews of completed suicides of people in contact with mental health services in Scotland, dates from the end of 2008. Prior to this the only reporting requirement was to the Mental Welfare Commission for Scotland but their reporting criteria did not capture all completed suicides.
In-patient suicides by health board
Statistics for suicides in NHS mental health wards are not available. Healthcare Improvement Scotland does not publish in-patient suicides by health board for the following reasons:
The numbers are very small and there is a high risk of the unintended disclosure of the identity of individuals, particularly in the smaller health boards. This would constitute a breach of confidentiality and the risk of great distress for the relatives of the people who have died.
Suicide is a multi-faceted and multi-factorial phenomenon. Suicidal risk can be increased by mental illness, social circumstances, addictions, life events and many other factors. The nature of mental health services and the communities they serve vary greatly across Scotland. Publishing completed suicides by health board could lead to unjustified comparisons of health board performance in relation to what is a highly complex and sensitive subject.
The primary purpose of reviewing the circumstances of the suicides of people in contact with mental health services is to identify areas of improvement and to share learning that can help reduce the risk of suicide. This requires a culture of openness and sharing which is not well served by using suicide statistics as a mental health services performance indicator.
In the Official Report
No contribution in the Official Report cites S4W-20760 by reference.