confidentiality & information sharing in acute …...08/06/2018 1 confidentiality &...

08/06/2018

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Confidentiality & Information Sharing in Acute Mental Health

Assessments

6 June 2018, Clifton House

Theresa Nixon The Regulation and Quality Improvement

Authority

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Professor Wendy Burn President - RCPsych

Dr Gerry Lynch Chair – RCPsych in NI

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Information Sharing and suicide

prevention Consensus statement - Jan 2014

GMC guidance

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GMC guidance- framework for

sharing information

• Trust is essential to the doctor-patient relationship and

confidentiality is essential to that trust

• Appropriate information sharing is an essential part of the

provision of safe and effective care

When you can disclose personal

information

• The patient consents, whether implicitly or explicitly, for the sake

of their own care

• The disclosure is of overall benefit to a patient who lacks capacity

to consent

• Keep disclosure to the minimum necessary for the purpose

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• Asking for a patient’s consent to disclose information shows

respect and is part of good communication between doctors and

patients

• Consent may be implied or explicit

Implied consent

• ‘You may rely on implied consent to access relevant information or share it with all those who provide direct care if....

1. You are accessing the information to provide or support the person’s direct care

2. The person is aware of how the information will be used, and that they have the right to object

3. You have no reason to believe the patient has objected

4. You are satisfied that any information you disclose will be treated as confidential

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‘You may rely on implied

consent to access relevant

information or to share it

if.....” • You are accessing the information to provide or support

the patient’s direct care • information is readily available to patients explaining how

their information will be used, and that they have a right to object

• You have no reason to believe that the patient has objected

• You are satisfied that any information you disclose will be treated as confidential

Introduction

• Families bereaved by suicide had repeatedly raised concerns

about issues of confidentiality; practitioners seemed reluctant

to take information from families or give them information

about a person’s suicide risk

• ‘We strongly support working with families’

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Introduction

•

Where the common law duty of confidentiality applies,

practitioners will be under a duty to respect a person’s refusal to

disclosure of suicide risk, if the person has capacity and does not

pose a risk to anyone but themselves

Consensus statement

• Obtaining information from and listening to the concerns of families are key factors in determining risk

• Even when a person wishes particular information not to be shared, this does not prevent practitioners from listening to the views of family members

• Practitioners should discuss with people how they wish information to be shared, and with whom, in advance

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Consensus statement

• If patient’s views have not been sought in advance, assess capacity to consent to information being shared

• If the person is at imminent risk of suicide, there may be sufficient doubts about their mental capacity at the time

• Disclosure may be in patient’s best interests

• Consider also public interest

Prof Louis Appleby

• ‘ The statement aims to reset the balance between autonomy and

safety, to encourage frontline staff to talk to patients’ families

about their suicide risk. It is a strongly held and sometimes bitter

concern of families that clinicians hide behind rules of patient

confidentiality and exclude them from what they as carers need to

know’

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The Matthew Elvidge Trust Sharing information to save lives

• ‘In our experience, it’s always much better to involve a trusted

family member, friend or colleague in your assessment, treatment

and recovery. This will result in you recovering much quicker.

Would you like us to make contact with someone, and would you

like us to do this together...?’

Dr Petra Corr Chair - Clinical Psychology

British Psychological Society NI Division

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19 www.bps.org.uk

MORE THEN ME:

A PSYCHOLOGICAL APPROACH

TO REDUCE SUICIDE

Dr Petra Corr

Chair DCPNI

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Paradigm Shift

• Moving from a position of an unclear

understanding of psychological processes

involved in suicide ideation and behaviours

• Emphasis on enhancing understanding of

psychological processes at work through active

research agendas

• Leading to opportunities to engage early, to

develop resilience and coping strategies, to

mobilise support from friends and family, to

engage with effective intervention and support

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Suicide Registration

Rates (ONS 2016) • UK 2015 6188

• UK 2016 5965 3.6%

• NI 2015* 318

• NI 2016 297 6.6%

• NI Male 2015* 30.3 per 100,000

• NI Male 2016 27.3 per 100,000

• NI Female 2015* 8.8 per 100,000

• NI Female 2016 9.2 per 100,000

*Recording Issues

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NI Features

• NI Peaks

– Male: 25-29; 55- 59

– Female: 45-49; 65-69

• 82% increase in male suicide in NI over 1985

to 2015 (Samaritans, 2017)

• Exposure to conflict related trauma associated

with greater risk of suicidal ideation but not

action; increased likelihood of death on first

attempt in NI sample (O’Neill et al, 2014)

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A significant societal

issue • 14th Leading cause of death worldwide

• 1.5% of all mortality

(O’Connor & Nock, 2014)

• Low public health priority

• Suicide prevention and research on suicide has not had the

investment required (WHO, 2014)

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Higher Risk Groups

• Men

• Pregnant women and new mothers

• People in CJS and leaving CJS

• Adolescents

• People leaving MH inpatient services

• People with history of self harm

• People with current / recent financial

difficulties

• People exposed to suicide contagion

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Biopsychosocial Models

• Risk groups identified

• Variation in positive predictive value

– 90% people who die by suicide have a mental disorder (Cavanagh,

2003) , only 5% of people admitted to hospital with affective disorder

die by suicide (Bostwick, 2000)

• Complex interplay between risk factors across domains

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27 Suicidal Behaviour Research Laboratory

Integrated Motivational–Volitional Model (IMV) O’Connor (2011). In O’Connor, Platt & Gordon (Eds.). International Handbook of

Suicide Prevention: Research, Policy & Practice Wiley-Blackwell

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Opportunities to Intervene

Premotivational

• Factors that create setting or context for later vulnerability – e.g. CSA, physical illness,

Motivational

•Understanding complex

psychological processes underlying

development of suicidal thinking

Volitional

•Factors that lead people to act on

their thoughts

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Psychosocial

Interventions • 60% of people with suicidal thoughts and behaviours do not

receive treatment (Bruffaerts et al, 2011)

• Treatment for depression does not reduce suicidal thoughts or

behaviours (Cuijpers et al, 2013)

• DBT is effective in people with PD (Linehan et al, 2006)

• CT reduce suicide reattempt rates compared to other treatment

(Brown et al, 2005)

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• E-Health Interventions – Apps (Dogan et al, 2017)

• Collaborative assessment and management of suicidality

designed to enhance therapeutic alliance and decrease risk

(Jobes et al, 2012)

• Safety planning interventions – sources of support

(connectedness), plans, means (Stanley et al, 2012)

• Postvention – particularly organisational postvention (Cox et al,

2016)

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Quality Improvement

and Prevention • Implementation of consensus statement to enhance social

connectedness & manage risk

• Research testing of models

• Improved understanding of the shift to volition

• Focus on psych’l factors that are protective

• Clinical practice informed by research

• Access to evidence informed interventions for targeted groups

across multiple delivery modalities

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QUESTIONS

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Oscar Donnelly & Christine Bateson Northern Health and Social Care Trust

Regional Protocol –

Notification of appointments

Mr Oscar Donnelly,

Divisional Director of Mental Health, LD & Community

Wellbeing NHSCT

Mrs Christine Bateson,

Head of Service for Mental Health

Inpatient Services NHSCT

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Background – Mr McC 21 yr old living in Belfast

Admitted to Knockbracken in 23/12/16 & discharged on

10/01/17 to NT CRHTT

RAID AAH on 19/01/17 - Admitted Holywell – 21/01/17

Delusional Disorder and Substance Misuse

Discharge Holywell 30/01/17

Post Discharge Arrangements

7 day follow-up 02/02/17

Urgent referral to CAS

Died in Birmingham 13/02/17

SAI Review A good standard of care had been provided

Transitions managed well

Parents felt excluded from care/care planning

Processes 7 day follow- up to be

strengthened

Recommendations 7 day follow up DNA response

Carers Assessment

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Coroner – Regulation 28 report

to prevent further deaths Matters of Concern requiring addressing

• No evidence in Trust’s records that details of the 7 day

follow up were given to Mr McC or his parents

• Discharging Consultant anticipated that the discharge nurse

would tell Mr McC and family about discharge arrangements

• Mr McC’s family had no knowledge of discharge plan

• The Trust no policy for notifying SU or Carers of Discharge

arrangements – esp written notification

• Risk that Sus and Carers will be unaware of discharge

arrangements

Processes versus Therapeutic

Alliance New ways of working

ICP

PQC

Discharge Planning Meetings

Facilitated Early Discharge

7 Day follow up

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How the Process of Discharge Planning was Reviewed and

Implemented

SAI process within the Trust with Learning Outcomes

identified

Feed back from the Coroner in Birmingham

Meeting with clinical leads of both community services and

also inpatient service

Review of the ICP

Amendments made to documentation

Implemented through the Acute Care Forum and learning

disseminated at ward meetings

ICP

Amendments made to ICP documentation

Section was added to the ICP to confirm that the service user was given follow

up arrangements and in particular the 7 day follow-up appointment with CMHT.

The section confirms that the arrangements have been provided in writing and

there is also a section to show that family were given information.

The documentation also contains the person’s support plan and relevant contact

numbers

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Key lessons learned -Communication

versus Family engagement in Discharge

Planning

Highlighted the need to involve family in the discharge

plan.

The importance that family/ carer play in the recovery/ well

being of the individual post discharge.

Whilst the processes support safe discharge planning the

way that we interact with both service user and family

ultimately influences the effectiveness of these processes

Effective communication is essential

The way forward

Therapeutic alliance between service user carer and MDT

must start from admission

Service Users supported to see Carers and family as a

resource to support recovery

Carers actively involved in drawing up recovery plans and

support plans.

Where there are difficulties or lack of consent - staff use

therapeutic approaches to engage and empower patients

to see the benefit of carer involvement

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The challenges ahead

To change culture to ensure that process does not replace therapeutic

approaches

To modify how we do things to ensure that we can facilitate true collaboration

with families and carers

Effective discharge planning cannot happen unless engagement with carers

occur at the start of the patients journey

Change the language we used to maximise the opportunity for therapeutic

alliance

Regional Protocol –

Notification of appointments

Mr Oscar Donnelly,

Divisional Director of Mental Health, LD & Community

Wellbeing NHSCT

Mrs Christine Bateson,

Head of Service for Mental Health

Inpatient Services NHSCT

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Dr Uzma Huda Divisional Medical Director MH&LD Northern Health & Social Care Trust

CONSENSUS ON

CONFIDENTIALITY STATEMENT

DR UZMA HUDA

DMD MHLDCWB,NHSCT

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So far

The Consensus Statement

-Coroner’s recommendations re Carer notification of 7 day follow-up

-Psychological approaches in risk management

-overview of some findings from NCISH NI

-use of statement

-discussion- re language that we use and achieving consistency

RED FLAGS?

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General population suicides: age and

gender profile

18%

24%

21%

19%

11%

5%

3%

15% 17%

23% 24%

13%

6%2%

0

100

200

300

400

500

600

Under 25 25-34 35-44 45-54 55-64 65-74 75+

Nu

mb

er

of

suic

ide

s

Age-group

Male Female

N IRELAND_SUICIDE (2005-2015)

© National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. All rights reserved.

Not to be reproduced in whole or part without the permission of the copyright holder.

Patient Suicide – Age and Gender Profiles

12%

22%

25%

21%

12%

5%

2%7%

18%

27% 27%

15%

3% 2%

0

20

40

60

80

100

120

140

Under 25 25-34 35-44 45-54 55-64 65-74 75+

Nu

mb

er

of

pa

tie

nts

Age-group

Male Female




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Living circumstances: patient suicides

Alone

335 (45%)

With parent(s)

114 (15%)

With spouse/partner

(w ith or w ithout

children)

197 (27%)

With children only

41 (6%)

Other shared

(e.g. friends)

35 (5%)

Prison/YOI

3 (<1%)Other specified

17 (2%)




Marital status: patient suicides




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Employment status: patient suicides




Patient suicides: Primary Diagnosis by

Gender




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Duration of illness: patient suicides

17%

25%

58%

0

50

100

150

200

250

300

350

400

450

within 12 months 1-5 years more than 5 years

Nu

mb

er

of

pati

en

ts




Number of patient suicides per week

following discharge (2005-2015)

28

17

10

3

9

13

7

56

54

6

8

0

10

20

30

1 2 3 4 5 6 7 8 9 10 11 12 13

Nu

mb

er o

f p

atie

nts

Weeks between discharge and suicide (Week 1 = First week following discharge)




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Mental health teams’ estimation of suicide risk

at last contact: patient suicides

9%

51%

35%

5%

31%

59%

10%

1%

0

50

100

150

200

250

300

350

400

450

No risk Low Moderate High

Nu

mb

er

of

pa

tie

nts

Suicide risk

Long-term risk Immediate risk




Mental Health Teams’ Views on Preventability: patient

suicides

(11%)

(21%)

(8%)

(5%)

(6%)

(3%)

(4%)

(11%)

(1%)

(6%)

(3%)

(2%)

0 20 40 60 80 100 120 140 160

Other factors

Adherence with drug treatment

Closer contact with patient's family

Availability of dual diagnosis services

Access to alcohol services

Access to drug services

Access to psychological treatment

Closer supervision of patient

Use of MHA

Better communication between teams

Better staff training in risk assessment

Greater availability of psychiatric beds

Number of patientsN IRELAND_SUICIDE (2005-2015)

© National Confidential Inquiry into Suicide and Homicide by People with Mental

Illness. All rights reserved.


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SAFER SPECIALIST MENTAL HEALTH

SERVICES :A TOOLKIT• OUR FINDINGS INDICATE THAT CRHT IS USED FOR

TOO MANY PATIENTS AT HIGH RISK OF SUICIDE.

• 44% OF CRHT PATIENTS WHO DIE BY SUICIDE LIVE

ALONE.43% DIE WITHIN 2 WEEKS OF LAEVING

HOSPITAL AND A THIRD OF CRHT PATIENTS WHO DIE

BY SUICIDE HAVE BEEN UNDER THE SERVICE FOR

LESS THAN ONE WEEK-ANNUAL REPORT 2017

• WORKING MORE CLOSELY WITH FAMILIES COULD

IMPROVE SUICIDE PREVENTION.IN 18% OF SUICIDE

DEATHS CLINICIANS BELIEVE GREATER INVOLVEMENT

OF THE FAMILY BY THE SERVICE WOULD HAVE

REDUCED THE RISK-ANNUAL REPORT 2017

Are we guilty of this sometimes?

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Confidentiality

‘We strongly support working closely with families. …listening to the concerns of families is a key factor in

determining risk.’ Consensus Statement

‘We need to engender a shift away from the current presumption that patients will not want their families

or friends to be involved in recovery.’ Select Committee

Sharing Information to save lives

General population suicides: age and

gender profile

Review how you involve trusted family members or friends in your patient assessment and care.

Review how you ask for consent.

Implement all the principles of the Consensus Statement.


Summary

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Confidentiality

‘In our experience, it’s always much better to involve a trusted, family member, friend or colleague in your

assessment, treatment and recovery. This will result in you recovering much quicker.

Would you like us to make contact with someone… and would you like us to do this together...?


Confidentiality

‘Insufficient evidence had been collected… from useful sources before

Matthew’s assessment.’


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CULTURAL CHANGE

WHAT IMPORT DO WE GIVE CARERS VIEWS?

ARE WE AWARE OF THE LIMITATIONS OF OUR RISK

ASSESSMENTS WHEN WE EXAMINE THE EVIDENCE

HOW DO WE GET CULTURAL CHANGE IN ATTITUDES

TOWARDS CARER ENGAGEMENT

OR WILL WE STILL HIDE BEHIND CONFIDENTIALITY?

Using the right language

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Confidentiality

‘In our experience, it’s always much better to involve a trusted, family member, friend or colleague in your

assessment, treatment and recovery. This will result in you recovering much quicker.

Would you like us to make contact with someone… and would you like us to do this together...?


Discussion

confidentiality & information sharing in acute …...08/06/2018 1 confidentiality &...

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