NHS trusts should avoid a common practise of scoring patients' risk of repeated self-harm or suicide using 'high', 'medium', or 'low' risk categories, as they were a "poor predictor" of future intentions, a report by the Healthcare Safety Investigation Branch (HSIB) said.
The conclusions followed an investigation into care delivery by community mental health teams (CMHTs), prompted by a case referral of a female NHS worker who died by suicide while under the care of a CMHT.
The 56-year-old, referred to in the report as 'Ms A', first had contact with a CMHT following a hospital stay for an attempted suicide. She was discharged home to the care of the CMHT in September 2019 with a diagnosis of psychotic depression. In May 2020 she was again admitted to hospital for around 4 weeks following a second suicide attempt, after which she was again discharged to the care of a CMHT. At the end of July, Ms A's family became increasingly concerned about her mental state, and on 2 August 2020 she was found dead at home. A coroner later recorded a verdict of death by suicide.
Assessing Risk
The HSIB's investigation focused on how people at risk of suicide were cared for by CMHTs, and the factors that contributed to care being delivered outside of national guidelines. It also examined how menopause was considered as part of a risk assessment, engagement with the families of patients, and management of individuals with a first episode of psychosis.
It found that, while national guidance stated that a patient's risk of harm should not be stratified into categories such as high, medium, or low, use of those techniques was common in many trusts because other methods of assessing and documenting risk were not available, and staff feared being blamed if a patient came to harm without some sort of risk assessment having been carried out.
In the case of Ms A, her risk of self-harm or suicide during her second episode of mental health care in the community was routinely assessed and categorised as high, medium, or low risk, a method that the report said "was in line with the policy of the local Trust at that time, but not with guidance from the National Institute for Health and Care Excellence, which states that risk of suicide should not be stratified into categories".
National experts in suicide and self-harm told investigators that categorising patients in such a way could lead to resources being focused on those assessed as high risk, whilst one expert said scales and tools for assessing suicide risk "have a positive predictive value of about 5% – meaning that they do not accurately predict the risk of suicide 95% of the time, and that suicide deaths in the large 'low-risk' group are often missed".
Clinicians told the investigation that risk categorisation was "often used as a justification for not providing care".
Menopause in Assessments
The investigation also found that menopause was a potentially unconsidered physical health factor in the case. When the HSIB looked at this issue on a national level, it found that menopause was not routinely considered as a contributing factor in women with low mood who were assessed by mental health services, and staff did not receive training in this area as standard practise.
The investigation included the view from one CMHT expert that midlife was a point of increased risk of mental health deterioration, and that women were at increased risk of developing schizophrenia or other psychotic disorders at or around menopause. The HSIB report noted that there was a gap in evaluating research that might show links between the menopause and severe mental health symptoms.
Recommendations by the HSIB included that:
- NHS England create guidance on culture change and develop a quality improvement programme to support practitioners in undertaking psychosocial assessments that were in line with guidance from the National Institute for Health and Care Excellence (NICE)
- The Care Quality Commission evaluated the way in which it reviews how community mental health services assessed risk of harm, to ensure its inspections were in line with the latest national guidance
- NICE evaluated the available research relating to the risks associated with menopause on mental health update existing guidance, if appropriate
The investigation also made findings on engagement with families in complex cases.
Amber Sargent, national Investigator at HSIB, said: "Our investigation findings all point to one thing: that it is absolutely crucial that patients at risk of suicide and self-harm are given a holistic assessment, one that moves away from tick boxes. It is widely recognised, and our investigation provides further evidence, that narrow categorisation does little to predict and prevent the worst outcomes for patients and their families.
"Our report has also started a conversation about some of the factors that could impact the individual – for example considering the effect of the menopause or understanding the benefits of engaging with families and carers and how this could be done consistently, even in complex cases.
"The findings and safety recommendations are aimed at supporting improvements in CMHTs to ensure patients are given care that is built around their specific needs. As Ms A's sister has said in our report, many will know the deep pain of losing a loved one to suicide and that they as a family wanted to share their experiences so that others can stay safe and recover."
