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Systems approach to analysing suicide incidents in community-based mental health care

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conference contribution
posted on 21.12.2017, 11:48 by Nye Canham, Gyuchan Thomas JunGyuchan Thomas Jun, Satheesh Kumar, Fabida Noushad
Mental health services in the UK are now predominantly community-based, rather than inpatient-based. Managing patients with suicidal risk within the community setting is challenging and suicides from those currently using or having recently used these services do occur; actually, more than half of the people who commit suicide have visited their doctors in the month before their death. In current practice within the UK health service, suicides of patients are investigated as serious incidents and analysed using Root Cause Analysis (RCA), which was considered to often fail to explore deep system problems. This study reanalysed 41 of these RCA incident reports using Systems Theoretic Accident Modelling and Processes (STAMP). The analysis revealed the weaknesses within the system safety control structure and the themes around those control flaws. There is an inherent weakness in the control structure with the need to monitor the patient’s risk without constant observation and rely on the patient to report issues and adhere to their treatment plan. Patient engagement issues are a major theme with loss of control and feedback on the patient status due to their lack of willingness to engage with services and treatment options. In some cases, patients have presented at a time of crisis but then declined the crisis support or inpatient treatment offered to them. Patients new to services present a problem where decisions on their care are having to be made with limited knowledge of the patient. Certain coordination and communication issues between the multidisciplinary teams and multiple services are also found. STAMP application enabled effective aggregation of multiple incident analysis and system-wide remedial action prioritisation.



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CANHAM, A. ... et al, 2018. Systems approach to analysing suicide incidents in community-based mental health care. IN: Ergonomics & Human Factors 2018: Proceedings of the Annual Conference of the Chartered Institute of Ergonomics & Human Factors, Birmingham, UK, 23rd-25th April 2018.


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This work is made available according to the conditions of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) licence. Full details of this licence are available at: https://creativecommons.org/licenses/by-nc-nd/4.0/

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