Sentinel MH 1 1 Suicide of a person subject to Limited family understanding of risk Close liaison with families on Actions completed or the Mental Health Act 1992. and their role in managing risk. what constitutes risk and how way. psychosis impacts on judgment, Information sharing regarding NGO Coroners report sent. function and communication. involvement with client was inadequate. Providers to have robust process in place and a standard process for information sharing. Sentinel MH 3 1 Suspected suicide of an Unclear expectations re second Clear direction for second Actions complete. outpatient not subject to the opinion. Handover from crisis team opinion to be drafted and Coroners report completed. Mental Health Act 1992 who to general team members was circulated to ensure clarity of is being actively managed by unclear level of follow up responsibilities including crisis mental health services. required. team role to review and update risk assessment prior to hand Liaison with GP was delayed as over to general team. there was no clarification about diagnosis. A letter is to be sent to the general practitioner with working diagnosis. Sentinel MH 3 1 Suspected suicide of an Recent changes in risk unclear in A new risk assessment and Actions complete or under outpatient not subject to the the risk assessment. management plan to clearly way. Mental Health Act 1992 who reflect changes to risk. Information sharing between is being actively managed by provider staff re changes in risk Process to be in place to ensure mental health services. could improve. that all staff formally notify crisis staff of any deviation from Information known to the family not agreed plan. made known to the clinical team due to lack of engagement with family Crisis staff to actively make members who were overseas during contact with known primary crisis period. caregivers and family members if a person is experiencing a significant period of crisis even if they are overseas. Waikato
Sentinel MH 1 1 Suicide of a person subject to the Mental Health Act 1992. Limited family understanding of risk and their role in managing risk. Information sharing regarding NGO involvement with client was inadequate. Close liaison with families on what constitutes risk and how psychosis impacts on judgment, function and communication. Providers to have robust process in place and a standard process for information sharing. Actions completed or way. Coroners report sent. Sentinel MH 3 1 Suspected suicide of an outpatient not subject to the Mental Health Act 1992 who is being actively managed by mental health services. Unclear expectations re second opinion. Handover from crisis team to general team members was unclear level of follow up required. Liaison with GP was delayed as there was no clarification about diagnosis. Clear direction for second opinion to be drafted and circulated to ensure clarity of responsibilities including crisis team role to review and update risk assessment prior to hand over to general team. A letter is to be sent to the general practitioner with working diagnosis. Actions complete. Coroners report completed. Sentinel MH 3 1 Suspected suicide of an outpatient not subject to the Mental Health Act 1992 who is being actively managed by mental health services. Recent changes in risk unclear in the risk assessment. Information sharing between provider staff re changes in risk could improve. Information known to the family not made known to the clinical team due to lack of engagement with family members who were overseas during crisis period. A new risk assessment and management plan to clearly reflect changes to risk. Process to be in place to ensure that all staff formally notify crisis staff of any deviation from agreed plan. Crisis staff to actively make contact with known primary caregivers and family members if a person is experiencing a significant period of crisis even if they are overseas. Actions complete or under way. Waikato
Serious-and-Sentinel-Events-Cases-2008_09.docx