Southern District Health Board www.southerndhb.govt.nz Serious or Event Description of Review findings Recommendations/actions Follow-up sentinel code Sentinel 2 Voluntary patient No clear single point of contact for A single contact point for family with Risk Management Working committed suicide the patient’s family and rostering a member of staff likely to be formed to review the service while on overnight of nursing staff means the primary consistently available. approach to risk assessment and leave. nurse is only intermittently management of clinical risk. Review of the current risk available. documentation practices. A draft revised treatment plan for The long-term high risk of suicide inpatient areas is currently under Discussion take place between for this patient was not consultation, part of which aims to Southern DHB mental health documented. Only short-term improve the recording and services and the NZ Police about the clinical risk was regularly noted. of clinical risk observations and removal of firearms licences during regularly changing leave status. Although the patient’s firearms significant episodes of depression were removed from his and the pathway to reinstatement of possession he was able to use his firearms licences when full recovery firearms licence to purchase a has occurred. new gun. Serious 6 Inpatient fall resulting Falls prevention strategies were All reasonable steps had been taken Staff are now more aware of the in laceration to appropriate and supervision to keep the patient safe while hazard and will consider the forearm. during activity was of a high permitting return to maximum potential risk when assisting or standard. independence. supervising patients’ mobility in areas where linen trolleys are located. Sentinel 2 Inpatient suicide. Investigation under way.
Southern District Health Board www.southerndhb.govt.nz Serious or sentinel Event code Description of Review findings Recommendations/actions Follow-up Sentinel 2 Voluntary patient committed suicide while on overnight leave. No clear single point of contact for the patient’s family and rostering of nursing staff means the primary nurse is only intermittently available. The long-term high risk of suicide for this patient was not documented. Only short-term clinical risk was regularly noted. Although the patient’s firearms were removed from his possession he was able to use his firearms licence to purchase a new gun. A single contact point for family with a member of staff likely to be consistently available. Review of the current risk documentation practices. Discussion take place between Southern DHB mental health services and the NZ Police about the removal of firearms licences during significant episodes of depression and the pathway to reinstatement of firearms licences when full recovery has occurred. Risk Management Working formed to review the service approach to risk assessment and management of clinical risk. A draft revised treatment plan for inpatient areas is currently under consultation, part of which aims to improve the recording and of clinical risk observations and regularly changing leave status. Serious 6 Inpatient fall resulting in laceration to forearm. Falls prevention strategies were appropriate and supervision during activity was of a high standard. All reasonable steps had been taken to keep the patient safe while permitting return to maximum independence. Staff are now more aware of the hazard and will consider the potential risk when assisting or supervising patients’ mobility in areas where linen trolleys are located. Sentinel 2 Inpatient suicide. Investigation under way.
SSE_cases_2010_11_FINALv1.docx