The guidance, drawn up by the Royal College of Psychiatrists (RCPsych), focuses on patients with severe mental illness and on four ‘red-flag’ scenarios, including where concerns have been raised by families and carers or where patients have experienced psychosis or had an eating disorder.
To ensure any opportunities for learning are not missed, trusts are also encouraged to review a sample of other patients’ deaths, such as those with dementia.
But concerns were raised over the handling of other patient deaths in 2015 after it emerged that in the case of one trust, Southern Health, more than 1,000 patients with learning disabilities or mental health problems over four years had not been properly investigated. The probe followed the death of teenager Connor Sparrowhawk, who had autism.
RCPsych has now drawn up national guidance, which is made up of a Care Review Tool and guidance on how to use it, for the first time at the request of NHS England.
Dr Adrian James, the College’s Registrar, who has been closely involved in the year-long project, said: “This is a really important piece of work.
“Around 2.5 million people are in contact with secondary mental health, learning disabilities and autism services each year and the deaths of many patients will be unconnected to the care they received.
“But it is crucial that ways of improving services are learned from patients’ deaths. Our guidance offers those services a great opportunity to do exactly that.
Liaison psychiatrist Dr Elena Baker-Glenn, from Cambridgeshire and Peterborough NHS Foundation Trust, led on the development of the Care Review Tool, which is a two-stage process and involves filling out a form.
Section one of the form, which should be filled in soon after the patient’s death, includes their details and the four ‘red-flag’ scenarios which should prompt further investigation.
Thousands of people in contact with mental health trusts die each year, with many of those deaths unconnected to the care they received. So a trust will not be expected to review all patients’ deaths; instead they are advised to look at those which meet the essential criteria as well as reviewing a sample of other deaths.
The guidance has proved incredibly successful at trusts involved in the pilot project.
Professor Wendy Burn, RCPsych President and an old-age psychiatrist at LYPFT, said: “I was really impressed with how using the guidance identified potential issues with how we look after our patients.
“It highlighted areas where we could improve the care we give.
Another trust, Mersey Care, found that the guidance much more quickly identified the patients’ deaths which most warranted review. By using it, it took only around 40 hours of dedicated time a month to identify those cases compared to around 100 hours a month under their old system.
Minister for Care Caroline Dinenage said: “Each preventable death is a tragedy and we must learn from every one.
“This new guidance will equip trusts with the tools to more quickly identify areas of improvement, provide more support for families and implement changes to better care for people with severe mental health conditions.
The Care Review Tool and the guidance for using it is published here.
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