20 Dec 2012 | Adverse Events
The annual District Health Board serious and sentinel event (SSE) report released from 2006/07 to 2009/10 included cases of suspected suicide by users of outpatients mental health services within seven days of contact with the service. The mental health sector advised the Commission in late 2011 that the inclusion of these cases in the SSE report was inappropriate. In addition, the sector advised the Commission that use of root cause analysis (RCA) methodology to review the cases was also inappropriate.
The Commission agreed with the sector representatives, and charged a working group with recommending alternatives to RCA and public reporting for serious incidents involving users of mental health services.
In July 2012, the Commission Board accepted the recommendations that are set out in this document as the process to follow for local review of adverse incidents involving users of mental health services.