Critical analysis of a patient safety incident

Assignment Task

Introduction 

In the introduction, it is useful to provide some referenced background discussion about the concepts of risk assessment, human factors, and change theory. Try to relate that discussion specifically to what you go on to discuss in the main body of your assignment. For example, provide some (referenced) discussion about the concept of risk assessment, and then follow that with a brief mention of the areas in your assignment that focus on risk assessment.

Module content 

• Professional governance & accountability as a mental health practitioner

• Risk assessment and management

• The impact of ‘human factors’ such as organisational culture

• Maintaining safety

• Leadership and management, delegation and conflict resolution

• Understanding and reporting serious and critical incidents, adverse effects and near-misses

• Care improvement methodologies and agencies

• Change theory in promoting safety and quality of mental health nursing care

Case Study ‘Gray’

History

Gary is a 38-year-old White British man. He first came into contact with mental health services in April 2022 when he was arrested for making threats to his ex-partner, Darren. Gary was assessed under the Mental Health Act 1983, but was not detained. His behaviour was put down to cocaine use, although Gary denied taking illicit drugs. Darren had told the police at the time that Gary had extreme mood changes, paranoid behaviour, auditory hallucinations and delusions. The staff conducting the Mental Health Act assessment did not contact Darren to obtain his perspective.

Recent events

In July 2022, Gary was assessed under the Mental Health Act 1983 again, and detained under Section 2 for assessment. At that time, Gary disclosed he heard two voices telling him to end his life, and that he constantly had thoughts about wanting to kill himself. He also said that his ex-partner Darren had told him when they lived together that Gary seemed to see and respond to things Darren couldn’t see.

Gary spent two weeks in hospital and was discharged in August to the care of his GP. A discharge letter was sent to the GP summarising Gary’s current presentation, and handing over responsibility for prescribing Gary’s antidepressant (amitriptyline). Prior to his discharge, protective factors regarding suicide were noted as follows: Gary saying he no longer had the thoughts/ voices, that he saw a future for himself, and he stated he had made no plans regarding any attempt to take his life. Gary did not qualify for local authority housing, so he slept in his van, and on the sofas of friends and his ex-partner.

On 20th September 2022 Gary went missing. Due to him not having a fixed abode, it took several days before the alarm was raised. He was subsequently found on 24th September in his van, dead. The cause of death was reported as an overdose of amitriptyline tablets.

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