The cost of failure

You may not have heard of the hundred families’ organisation. They are involved in campaigning, training and offering support to families bereaved where the victim has been killed by someone in the care of mental health services. They have produced a new guide for families affected by such tragedies. The guide is available at: http://www.hundredfamilies.org/wp/wp-content/uploads/2015/12/HF_informationBrochure-web.pdf. Part of the work of the group is working with mental professionals to try and prevent tragedies in the future. One of the sections in the guide I think is worth circulating amongst all organisations provide care for people with mental health problems is on the findings of inquiry reports where a number of messages emerged. Making sure we learn lessons from tragedies is a topical issue at the moment. These are some key themes that emerge where services have failed their users:

Failure to keep decent and accurate records

One of the first questions when there is any kind of investigation will be ‘where’s the file?’ I’ve said before in previous blogs, if it’s not recorded how do we know it happened? The message is wider than that though, how will other people and other agencies know about risks and incidents if they are not written down.

Failure to do adequate care planning

The principles of care planning should be well known. Effective care planning is based on thorough assessments, and a planning of care that involves users and their families.

Failure to do adequate risk assessments

Perhaps surprisingly there isn’t a national template for risk assessments. However, the most important thing is to ensure you are undertaking risk assessment as part of the assessment and care planning process. The Department of Health’s guide Best Practice in Managing Risk gives sixteen straightforward pointers to making sure your risk assessments are sound. Most important of these perhaps is that your risk plans are only any good if you communicate the plan to others. You can find this guide at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/478595/best-practice-managing-risk-cover-webtagged.pdf.

Failure to listen to the family

Whether we find it helpful or not to work with some families, they have the benefit of a lot more knowledge and experience of the person than we do. The operative word is listen.

Failure to follow up missed appointments

This is a very common theme. Because someone misses an appointment doesn’t necessarily mean the person doesn’t need further care and support. It may mean the person’s mental health is deteriorating.