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Keeping watch

01 September 2012

Mr L, a 22-year-old unemployed man, presented with his parents to the Emergency Department complaining of low mood and thoughts of suicide. He was assessed by Dr P, a junior hospital doctor on-call for psychiatry.

Mr L told Dr P that he had recently experienced the acrimonious break-up of a long-term relationship. He also volunteered a psychiatric history of ongoing treatment for depression starting as a teenager. He said he currently attended regular appointments with a community psychiatrist and was prescribed antidepressant medication.

In the past he had once been admitted to hospital following a deliberate large overdose of paracetamol. During the interview Mr L said he had not written a suicide note but that he had a plan for his suicide. He would not disclose what this was, but said that he was very likely to enact it soon. In view of his current presentation and history Dr P documented that Mr L was at high risk of a further suicide attempt. Dr P agreed with Mr L and his parents that Mr L should be admitted voluntarily to a psychiatric ward.

Mr L arrived at the ward and was seen for a ward clerking by Dr Q, a psychiatry trainee. Dr Q read Dr P’s assessment and also talked to Mr L about his intentions. Dr Q relayed to the nursing staff that Mr L’s supervision on the ward should consist of observations at 15-minute intervals.

That night Mr L went to bed. The next morning he kept a low profile and did not give the nursing staff any cause for concern. There was no ward round that day and the frequency of his nursing staff observations was not reviewed. In the afternoon Mr L received several visitors. As they were leaving he mentioned to them that he was desperate for a cigarette. They were not aware that any items were restricted on the ward and left him with a packet of cigarettes and a lighter.

Later that evening Mr L set his clothing on fire. Although this was quickly extinguished, he nevertheless received serious burns to his legs that required skin grafting. Mr L’s family started a claim against Dr Q, stating that the level of supervision Dr Q recommended for Mr L was inappropriate in light of his suicide risk. Dr Q said that at the time he had seen Mr L he was keen to recommend constant ‘one-to-one’ nursing supervision.

However, he did not as he had recently been told that this level of supervision was only appropriate in exceptional circumstances due to its high cost. No mention of this restriction was made in the notes. The claim was settled for a moderate amount.

Learning point

  • All psychiatric patients require a suicide risk assessment on admission. This should be particularly detailed if a patient has a history of suicidal actions. Some patients, especially those at high risk, will require one-to-one nursing.
  • In times of increasing pressure on finite resources, it is likely that hospital managers and clinicians will be under increasing pressure to keep expenditure under control. However, a doctor’s first responsibility is towards patient safety, so potentially dangerous policies should be clarified with management.
  • If the patient management you consider clinically appropriate is blocked make sure this is clearly documented. If on-call trainees feel their clinical decisions are being inappropriately restricted they should alert the senior who is on-call.
  • For reasons of safety, some items are restricted on psychiatric wards. Transgressions like this should not be possible and appropriate safeguards should be in place. If necessary, at-risk patients should have their visitors restricted.
  • More information about suicide risk management can be found here.