1. Avon & Wiltshire Mental Health Partnership NHS Trust: Suicide data: open and transparent?
Welcome

2. Welcome
Suicide date: open and transparent?
“Absolute transparency is the key to driving improvements in standards of care. We need to ensure that every single patient receives great care, every time.”
“Our patients and their families and carers will be the judge of whether we are succeeding.”

3. Welcome
Suicide date: open and transparent?
“Never before has change been more important. Absolute transparency is the key to driving improvements in standards of care and we need to ensure that every single patient receives great care, every time.”
Chief Nursing Officer for England, 2013

4. Welcome Sharing organisation-specific suicide information and data.
Suicide date: open and transparent?
Sharing organisation-specific suicide information and data.
Reflections:
Is being open about organisation-specific suicide data an exception? Should it be?
How does your organisation approach this?
How does your management of this information fit with your organisation’s cultural values?
Is there something inherently different about suicide data, as opposed to other data?

5. Situation
External
AWP seen as an ‘outlier’ – “one of the 20 trusts with the highest suicide rates in England”.
Seen as ‘never getting it right’ and failing to learn.
Uncaring.
Negative – lack of confidence in mental health care by current and future service users.

6. Situation Internal Clear sense of hopelessness among staff.
‘Training’ as a solution – re-train, more of the same…
SUI investigations repeat care and service delivery problems.

7. Background Main title slide page
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Aims of our journey
Retain focus on improvement as opposed to ‘more of the same’.
Use information-sharing as a motivator for change and improvement.
‘Own’ our data.
A way of translating the expectation of “absolute transparency” into something tangible.
Visible focus on patient safety and suicide prevention.
One way of tracking improvements in quality.

8. Plan Main title slide page
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Identify like-minded colleagues – engage in conversations about being open.
Time and resources allocated to analysis of data – ie: suspected suicides.
Champions – a lead for the work, executive and non-executive champions.
Ask explicit questions (Q&S Committee) – we need to think about this aspect of our work – no place for avoidance! “Can we publish this work?”
Communication strategy.

9. Do Main title slide page
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Data collection – think about the challenges, as there are lots of them!
Data analysis – prepare for challenges about ‘rates’ versus ‘numbers’. De-contextualised numbers may tell us very little.
Public health context – two thirds of suicide deaths not known to secondary mental health services.
Define ‘secondary mental health services’ – eg: to include IAPT, primary care or private counselling services, etc.?
Preparing to share findings in an accessible format – inherent sensitivities regarding the discussion of suicide data.

10. Study Main title slide page
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Accurate information regarding suicides numbers of people in contact with the mental health service at the time of their death.

11. Main title slide page
Act
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Refine our analysis – eg: provide denominators for suicides by service – suicides per 1,000 service users; aim to pool data across 3 years for items where there are small numbers (eg: time of year).
Suicide prevention as an annual trust objective.
Identification of patient safety actions.

12. Assessment

13. Recommendation Developing staff
Ensuring all practitioners are up-to-date with specific knowledge and skills regarding suicide prevention and effective risk assessment.
Support and encourage all staff to become suicide aware - Zero Suicide Alliance – Suicide Let’s Talk.
Ensure that the learning from any patient death forms the basis for practice and service improvement.

15. Recommendation Improving practice
Develop and implement tools to continually improve risk assessment and risk management.
Provide the most intensive level of follow-up and support for people discharged from hospital.
Relentless focus on getting risk assessment and management right.
Ensure family and carers are able to contribute to, and participate in, risk assessment and management.
Develop care pathways for people with conditions where there is a known increased suicide risk.

16. Take away messages How open and transparent are you?
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How open and transparent are you?
Who do you need to influence in order to address this issue in a meaningful way?
How do you tackle the stigma of suicide if services adopt a parental approach to sharing data?
How collaborative are you prepared to be across the NHS family?

17. Thank you for listening
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Thank you for listening
Welcome
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