It is important that mental health services, as with all parts of the health service, are subject to periodic review or audit where issues of potential concern are identified. Such review processes facilitate services to improve the quality and safety of the care and treatment provided, by identifying any matters of concern and making recommendations as to the steps necessary to address these.
In 2013, as part of its patient safety and quality process, the HSE Mental Health services and Quality and Patient Safety Directorates requested an audit of compliance with regulatory requirements and HSE policies and procedures in relation to the notification and investigation of incidents of sudden, unexplained deaths of persons in community mental health services.
The HSE audit report was completed on 15 January, 2014. The report concluded that, based on the information submitted, the audit team could not provide assurance that incidents of sudden, unexplained death of persons in community mental health services were being notified in accordance with HSE policy and procedures, nor could it provide assurance that incidents of this nature were investigated using the systems analysis methodology.
The audit report made a series of detailed recommendations in relation to the notification, recording and investigation of sudden unexplained deaths of users of mental health services. The HSE is taking steps to ensure that each of these is addressed. In March 2014 the National Director of Mental Health Services issued a memorandum to all relevant managers, re-emphasising the requirements in relation to the reporting of sudden unexplained deaths. Work is under way in conjunction with the Mental Health Commission in respect of two recommendations. The Executive is also working to ensure that the other shortcomings identified are addressed through appropriate performance management and service improvement processes.