This learning from reporting section, taken from Quarterly Data Summary Issue 7, focuses on absconding and missing persons, sexual safety and ligature points in relation to mental health. It considers incidents which took place between October 2006 and September 2007 and suggests initiatives which address each of these areas.
There were 8,743 reports of incidents involving mental health service-users who went missing or absconded from acute mental health inpatient settings. The Missing Patients Toolkit, which is aimed at mental health units, acute and community hospitals, is intended to help trusts review and improve policy, procedure and practice in relation to patients who could be harmed if they went missing from inpatient care.
There were 887 incident reports which related to sexual safety, including alleged rape or sexual assault, exposure, sexual advances, touching, harassment and consensual sex.
Initiatives in this area include the National Patient Safety Agency (NPSA) Response Team identifying all allegations of rape and sexual assault, and passing these to the relevant clinical team for follow-up.
Finally, 17 incidents were reported which related to attempted hanging from curtain and shower rails. The NPSA has contributed to the National Mental Health Risk Management Programme and produced guidance which includes assessment for self-harm and suicide.