National Confidential Inquiry

Sir: Following the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (Appleby et al, 1999) we compared our services to the recommendations made for follow up of high-risk patients discharged from in-patient care.

Of 158 admissions to our service between 1 August 1999 and 31 January 2000, 40 were identified as high risk because they required one to one continuous nursing supervision. Eleven were offered follow up within 48 hours, 25 between 48 hours and 4 weeks and one after 4 weeks after discharge. Three had no follow up arranged. Twenty-three patients had trial leave before discharge.

Care Programme Approach was completed in 38 cases and six patients had the risk assessment form completed at discharge. Thirty-seven patients had discharge summaries — one recorded the nature of risk and two the need for special observation during admission. Thirty-eight patients were discharged with medication supply of less than 14 days and one with 19 days (missing data=1).

Following discharge, seven patients were involved in nine adverse incidents (seven overdoses, one suicide and one violence to property). Three of these adverse incidents occurred within 1 week of patient discharge and two of these patients had follow-up appointments within 48 hours, including the patient who committed suicide.

Seventy-three per cent did not meet the recommended guidelines for follow-up; 95% met the guidelines for 2-weeks supply of medication. There was a lack of documentation in discharge summaries of the nature of risk. Risk assessment forms were not completed on discharge in 85% of cases.

We have concerns that the recommendations are not being adhered to locally and suspect our service is similar to others nationally. To implement the recommendations considerable changes need to be made to existing practice.