Healthcare Safety Investigation Branch, January 2018
This bulletin relates to an investigation of a woman experiencing a mental health crisis who, having presented to her general practitioner, ambulance service and the emergency department of her local hospital, subsequently took her own life. A preliminary investigation reviewed the care pathway of the woman spanning the two years preceding her death. During the HSIB’s preliminary investigation the following safety issues were identified and will form the basis of the ongoing investigation:
- The appropriateness of assessment tools to identify patients at risk.
- Difficulties in the sharing of patient information within the emergency department.
- The emergency department may not be a place of safety for a patient experiencing a mental health crisis.
- Access to psychiatric liaison services
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