The head of the island's mental health service is planning to meet the family of a "much-loved" 23-year-old man whose suicide has sparked calls for urgent improvements in staff training.
A Serious Incident Review was carried out after the man, who required hospital treatment following a suicide attempt, was able to leave the building without anyone noticing before taking his own life in 2019.
Andy Weir, Director of Mental Health and Adult Social Care, confirmed that all the recommendations had been accepted by the department and work was being undertaken to ensure improvements are made in the provision of mental health care, both within the hospital and the wider service.
"This has been a terrible, tragic death and I cannot begin to imagine the impact that has had on this man's family. I want to offer my condolences to them," he said. "I have written to ask if I can meet them. I would like to speak to them about the recommendations and what we are doing to make improvements."
Pictured: The inquest was heard at Morier House earlier this week.
The findings of the serious-incident review, carried out by UK-based consultant psychiatrist Dr Paul Myatt, were heard during an inquest into the man's death this week.
Among the recommendations were the need for an updated suicide prevention policy and appropriate training for staff. Dr Myatt also suggested that 'serious consideration' be given to introducing mandatory training for all staff working in healthcare, as is required by law in the UK.
As part of her ministerial plan for 2023, Health Minister Karen Wilson has committed to provide an updated suicide prevention policy which will 'focus on preventing suicide and reducing incidence of self-injury associated with mental distress'.
As part of his review, Dr Myatt spoke to staff at the Hospital about general arrangements for mental-health patients who needed to be cared for in a medical ward.
Mr Weir said: "The recommendations have been accepted. Some work has been undertaken in relation to these recommendations and a couple of them have been fully completed while some work is still in train.
"Obviously, the key to all of this is how care is provided for people with mental health needs when they need to be in the General Hospital."
The inquest heard that the man had been assessed as being at "low risk" following admission to the Hospital and it was not considered necessary for him to receive one-to-one supervision.
Mr Weir said: "General nurses are highly-skilled professionals but are not mental health specialists and will need to be supported to provide the mental health care required or that care will need to be provided by a mental health professional.
"This is not just a problem here."
He added that the policy around whether supervision is required had been reviewed in 2020 and that "work has been done this year to totally overhaul that policy' and was currently going through a consultation phase.
"As part of our redesign of community and mental health services we are going to introduce a seven-day-a-week mental health nurse at the Hospital. This builds on the report and will make sure those nurses in the Hospital have the support they need."
He said work is being carried out to ensure better staff training to ensure quality of care for patients with mental health needs. This includes online training courses – which have been made available island-wide – as well as more intensive training in certain key areas.
"This is for when someone is on a one-to-one that we make sure we provide training for those staff to undertake that work. Often is can be someone who does not know too much about mental health.
"We have begun that but there is more we need to do in this area. There is an online course and we are encouraging staff to do that. Another piece of work we are doing around this is we are thinking of developing a small group of staff who, if you like, will kind of major in this and give them some really intensive training."
He added that the training provided would be tailored depending on which area of the Hospital the member of staff worked in.
The way risk assessments are carried out are also been overhauled already, Mr Weir said.
"Risk assessments at this time of this incident were categorised as high, medium or low – modern risk assessments would not do that. Risk changes – a risk level might be low today but not be by tomorrow. We have totally redesigned our risk assessment model."
Relief Coroner Advocate Cyril Whelan said during the inquest that the "real heart of the problem" was in the "difference between the two disciplines of mental and physical care". He added that the "reality is that Portelet Ward is a medical ward; it is not a psychiatric specialist ward and that's not its function".
Mr Weir said: "The report makes clear recommendations where we need to learn and I am really committed to it. It is so important that we do do things differently where we can and always look to improve."
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