A retrospective case analysis of serious untoward incidents in super catchment mental health services in the HSE South East

Crowhurst, Neil (2023) A retrospective case analysis of serious untoward incidents in super catchment mental health services in the HSE South East. Masters thesis, SETU Waterford.

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Serious untoward incidents, occurring in the context of mental health services and mental disorder, continue to attract widespread concern amongst professionals, policy-makers and the wider population. Such occurrences can range from the most serious incidence of violence and self-harm in communities to more minor but often pervasive and distressing incidents of violence/aggression/self-harm occurring within inpatient or long-term residential health settings. Mental health services, internationally, have sought to reduce or limit such occurrences through the implementation of risk management and patient safety strategies. This study examined serious untoward incidents occurring within mental health services in the South East of Ireland over an 8 year period. Utilising a database of staff-completed incident report forms and with access to relevant patient charts, the study examined and analysed incident types, prevalence, patterns of activity and contributing/contextual factors. A mixed-method design was utilised, using the established research methods retrospective chart review and content analysis. A sample of 325 patients charts were examined with analysis supported by statistical testing. Violence and aggression was by far the most widely reported incident type, with occurrences of self-harm mainly limited to acute psychiatric services. Inpatient care was the predominant location for untoward incidents with a pervasive level of violence and aggression relating to longer stay and older adult units. Whilst patient factors such as acute mental disorder, history of trauma and external pressures were recognised as contributory factors in the incident reports studied, a number of other areas relating to clinician-patient interaction and organisational/environmental factors were also considered. The potential for conflict or ‘flashpoints’ occurring was a significant finding of the study, particular conflict occurring amongst patients and violence and aggression in the context of direct clinical care. Issues of safety, security and risk are considered in relation to the study findings, in addition to an analysis of the various systems in place governing mental health service provision.

Item Type: Thesis (Masters)
Uncontrolled Keywords: Mental health services, HSE
Departments or Groups: *NONE OF THESE*
Divisions: School of Health Sciences > Department of Nursing
Depositing User: Derek Langford
Date Deposited: 27 Sep 2023 13:14
Last Modified: 27 Sep 2023 13:14
URI: https://repository.wit.ie/id/eprint/7745

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