Observation

Introduction

A report in The Guardian newspaper in September 1999 told the sad story of a talented playwright called Sarah Kane who committed suicide at the age of 28 (Guardian, 1999). She has been hailed as ‘the young playwright of her generation’ yet her professional success was blighted by a long history of severe depression. In the two years before her death she had been in and out of psychiatric care, and her illness finally resulted in her taking her life. The story is tragic. What is even more tragic is that Sarah Kane took her life when she was in hospital, where she should have been ‘safe’. According to The Guardian newspaper report, medical staff had recognised her suicidal risk as she had been admitted three days earlier after a suicide attempt from taking an overdose of anti-depressants and sleeping pills. However, the two psychiatrists who assessed Sarah Kane did not communicate to nursing staff that she should be observed closely because of her high risk. A psychiatrist told the coroner's court that he ‘took it as read’ that she would be ‘constantly observed’ by nursing staff. The nursing staff therefore had not been ‘directly’ informed that she required special monitoring. Shortly after 3.30 a.m. on 20 September 1999 a nurse found Sarah Kane hanging from the hook inside the toilet door, hanging by a shoelace. She had not been seen by nursing staff for 90 minutes.

We acknowledge that this is just one tragic case, and our intention is not to sensationalise it or make judgements, as none of us knows the full details of what happened. The purpose of discussing this case is that so many of the things that went wrong in the care of Sarah Kane have been highlighted as being endemic in the care of suicidal patients in acute in-patient care. Key findings from Safety First, Five-Year Report of the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (DoH, 2001) bear a strong resemblance to the circumstances that contributed to the suicide of Sarah Kane. Of particular significance are the following findings from the Inquiry: that approximately one-quarter (24%) [Page 163]of people who had committed suicide had been in contact with mental health services in the year before their death; 16% of all suicide inquiry cases in England and Wales (12% in Scotland and 10% in Northern Ireland) were psychiatric in-patients; in-patient suicides account for 4% of all suicides in the UK population; in-patient suicides, particularly those occurring on the ward, were most likely to be by hanging; around one-quarter of inpatient suicides died during the first week of admission. Regarding observation specifically, around one-fifth of in-patient suicides occurred when patients were under non-routine observation (constant and intermittent), and many in-patient suicides were associated with reported difficulties in observing patients because of ward design (24%) and where wards had a shortage of nurses (25%) (Appleby et al., 1999; DoH, 2001).

The main circumstance that is not relevant to the case of Sarah Kane is that she was not being observed closely by nursing staff at the time of her death. But even when psychiatric in-patients are placed on observation, the Confidential Inquiry Report (DoH, 2001) demonstrates that this nursing intervention is not always effective in keeping people safe from harm. Concerns about the standards of care provided in in-patient settings, particularly regarding patients' safety, stimulated the report on which this book is based – Mental Health Nursing: Addressing Acute Concerns (DoH, 1999a) – which was produced by the Standing Nursing and Midwifery Advisory Committee (SNMAC). The concern regarding the practice of observation prompted a focus of the report to review policies and procedures for observation at a national level (England and Wales) and to produce practice guidance on Safe and Supportive Observation of Patients at Risk (Department of Health, 1999b). This guidance, known commonly as the ‘SNMAC Practice Guidance on Observation’, is intended to be a template for local services to use in developing protocols and practice.

...