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Investigation into thev provision of mental health care to patients presenting at the emergency department

Independent report by the Healthcare Safety Investigation Branch

The reference safety event

Diane, a 57-year-old woman with a history of mental health problems, was in the care of the community mental health service. As her mental state fluctuated, she experienced increasing levels of anxiety, self-harmed and expressed thoughts of suicide. Over a two-year period she had received treatment from her GP, the local crisis resolution and home treatment team, the ambulance service and the emergency department of the local district general hospital.

Diane presented four times to the same emergency department following self-harm, receiving different levels of care on each occasion. Her physical health was generally well attended to by the emergency department staff. National guidelines recommend those who have self-harmed should receive a psychosocial assessment from a specialist mental health professional. The liaison mental health service team was located close to the hospital and was commissioned to operate between 08:00hrs and 23:00hrs; Diane was referred for assessment on the first two occasions but not thereafter.

Consequently, the community mental health team was unaware of Diane’s crises when she attended the emergency department following self-harm on the last two occasions.

Six weeks after she had presented to the emergency department for the third time she received a visit from her care co-ordinator.

After this visit Diane reported she had taken an overdose and the next day presented to her GP who advised her to go to the emergency department. However, she did not go there and later that day her carer called 999. Diane arrived at the emergency department by ambulance at 20:19hrs. Following prolonged pressure on services, the emergency department was on ‘black status’ and experiencing its busiest day of the month.

After waiting for almost one hour, Diane was assessed, and her self-harm was recorded. The clinical notes remark that she wanted to go home. Her physical health was attended to; however, no referral was made to the liaison mental health team and Diane left the department sometime in the early hours of the morning. Later that morning she attended her GP practice for a repeat prescription but the GP was reluctant to prescribe, and deferred the decision until later that day.

In the early afternoon, Diane left a note on the railway station platform before lying in the path of an oncoming train. Following treatment at the scene, she was airlifted to a major trauma unit, where she died from her injuries.

There is a strong link between self-harm and suicide. Diane’s case highlights the challenge to the healthcare system when treating people experiencing a mental health crisis. Emergency departments treat approximately 220,000 cases of self-harm a year. The Five Year Forward View for Mental Health is attempting to address this situation by increasing the presence of liaison mental health services in acute hospitals.

Following an initial investigation which reviewed Diane’s four presentations to the emergency department, HSIB progressed to a full investigation. As part of its investigation, the HSIB conducted a series of observational studies, interviews and discussions with subject matter experts to establish how risk to mental health is assessed and then managed nationally in the emergency department.


  • Diane did not come to direct harm during treatment in the emergency department.
  • Diane’s final two presentations at the emergency department represented missed opportunities to intervene and to take measures that may have helped to improve her mental state.
  • The provision of liaison mental health services was variable across England and there was no consensus on commissioning models.
  • Liaison mental health services had a positive influence on managing the care of patients in the emergency department and were most effective when services had a permanent integrated presence in the emergency department.
  • The benefits of liaison mental health services were difficult to quantify in financial terms for commissioners. However, they were broad and stemmed from the integration of mental health professionals in the general hospital and the consequent shift in attitudes towards understanding the complexities of mental health.
  • The process for triage and initial assessment completed by emergency department nurses was effective at identifying physical health problems but lacked structure when assessing mental state.
  • There was the potential for misunderstanding in the self-harm guidance around interpretation and use of the Australian mental health triage tool.
  • The national guidance issued to emergency department staff for the initial assessment of people who have self-harmed lacked coherence between documents and did not consistently describe a detailed process.
  • In the absence of clear national guidance on the conduct of initial assessments, emergency departments continued to use locally developed, unvalidated tools of varying standards.