Patients at risk of self-harm: continuous observation

The aim of this investigation is to help improve patient safety in relation to the use of continuous observation with adult patients in acute hospital wards who are at risk of self-harm. It includes a real patient safety event, referred to as ‘the reference event’, through which to explore the use of this intervention in reducing the risk of patients self-harming.

Self-harm – where a person intentionally hurts themselves through self-poisoning or injury, irrespective of the apparent purpose – is one of the commonest reasons for people attending an acute hospital (a hospital that treats physical rather than mental health problems). Continuous observation is one method that is used to keep people who are at risk of self-harming safer while they are in a hospital ward.

This report uses the term ‘continuous observation’ to describe the practice where one or more members of staff continuously engage with and observe a patient to reduce their risk of self-harm. It is commonly used in hospitals as a way for staff to monitor and assess the mental and physical health of a person who might harm themselves.

The reference event involved a patient called Emily-May, who was at high-risk of significant self-harm. Emily-May was being cared for in a mental health hospital where she was detained under the Mental Health Act to allow for her mental disorder to be treated. Emily-May was taken to an acute hospital after self-harming, where she had surgery to repair her wounds and stayed in an intensive care, and then a high dependency unit. A high dependency unit in an acute hospital looks after patients who need more intensive monitoring and treatment than is possible on a general ward but slightly less than that given in an intensive care unit.

While in the high dependency unit, Emily-May self-harmed while two members of staff were continuously observing her.

The investigation of the reference event found a range of factors that may have influenced the effectiveness of continuous observation at preventing patients in an acute hospital setting from self-harming.

The reference event was referred to the Healthcare Safety Investigation Branch (HSIB) by the acute hospital that cared for Emily-May. An investigation was undertaken to explore the activity of continuous observation and its use in reducing the risk of patients self-harming while being cared for in a hospital ward.

The investigation engaged with three acute hospitals; three mental healthcare providers; specialist staff; and national bodies (such as government departments and professional bodies) that influence policy and strategy within the NHS.

• There is a lack of evidence about how to optimise the safety and quality of continuous observations of adults, or when it is most appropriate to use this intervention.
• Decisions about when to use continuous observation are made at healthcare provider level. This is because there are limited national guidelines and standards on when and how continuous observation should be carried out, and a lack of clear guidance on the training needs and competencies of staff doing this.
• Variation exists within and across healthcare settings in the terms used to describe continuous observation, its purpose, when it should be used, how it is done, and which staff carry out this intervention for patients at risk of self-harm.
• In order to create the conditions in which staff can best carry out continuous observation, consideration of human factors principles is needed to understand the complexities of this intervention and the environments in which it may take place.
• Formal processes are often not in place to anticipate and support effective collaborative working where mental health staff work alongside physical health staff in an acute hospital to provide care to a patient at risk of self-harm.
• When staff caring for a patient at risk of self-harm have witnessed a significant self-harm event this can be traumatic and staff cannot always access the support that they need.