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The NHS must begin investigating the deaths of over 100,000 mental health patients annually, with the aim of reducing the number of deaths related to poor care.
The 54 mental health trusts in England were invited to examine each death to learn from the mistakes.
In the future, they should further investigate cases in which the patient might have received poor or unsafe care, particularly if he was suffering from bipolar disorder or d? a disorder of the diet.
The Royal College of Psychiatrists has written for the first time on the subject and is supported by the NHS England. It is supposed to put an end to the existing ad hoc system under which different trusts examine more or less important numbers of deaths.
"We hope this will improve care, save lives and rebadure friends and family who have lost a loved one and tell them that if they have concerns, they will be implemented. [by the trust which was providing care]Said Dr. Adrian James, college clerk.
The inability of mental health trusts to investigate the deaths of patients became a problem in 2015 when it became apparent that Southern Health Trust had not examined the deaths of approximately 1,000 patients with autistic disorders or with learning disabilities.
His failures were highlighted by the bad care he gave Connor Sparrowhawk, an 18-year-old boy with epilepsy and autism, who drowned in a bath at the Oxford Foundation's premises. at Slade House after his doctor made 39 different mistakes.
Under the leadership, one of four "red flags" will automatically trigger a thorough investigation by an experienced trusted doctor who would not have supported the deceased patient.
These are family members or staff members who have expressed concerns about the care of the deceased and any patient who has recently suffered from psychosis or an eating disorder.
An investigation will also be mandatory when a patient has recently been treated in a psychiatric ward or was taken in by a crisis team or home treatment team at the time of death.
Louis Appleby, professor of mental health at the University of Manchester and director of the National Confidential Inquiry into Suicide and Mental Health Safety, welcomed the decision.
"It's two things: learning about what's wrong and the public responsibility of public services," he said.
"Families can be extremely frustrated by the repetition of" lessons learned "after a tragedy. Here is an attempt, a practical process, for this to happen.
"Big studies are one way but the examination of individual cases can bring crucial details – gaps in care that can be corrected for the safety of others."
The Guardian revealed in March that at least 271 mentally ill patients in England and Wales had died since 2012 after mistakes by NHS trusts.
Dr. Panchu Xavier, deputy medical director of training journals at Mersey Care NHS, said his confidence – one of the 11 involved in steering guidance – uses it to review 350 400 deaths per month.
As a result, he recently increased the number of topics to be revised from three or four to eight or ten per month.
"The supervision of the college has been extremely effective. We found that the red flag system highlighted all the most urgent cases and saved us hundreds of hours of staff time. "
Barbara Keeley, Minister of Mental Health, said, "These guidelines will provide families of people with mental disorders with the essential badurance that the deaths of some of the country's most vulnerable patients will be addressed. of an investigation and that these heartbreaking cases can be prevented from occurring in the future. "
Caroline Dinenage, the Minister of Care, said, "Every preventable death is a tragedy and we must learn from each one of them.
"These new guidelines will provide trusts with the tools they need to identify areas of improvement faster, provide more support to families, and implement changes to improve the care of people with serious mental health issues."
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