Recommendations Of Independent Sentinel Review of July 2016 Suicide of New Hampshire Hospital Patient and Action Taken to Ensure Patient Safety and Quality of Care at New Hampshire Hospital

Concord, NH – Governor Christopher T. Sununu and DHHS Commissioner Jeffrey A. Meyers today announced that DHHS is releasing the recommendations made by the Sentinel Review Panel made in connection with its review of the July 27, 2016 suicide of a New Hampshire Hospital patient following discharge, as well as identifying steps that have been taken to ensure patient safety and quality of care at the hospital.

The Independent Sentinel Review Team was led by Dr. Susan Wehry, a Vermont psychiatrist, and also included retired New Hampshire Supreme Court Justice James Duggan, Judge James Leary of the New Hampshire Circuit Court, retired Assistant Commissioner of Safety and NH State Trooper Kevin O'Brien, and Assistant Attorney General Jill Perlow. The Sentinel Review Team submitted its confidential report to Commissioner Meyers along with the recommendations earlier this month. The work of the Sentinel Review Team was conducted as a confidential quality assurance review under the provisions of RSA 126-A:4 and the federal Health Insurance Portability and Accountability Acts privacy rule, 45 C.F.R. 164.501. The report of the Sentinel Review Team remains confidential. The Department had previously announced that the recommendations resulting from this review would be made public.

"The July 27, 2016 suicide of a patient who had just been released from New Hampshire Hospital raised very significant concerns about the level of care. It was essential that this tragic event be reviewed thoroughly by an independent panel so that any and all necessary steps be put in place to ensure patient safety and quality control at New Hampshire hospital," said Governor Chris Sununu. "Commissioner Meyers has briefed me on the findings of the report and has taken immediate action steps based on the Sentinel Review Teams recommendations, including enhanced suicide risk training for nursing staff, strengthened communication and collaboration between New Hampshire Hospital and community mental health centers, and requiring additional review of discharge plans to which any NHH patient does not agree. It is important to note that new staff in key positions are being recruited as well.

"The protection and care of those who suffer from serious mental illness must be assured at New Hampshire Hospital. I have directed Commissioner Meyers to report to me within 30 days on the steps New Hampshire Hospital and the Department have taken to implement each of the teams recommendations," said Governor Sununu.

"The confidential sentinel review of the July 27, 2016 suicide of a New Hampshire Hospital patient was conducted in order for the Department to understand fully that tragic event and to take any necessary steps to assure patient safety and quality at the hospital. Because the review examines all relevant information, including about the patient, diagnosis and treatment, the review was conducted as a confidential quality assurance review under state and federal law," Commissioner Meyers said.

"I share the Governors deep concern and sense of urgency in addressing the Sentinel Review Teams recommendations. Our Department is committed to ensuring the safety and care of all patients at New Hampshire Hospital. The recommendations plainly point out areas where there need to be clearer policies and procedures, as well as closer collaboration with the community mental health centers across the state," said Commissioner Meyers.

"In connection with the oversight of clinical psychiatric services at New Hampshire Hospital, there is now underway a process to search for a new permanent chief medical officer. Dr. David Folks stepped down earlier this month. Other staff changes at New Hampshire Hospital have also taken place. The Departments effort with Dartmouth Hitchcock to continue to provide the highest quality of care at New Hampshire Hospital is ongoing," said Commissioner Meyers.

The recommendations of the Sentinel Review Team, in the order presented to the Department, are:

• Reevaluate and revise, as needed, collaboration and communication processes between NHH and the community mental health centers. Provide training to staff regarding the need for meaningful collaboration and communication. Consider whether the LEAN program would be an effective tool for implementation of this recommendation. Evaluate NHH policies and procedures to insure full alignment with the transition provisions and in reach activities as outlined in the Amanda D. Settlement Agreement. Provide training to NHH staff on the meaningful implementation of the NHH Transition/Discharge Planning policy and any other related policies.
• Establish a written policy for the method a patient, guardian, community mental health center, or NHH staff member can use to raise concerns with the treatment or discharge plan of a patient. Provide training to staff on this policy and how to recognize when this policy is triggered. Provide information to community mental health centers, patients, and guardians on this policy.
• Implement existing Administrative Review Committee (ARC) policy regarding the types of cases referred for review by the ARC. Provide training to staff on the policy and other available resources, such as clinical case conferences and the central team to address barriers to discharge. Review and revise, as appropriate, policies regarding patient cases requiring review of the treatment and discharge plan by the ARC or any other external or peer review team. Factors that may qualify for review include multiple and frequent hospitalizations, multiple medications, and inconsistency and/or disagreement in diagnoses.
• Restructure the assignment of social workers, nursing staff, and/or attending psychiatrist to provide continuity of care with the same providers across multiple admissions.
• Review whether the community mental health centers should have a greater role in the treatment and discharge planning process since they provide continuity of care to the patient
• Establish individual and confidential support options and a facilitated peer support program for staff that does not involve direct supervisors. Consider whether participation at a regular interval (monthly or quarterly) in a peer support program should be mandatory.
• Establish a policy for determining when to obtain treatment records from outside providers and the most expeditious manner to obtain the records.
• Evaluate whether a policy should be developed and implemented for determining when a patient is appropriate for a short admission to NHH. Consider whether factors such as recent admissions, length of time outside of the hospital, and history with the community providers are relevant to determining whether a short admission is appropriate. Consideration should also be given to how short admissions are integrated with existing transition/discharge policies and the Amanda D. transition provisions.
• Evaluate whether there is adequate competency-based training for suicide risk assessment and prevention and whether such training is based upon best practices. If not, take appropriate remedial measures.