Suicide Review Yields Recommendations for State Hospital

Valley News Staff Writer
Published: 2/3/2017 12:18:24 AM
Modified: 2/3/2017 12:06:55 PM

Lebanon — A panel that investigated the suicide of a woman who killed herself just after she was released from the state’s main mental hospital has recommended measures to improve care continuity and coordination, allow more input on discharge and treatment plans and evaluate suicide risk assessment and prevention.

A five-member “sentinel review” panel appointed in September found “areas where there need to be clearer policies and procedures, as well as closer collaboration with the community mental health centers across the state,” Health and Human Services Commissioner Jeffery Meyers said in a written statement.

That sounded right to Suellen Griffin, executive director of West Central Behavioral Health and chairwoman of the state Community Behavioral Health Association, an organization of clinics.

Griffin noted that the state hospital often provides care to a patient for seven to 10 days, while community clinics provide care that can last for years.

The panel recommended various steps to synchronize the work of New Hampshire Hospital, a state-owned, 168-bed facility where Dartmouth-Hitchcock has a contract to provide psychiatric care, and the state’s 10 community mental health clinics.

The state should “include us more intimately in the determination of the discharge and the ongoing treatment,” Griffin said.

New Hampshire law calls for sentinel reviews of any event in which a person with serious mental illness is killed, injured or endangered. The sentinel reports are kept confidential, but after launching the review of the events connected to the July 27 suicide of the 63-year-old Nashua woman, HHS had promised to make public the recommendations of the panel, which was led by a former Vermont regulator and included a former and current judge.

Ken Norton, the executive director of the New Hampshire affiliate of National Alliance on Mental Illness, said that he was surprised that the panel included a lawyer, two judges and someone from law enforcement, while only the chairwoman had a clinical background. Nonetheless, the measures called for, if implemented, could strengthen the state’s mental health care, he said.

The panel suggested improving continuity of care by adjusting the divisions of labor among psychiatrists and other caregivers, establishing a policy for reviewing records of patients’ treatment by outside providers and considering an expanded role for the community centers.

The report was sent to Gov. Chris Sununu and announced on Tuesday. “The protection and care of those who suffer from serious mental illness must be assured at New Hampshire Hospital,” he said in a release.

Sununu, a Republican who criticized the fairness and objectivity of the process in which D-H won its psychiatric services contract last year, said he had directed Meyers to report back in 30 days on his progress in implementing the sentinel panel’s recommendations.

That heartened Norton: “If he holds the department accountable, then this could be a positive thing.”

Some of the new report’s recommendations echoed those in a January 2014 report that was ordered by Maggie Hassan, Sununu’s Democratic predecessor, after a year in which 228 sentinel events occurred. An HHS spokesman said data on the number of sentinel events in more recent years was not immediately available.

The 2014 report described a pair of violent events involving patients being held in the emergency department of Elliot Hospital in Manchester awaiting space for care at New Hampshire Hospital: a July 2013 attack in which a nurse and another employee were critically injured, and an October 2013 incident in which a patient and security guard exchanged punches.

The 2014 report found “a frequent disconnect between the hospitals, the regional mental health centers and other community-based providers.”

It said that the situation had been made worse by “the elimination of liaison positions between (New Hampshire Hospital) and the (community mental health centers), potentially leading to longer periods of hospitalization.”

Each mental health clinic now has a liaison with New Hampshire Hospital, Griffin said.

“We can always improve our communication,” she added, noting that on occasions patients have been discharged without the community health clinics being aware of it.

Improving the relationship between the state’s main mental health facility and the state-supported nonprofits that provide mental health care in communities was a goal of a 2012 lawsuit against New Hampshire officials by advocates and the U.S. Justice Department.

That case was settled with a 2014 agreement in which the state promised to take various stops to improve care, including the expansion of housing and employment supports for people with mental illness and the creation of interdisciplinary “assertive community treatment” teams throughout the state. However, a court-appointed reviewer has criticized the state for failing to meet its targets for assertive community treatment and to keep other key promises.

The reviewer also found that patients continue to regularly end up stranded in hospital emergency departments because of wait lists for treatment at New Hampshire Hospital. During the third quarter of 2016, the average number of patients waiting each day exceeded 31, up more than 30 percent since 2014.

On Thursday, 44 adults and 10 children were waiting in emergency departments, said Norton, citing data compiled by New Hampshire Hospital.

The latest sentinel event report also called for the creation of a new policy under which staff at the hospital or clinics or patients themselves could “raise concerns with the treatment or discharge plan of a patient” and for the provision of confidential and peer support for staff that would not involve their direct supervisors.

The report also calls for consideration of the need for a short-term admissions policy at the state hospital, and for an assessment of the quality of current training in suicide risk assessment and prevention.

The report also calls for the hospital to implement “existing Administrative Review Committee policy.” The committee at New Hampshire Hospital, which was the first of its kind in a nation, was composed of hospital administrators and a lawyer and was designed to provide “a risk management process to mitigate potential liability to the hospital and to treating clinicians,” according to a 2010 paper by Alexander de Nesnera, the interim chief medical officer at New Hampshire Hospital, and David Folks, who last month left that job.

In a 2012 paper, de Nesnera and Folks wrote that the committee was “an integral part of the (New Hampshire Hospital) culture, accepted by clinicians as an added element of support and guidance in treating these challenging patients.”

Rick Jurgens can be reached at or 603-727-3229.

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