Independent review team offers suggestions for NH Hospital following patient’s suicide

Feb. 01--A team charged with conducting an independent review of the discharge of a New Hampshire Hospital patient who committed suicide hours after her release on July 27 issued a list of recommendations Tuesday, including augmented suicide risk training.

The sentinel review team submitted a confidential report to Department of Health and Human Services (DHHS) Commissioner Jeffrey Meyers, along with the recommendations, earlier this month. Only the recommendations were made public Tuesday.

The review team's recommendations include 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.

Joy Silva, 63, of Nashua leapt to her death from the third floor of her apartment building at 237 Main St. on July 27, hours after her discharge from New Hampshire Hospital. A question that remains unanswered is whether Silva asked to be discharged on July 27, or if she was released at the initiative of doctors.

A request sent to Gov. Chris Sununu's office and DHHS for the details contained in the confidential report by a New Hampshire Union Leader reporter was denied.

"In announcing the sentinel review team last fall, Commissioner Meyers pledged to release the team's recommendations," said DHHS spokesman Jake Leon. "The sentinel review report is confidential under state and federal laws in order to protect patient privacy."

According to a DHHS release, the sentinel review team conducted its confidential quality assurance review under the provisions of RSA 126-A:4 and the federal Health Insurance Portability and Accountability Act's privacy rule, 45 C.F.R. 164.501.

Since 1996 the Joint Commission Accreditation of Healthcare Organizations has had a formal "sentinel event" procedure in place to help hospitals that experience serious adverse events to improve safety following these incidents. The federal policy calls for the review to be done within 45 days of the incident.

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 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," Sununu said in a statement. "Commissioner Meyers has briefed me on the findings of the report and has taken immediate action steps based on the Sentinel Review Team's recommendations. The protection and care of those who suffer from serious mental illness must be assured at New Hampshire Hospital."

"I share the governor's deep concern and sense of urgency in addressing the Sentinel Review Team's recommendations," said Meyers in a statement. "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."

[email protected]

___

(c)2017 The New Hampshire Union Leader (Manchester, N.H.)

Visit The New Hampshire Union Leader (Manchester, N.H.) at www.unionleader.com

Distributed by Tribune Content Agency, LLC.