Method and analysis
The objective of the investigation and analysis was to describe factors that can lead to children and adolescents who need it not always being identified and provided with appropriate healthcare. The investigation was based on and described an individual event relating to an adolescent with undiagnosed mental health issues. We started the investigation by contacting this adolescent’s next of kin and interviewed them first.
During the discussion we have elevated our findings to a thematic level.
The investigation has been based on the collection of information from interviews, medical records, publicly available documents, figures and statistics, specialist literature and dialogue with professional communities. The information has been sorted and analysed to identify any findings that may shed light on causes and risks.
Interviews and written documentation
Interviews were conducted with a total of 13 people who had been involved in the event in question. The interviews included parents, the GP, educational and psychological counselling service employees, CAP employees, the school nurse, a social educator (youth worker), the head of municipal affairs, the chief municipal medical officer and the head of the inter-municipal cooperation.
The interviews and the document review formed the basis for the topics highlighted in the report. The interviews were semi-structured but with an emphasis on open, exploratory questions.
All interviews were recorded and subsequently transcribed. In some cases, supplementary information was obtained by telephone. The purpose was to clarify any ambiguities and to quality-assure the information we chose to use.
Figures
We obtained figures in order to investigate the variation in referrals and activities within the CAP field. The figures were collected from the Norwegian Directorate of Health, department for health registers, NESTOR (48) and board issues and internal audits in regional health trusts. The abovementioned parties have obtained figures from the Norwegian Patient Register and the Municipal Patient and User Register. According to the Norwegian Directorate of Health, the activity data has only been used to a limited extent in the past and has not yet undergone quality assurance. Nevertheless, HIB has found that all figures can be used to highlight the variations described in this report.
Other sources
We have been in contact with professional specialists in the municipal health service, specialist health service, the Norwegian Association of Local and Regional Authorities and the Norwegian Directorate of Health throughout. We have also familiarised ourselves with publicly available documents and we have been in contact with various professional communities in order to obtain knowledge of the challenges involved.
Analysis and causalities
Based on interviews and obtained documents, we examined the material with a special focus on identifying risks, known as top events (52), for patient safety. Factors that stood out were highlighted and sorted into various categories for breakdown and compilation into (meaningful) units as the basis for further analysis and processing (53).
The risk areas were assessed using a bow tie approach in order to highlight reasons why children and adolescents do not always get the help they need. We have considered these causalities in the report and refer to them as risk areas.
When a serious event occurs, the picture that can explain what went wrong and why will often be complex. Several safety barriers are required to prevent serious events. A bow tie approach can be useful in order to identify both risks and a lack of barriers, as well as to present multifactorial causalities. The analysis must also provide the basis for making recommendations (54).
Validity requirements
In questions about the reasons why an event occurred, hindsight is often a source of error that it is important to be aware of. It is not possible to test the causal explanations. In order to support our understanding of the causalities and the necessity of the recommendations, we have assured ourselves of the following:
- Descriptions, findings and recommendations have been presented to the informants.
- The explanations can be linked to documentable events or phenomena as they appear in written reports, specialist literature and/or statements in interviews.
- Findings and recommendations have been discussed with user organisations, other interest groups, unions, undertakings and professionals at both a clinical and authority level. Overall, we have been in contact with a total of 19 different service providers throughout the investigation and the final round of input. Each service provider has been represented by one to six people in meetings with us and there have normally been around four people present at meetings. The input we have received has helped shape the report. Throughout the investigation, we have engaged in dialogue with and received useful input from HIB’s reflection panel (55).