Suicide Prevention
Strategy
2016 - 2019
April 2016
Author: Mike Ventress
www.southwestyorkshire.nhs.uk
SWYPFT Suicide Prevention Strategy 2016-19
Introduction
Suicide and its aftermath can be devastating to those affected and have far-reaching
consequences long after the event. The Trust views suicide prevention and support
to those affected by suicide as one of its key priorities.
This strategy sets out the Trust's intentions over a 3-year period to identify and
engage those at increased risk and to work collaboratively with them, their carers
and partner agencies to provide effective interventions to reduce the risk of suicide.
It takes into account national and local drivers and has been written to complement
the Trust’s overarching patient safety strategy1.
Primary suicide prevention involves building and strengthening protective factors and
increasing resilience to suicide, whereas secondary prevention involves intervening
early when risk factors for suicide have emerged or are emerging, to prevent the
onset of suicide related behaviour. Tertiary prevention (or postvention) entails
intervention for those already displaying suicide related behaviours and their
aftermath. To be effective, this strategy must include elements of all three.
Context
Information relating to people who die by suicide is collected by the National
Confidential Inquiry into Suicides and Homicides by People with Mental Illness
(NCISH) 2 . The Inquiry publishes its findings on an annual basis, along with
recommendations for mental health services about interventions that might reduce
the suicide rate.
According to the NCISH, 70% of people who die by suicide do not have current or
recent contact with mental health services, the remaining 30% having been actively
involved with services or discharged within the preceding 12 months. The overall
prevalence of suicide in England and Wales has increased slightly in recent years,
having shown a downward trend since comprehensive analysis began in 2003 3 .
However, the rate in patients, particularly males, has risen significantly from its
lowest point in 2008.
Where previously clinical commissioning groups had taken a lead locally in suicide
prevention through public health departments, this function was transferred to local
authorities in April 2013. The catchment area of the Trust includes four such local
1
SWYPFT Patient Safety Strategy April 2015
The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness Annual
Report 2015: England, Northern Ireland, Scotland and Wales July 2015. University of Manchester.
3
The NCISH reports on data from 2003, with provisional data only for 2012-13.
2
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authorities; Barnsley, Calderdale, Kirklees and Wakefield. These authorities are at
differing stages of developing local suicide prevention strategies at the time of
writing. Two have recently completed suicide audits to which the Trust has access,
providing information to help target interventions and resources.
The Trust prepares quarterly and annual reports of incidents, including apparent
suicides, in order to identify any trends or patterns which might be the focus of
service development to improve safety. Based on population data from the Office for
National Statistics and NCISH, the expected prevalence of suicide for patients in the
catchment area served by the Trust (a population of 1.2 million) is 31-36 per year.
The actual average prevalence between 2011-15 was 31 4 , although there was
significant variation over this time and a substantial increase to 45 in 2014-15. It is
not clear at this point whether this represents an ongoing trend, however. In keeping
with the national pattern of a reduction in the frequency of in-patient suicides, the
proportion of patient suicides taking place in the community has increased, and in
particular within crisis and home based treatment teams.
The Government has published two suicide prevention strategies, most recently in
20125, highlighting key objectives and areas for action in trying to reduce suicides.
The National Strategy has two overall objectives: a reduction in the suicide rate in
the general population in England and better support for those bereaved or affected
by suicide. There are six main areas of action to support delivery of these
objectives:
1.
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4.
5.
Reduce the risk of suicide in key high-risk groups
Tailor approaches to improve mental health in specific groups
Reduce access to the means of suicide
Provide better information and support to those bereaved or affected by suicide
Support media in delivering sensitive approaches to suicide and suicidal
behaviour
6. Support research, data collection and monitoring.
The Trust is committed to defensible positive risk taking in partnership with service
users and their carers to enable them to safely live their lives to their full potential,
still managing risks to reduce the likelihood of harm. This can lead to greater
independence, choice, support and recovery, while fostering hope and avoiding
restrictive practices and unnecessary interventions.
Many factors contribute to the risk of a person taking their own life and these are
often complex and highly personalised to that individual. However, suicidal thoughts
do not necessarily mean a progression to suicidal acts. It is essential that mental
health services try to understand those problems or concerns that are most relevant
from the service user’s perspective and develop an individual plan in partnership with
them to reduce the risk of suicide.
4
Based on known details of incident at time of reporting, rather than coroner verdict.
Department of Health (2012), Preventing suicide in England and Wales: A cross-government
outcomes strategy to save lives.
5
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NCISH data indicates that about 90% of service users who die by suicide are
thought to have been low risk when last seen by mental health services. Raising the
general level of mental wellbeing and optimising treatments we know are effective
are therefore key components of suicide prevention. Where particular groups in the
population are identified as being at greater risk of suicide we should, working with
partner agencies, work to provide access to the right support at the right time.
Where an intervention capable of reducing the risk of suicide can be provided by the
Trust, we aim to achieve excellence in this regard, for example in the treatment of
mood disorders. However, where resolution of a problem lies beyond the scope of
services provided by the Trust, we will endeavour to ensure that service users and
carers are supported in accessing an appropriate service, often involving partner
agencies.
In addition to avoiding the enormous personal impact of suicide, preventing suicide
has major social and economic implications 6 and the Trust’s role in preventing
suicide extends to supporting other agencies, including primary care, alternative
mental health and social care providers, emergency services, addiction services,
housing, independent and voluntary sectors among others.
Aims of the strategy
The primary aims of this strategy reflect those of the National Strategy, namely to
reduce the frequency of suicide in the population served by the Trust and to support
those affected by suicide or suicidal behaviour.
Objectives
In order to achieve these aims we plan to:
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improve access to mental health services for those at risk of suicide who might
otherwise not have engaged with services.
provide excellent care in treating conditions known to be associated with an
increased risk of suicide.
facilitate access to interventions that will reduce the impact of social and other
factors that contribute to an increased and ongoing risk of suicide.
tailor interventions to reflect key areas identified in the National Suicide
Prevention Strategy.
reflect the needs of the population served by the Trust, based on local authority
and Trust suicide audit data.
incorporate recommendations from the National Confidential Inquiry into Suicides
and Homicides by People with Mental Illness into practice.
complement and support suicide prevention strategies of local authorities.
6
Knapp, M., McDaid D., Parsonage M., (Eds): Department of Health (2011) Mental health promotion
and mental illness prevention: the economic case.
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ensure that lessons learned from every suicide by service users of the Trust
contribute to improving the quality of care provided and efforts at suicide
prevention.
work collaboratively with partner agencies and to make the best use of available
resources in innovative approaches in suicide prevention.
Strategic goals
Culture
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The Trust will raise awareness amongst staff of suicide as a preventable
outcome.
Screening, assessment, formulation and management of the risk of suicide will
be a continuous process, integral to providing safe, high quality care.
The Trust will have a lead for suicide prevention, responsible for coordinating the
implementation of this strategy.
Supporting a service user at risk of suicide will always be based on an individual
formulation of their risks and needs.
Support and interventions for service users at potential risk of suicide will take
account of protective factors and opportunities for safe, positive risk-taking.
Each service in the Trust will be asked to demonstrate how they plan to meet the
objectives of this strategy within their respective areas of influence.
Training
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Every employee undertaking clinical work whose role requires it will have basic
suicide awareness training.
Every qualified clinician whose role requires it will have specific suicide risk
assessment and management training, with a focus on individualised formulation
and intervention.
Initial delivery of training will be prioritised for single point of access, intensive
home based treatment and mental health liaison teams.
Suicide prevention training will include understanding key risk factors and
highlight specific groups at greater risk.
Where appropriate, training will be provided in relation to specialised risk
assessment tools.
Training will be provided on how to use the electronic resources needed to record
and communicate information about suicide risk.
Where appropriate, training will be relevant to specific patient groups (e.g. Child
and Adolescent Mental Health Services, Learning Disability and Older People's
Services).
Training will include understanding the role of the Mental Capacity and Mental
Health Acts in determining appropriate management where a service user is
thought to be at high risk of suicide.
Practice-based suicide prevention training will be an ongoing process for teams
and individuals, as part of their continuing professional development.
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Assessment and formulation of risk
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Initial assessments, including those by telephone, will be guided by an evidencebased common assessment framework to aid decision-making.
Service users and carers will be actively involved in the assessment process and
contribute to a formulation of their risk.
Assessment will take account of factors which are protective in relation to suicide,
in addition to those which raise risk.
Individualised safety plans will be developed, implemented and reviewed in
collaboration with service users at risk of suicide and include carers where
appropriate.
Where a practitioner has doubt about potential diagnosis or treatment, timely
advice will be sought from a suitably qualified practitioner.
Standardised electronic systems will be used to record and communicate
assessments about suicide risk, with additional tools for specific populations
where necessary.
In-patient services
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The Trust will undertake an annual ligature audit of all in-patient areas and
develop action plans to reduce identified risks.
The Trust will ensure that windows in multi-storey buildings to which in-patients
have access have restricted opening.
The Trust Observation and Engagement Policy7 and other relevant policies will
be reviewed in accordance with advice from the National Confidential Inquiry into
Suicides and Homicides by People with Mental Illness8.
Approaches will be developed to reduce the likelihood of in-patient service users
leaving the ward without prior arrangement and to intervene appropriately where
risks indicate this is necessary.
Where discharge is planned from in-patient mental health and learning disability
services a care coordinator will be allocated to those thought to be at increased
risk of suicide prior to discharge.
Assertive efforts will be made to engage service users during high risk periods
after discharge from in-patient units.
All service users with a planned discharge from in-patient services will have a
pre-discharge meeting which will include specific plans for community support
where it is needed. Where discharge occurs without prior planning (for example,
against medical advice), plans to support the service user in the community will
be put in place as soon as practicable.
All medicines on in-patient areas (including those belonging to service users) will
be stored securely in accordance with the medicines code.
Medicines on discharge will be supplied in amounts appropriate to any identified
risk.
7
SWYPFT Observation and Engagement Policy April 2014.
National Confidential Inquiry into Suicides and Homicides by People with Mental Illness (2015) Inpatient suicide under observation. Manchester: University of Manchester.
8
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The Trust will continue to review ways to reduce acute admissions in out of area
placements.
Service users in the community
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A systematic approach to establishing contact with service users who have left
the care of the Trust unexpectedly will be implemented, using telephone, text
messaging and email, as well as letters.
Contact will always be made (and followed up) with a service user’s GP where
they have unexpectedly left the care of the Trust.
The risk of suicide will be clearly communicated to all of those involved in the
service user’s care on discharge from an in-patient unit or from a period of
intensive home-based treatment, subject to ordinary confidentiality considerations
and in discussion with the service user.
Where a service user has made a recent apparently serious attempt at suicide,
options for further support and intervention (for example admission or home
based treatment) will be guided by a structured decision support tool.
Where a service user presents with a history indicative of a current increased
suicide risk he/she will always be assessed in person before any decision is
made not to offer a service from the Trust.
Systems will be developed to maintain contact with service users offered
psychological interventions where suicide is thought to be a significant longer
term risk but there is a substantial waiting time for therapy and the service user
has no other contact with the Trust.
Intensive home based treatment services will be used appropriately and
effectively for those at risk of suicide and, as an alternative to in-patient care,
skills and contact time will reflect this specialised role.
Community treatment teams will ensure that service users who are thought to be
at increased risk of suicide are discussed regularly by the multi-disciplinary team
within the service.
Clinical interventions
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Clinicians will be vigilant for evidence of untreated or undertreated depression.
Psychological, pharmacological and physical treatments for mental illness will be
in keeping with national and local guidelines, with a particular focus on excellence
in treating depression, whether occurring in isolation, as part of, or in addition to,
other mental or physical disorders.
Practitioners will be aware of and attempt to limit access to means of suicide,
liaising with primary care where necessary. Where prescribing medicines with a
high risk of toxicity in overdose, care will be given to prescribing less toxic
alternatives and/or limited quantities.
The Trust has a system in place to identify prescribing of dosulepin and will
continue to work with primary care to reduce its use in general practice.
Interventions provided to those with personality disorder will reflect the increased
risk of suicide in this population.
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Service users engaging in repeated self-harm will be offered a psychological
assessment with a view to understanding/reducing/stopping this behaviour.
The intensity of interventions and monitoring will reflect key periods of increased
risk for discharged in-patients, namely 48 hours for those admitted due to high
risk, the first week and then three months after admission in particular.
Practitioners will seek peer review of cases where the risk of suicide is thought to
be high.
Transitions in care between emergency departments, primary and secondary
care, inpatient and community care, will be planned and communicated clearly to
those involved.
Dual diagnosis
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Where service users are involved with dual diagnosis/addiction services,
representatives of such services will always be invited to contribute to overall
care planning for a service user, unless there is a clear reason not to do so.
Trust services will communicate with dual diagnosis/addiction services where the
latter prescribe psychotropic medication, to avoid duplication or risk of toxicity.
Intoxication will not constitute a reason not to engage or provide a service to a
service user in order to keep them safe where there is thought to be a significant
risk of suicide.
Where there are indications of substance misuse problems, a referral to or
support in accessing dual diagnosis/addiction services will always be considered,
after a thorough assessment of the nature and extent of these problems.
Opportunities to increase the skills of practitioners within community teams in
relation to supporting service users with substance misuse problems will be
identified.
Support
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Carers will be provided with information to help them understand the reasons a
service user might be at risk of suicide and how they can help.
The views and concerns of carers will always be sought where there is an
identified risk of suicide unless there are clear reasons not to do so.
Carers will be invited to contribute to, and be part of, crisis plans unless there are
clear reasons not to do so.
Appropriate support will be available to users and carers affected by suicide or
suicidal behaviour.
Where required, a clear route to alternative non-Trust services which support the
bereaved will be provided.
Staff affected by suicide will have timely and appropriate support available, both
on a team and individual basis.
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Collaboration
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The Trust will engage with vanguard groups and local authorities in health
promotion, helping to reduce stigma and promoting access to mental health
services, including to those less likely to use services.
The Trust will be a key contributor to a multi-agency suicide prevention forum
across South West Yorkshire to share best practice and to plan partnership
approaches to suicide prevention.
The Trust will work in partnership with leads in local authorities to support
implementation of relevant aspects of their suicide prevention strategies/action
plans.
Providers of primary care will be engaged to identify areas in which the Trust can
work in collaboration in reducing suicide risk in the community.
The Trust will contribute to efforts to reduce the occurrence of suicide attempts at
high-risk locations, along with transport providers and emergency services.
All staff will have access to an up-to-date directory of services towards which a
service user can be signposted where a specific need cannot be met by the Trust
(e.g. addiction services, debt management, Citizens Advice Bureaux,
bereavement counselling etc.).
British Transport Police (BTP) develop suicide prevention plans for those
identified through their service as being at risk of suicide and the Trust will
explore with BTP the role it can have in supporting this initiative locally.
The Trust will take opportunities to ensure that reporting of issues related to
suicide and mental health in the local media is both responsible and balanced.
Improving mental health in specific groups
The Trust recognises that there are groups of people who may feel marginalised,
who may be less likely to access healthcare generally or seek support with their
mental health, and who may have particular mental health needs. These include
people from black, Asian and minority ethnic groups, LGBT people, veterans, those
with long-term physical health problems, prisoners and young people leaving care. In
addition, particular groups of people may be identified through the National
Confidential Inquiry, for example young and middle-aged males, as having a greater
risk of taking their own life, but where many additional factors have either a direct or
indirect effect on this risk.
The Trust commits to working with them and with partner agencies to understand
and respond to their specific needs, supporting them to engage with health and other
services.
Learning, research and monitoring
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The Trust will keep a continuous database of all suicides and suspected suicides
that occur within its services so that any themes and trends can be identified at
an early stage.
The Trust undertakes to learn from incidents where suicide or near misses have
occurred, using a consistent and robust investigative framework.
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Learning will be shared with carers, teams directly involved in incidents and
across the wider Trust in a format which can readily be translated into changes in
practice.
Where evidence exists of successful intervention strategies in other
organisations, nationally or internationally, the Trust will review their applicability
to its service user population and where appropriate implement them accordingly.
Information from local authority suicide audits will be used to inform service
planning locally.
The Trust will provide data which supports wider analysis of trends or factors
associated with completed and attempted suicide, both locally and nationally.
We will support research and innovation within and beyond the Trust which aims
to better understand ways of preventing suicide and the needs of those at risk of
suicide.
Implementation and evaluation of the strategy
This strategy sets out our ambitions to improve the quality of care we provide to
those at risk of and affected by suicide. We will use both qualitative and quantitative
information, feedback from key stakeholders and narratives from patients, carers and
staff to achieve this.
The Trust will implement, monitor and evaluate progress made against the patient
safety strategy by:
1. Identifying a Trust lead for the implementation, monitoring and evaluation of the
strategy.
2. Forming a dedicated implementation group to include key stakeholders that will
regularly monitor progress and evaluate outcomes, reporting to the Clinical
Governance and Clinical Safety Committee.
3. Identifying suicide prevention leads in each of the BDUs, who will be asked how
they plan to implement and achieve the aims of this strategy
4. Developing a SMART implementation plan that highlights short, medium and long
term goals and which takes account of the process of transformation of Trust
services.
5. Identifying and securing additional resources and specialist advice as required.
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