Preventing suicide A toolkit for community mental health
Foreword Over a quarter of people who take their own life have been in contact with mental health services in the previous year. While much improvement has been made over the last 15 years in reducing the suicide rate, there is no room for complacency. It is vital that community mental health services have the right risk management systems in place. As the Government outlined in its Consultation on Preventing Suicide in England, risk management ensuring that any potential for suicide is identified and addressed before it is too late is an integral part of good clinical care, not an extra. The service users journey may take them through community and inpatient mental health services, acute hospital services and primary care. At each step on that journey there needs to be understanding of what took place previously and what support is presently available to that individual, so that the right care can be provided in the future. This audit toolkit will help services to check whether that continuity is in place. The National Patient Safety Agency has developed this toolkit to build on the achievements of their inpatient suicide prevention tool and in recognition that suicide prevention is not just an issue for acute services. Developed in cooperation with community mental health teams, this toolkit reflects the circumstances and needs of service users as they move between different parts of the health system and into the community. I am pleased to commend this toolkit to community mental health services. Please make use of it to continue to drive up the quality of care. Professor Louis Appleby National Director for Mental Health
Contents Overview and instructions 2 The standards 4 Standard 1 General 4 Standard 2 Risk assessment 5 Standard 3 Care Programme Approach (CPA) patients 6 Standard 4 Non-CPA patients 7 Standard 5 Engagement and suicide awareness 8 Standard 6 Family and carer involvement 9 Standard 7 Discharge and transfer 10 Standard 8 Ligature point awareness 11 Useful resources 13
2 Preventing suicide: A toolkit for community mental health Overview and instructions This section gives details of how to use the toolkit, including an explanation of the assessment tools and the use of case note review, and an example completed audit form and checklist. The eight standards are then set out, and a list of useful resources. All the documents are available to download from www.nhsconfed.org/mhn The standards The eight standards are organised to look at the process of admission through to discharge of a working age adult. Accompanying these standards are detailed audit procedures which will help you measure your current practice and identify areas for improvement. It is necessary to read through each of the standards prior to commencing the general audit tool, in order to provide you with a more detailed context for each standard criteria. Assessment the general audit tool The general audit tool provides an annual method of tracking and measuring the level of care provided to patients at risk of suicide or self-harm. It provides a comprehensive view of the level of adherence to the suicide prevention standards contained in the updated toolkit, and combines a review of trust policy, environmental and patient risk assessments, and the review of a small sample of patient records. It is recommended that the general audit tool is used on an annual basis. The general audit tool contains: a performance summary and performance dashboard that are automatically generated after completing responses to each of the questions audit questions relevant to each of the eight standards an action plan that lists all actions that have not reached 100 per cent compliance in the sample of inpatient case notes reviewed. It is recommended that the general audit tool is undertaken on an annual basis. It is also recommended that organisations print the performance summary worksheet to provide both front-line staff and the board with regular feedback on the level of care. However, if your trust has a well functioning method of updating both front-line staff and the board on such matters, there is no need to adopt a new practice.
Preventing suicide: A toolkit for community mental health 3 Example of a completed performance summary Bar Chart Key: Standard 1 - General Standard 2 - Risk assessment Standard 3 - Care Programme Approach (CPA) patients Standard 4 - Non-CPA patients Standard 5 - Engagement and suicide awareness Standard 6 - Family and carer involvement Standard 7 - Discharge and transfer Standard 8 - Ligature point awareness Example of a completed performance dashboard
4 Preventing suicide: A toolkit for community mental health The standards Standard 1 Standard 2 Standard 3 Standard 4 Standard 5 Standard 6 Standard 7 Standard 8 General Risk assessment Care Programme Approach (CPA) patients Non-CPA patients Engagement and suicide awareness Family and carer involvement Discharge and transfer Ligature point awareness Standard 1 General Audit procedure 1.1 Was the care or other management plan filed with the case notes/electronic records? 1.2 Has a risk assessment been undertaken and included with the case notes/electronic records? 1.3 Is there evidence that documentation is kept as up to date as possible?
Preventing suicide: A toolkit for community mental health 5 Standard 2 Risk assessment Audit procedure 2.1 Does the risk assessment include relevant history of stress factors, impulsivity and/or triggers? 2.2 Is there evidence of positive risk management as part of a carefully constructed recovery and risk management plan? 2.3 Is there evidence of sharing information with other agencies in risk assessment plans, risk and relapse plans, management plans (include criminal justice system)? 2.4 Does the risk assessment address the level of vulnerability of the client? 2.5 Is there evidence of up to date risk assessment, with documentation present in the client s notes? 2.6 Is there evidence that risk and relapse plans have with them a contingency plan should the risk profile of a client change?
6 Preventing suicide: A toolkit for community mental health Standard 3 Care Programme Approach (CPA) patients Audit procedure 3.1 Does the care or other management plan reflect that the patient is allocated to CPA, if appropriate? 3.2 Has the risk assessment and care or other management plan been undertaken by a multi-disciplinary team? 3.3 Does the CPA review include a risk assessment? 3.4 Is there evidence that the patient was involved in this assessment? 3.5 Has the client been reviewed other than on CPA in the last six months? 3.6 Is there evidence to indicate whether or not a service user has been discharged to the community team on a community treatment order or guardianship? 3.7 Is there evidence that the care plan specifies action to be taken if a patient is non-compliant or fails to attend?
Preventing suicide: A toolkit for community mental health 7 Standard 4 Non-CPA patients Audit procedure 4.1 Is there evidence that a lead professional (within community service) has been identified? 4.2 Is there evidence that the degree of self directed care and supported care is clearly detailed? 4.3 Is there evidence that a full assessment of need for clinical care and treatment, including risk assessment is communicated to the lead clinician in the community? 4.4 Is there evidence that an assessment of social care needs against Fair Access to Care Services (FACS) eligibility criteria (plus direct payments) has been carried out and communicated to the lead clinician in the community? 4.5 Is there evidence of the communication of a clear understanding of how care and treatment will be carried out, by whom, and when (can be a clinician s letter)? 4.6 Is there evidence that the need for ongoing review (as required) has been communicated to the lead clinician in the community?
8 Preventing suicide: A toolkit for community mental health Standard 5 Engagement and suicide awareness Audit procedure 5.1 Is there evidence that the team employs the use of zoning boards and/or daily communication meetings? 5.2 Is there evidence that the client is engaged in recovery enhancing activity? 5.3 Is there evidence of regular reviews and forums for communicating changes in the service user s presentation? 5.4 Is there evidence that the practitioner has checked whether there is a family history of suicide or suicide attempts? 5.5 Is there any evidence that the clinician has discussed the client s thoughts on suicide outside of the risk assessment? 5.6 Is there evidence of assessment of physical health, medication and social circumstances, with assessment on their potential to contribute to suicide risk? 5.7 Is there evidence of assessment of recent loss/separation and family issues, with assessment on their potential to contribute to suicide risk? 5.8 Is there evidence of assessment of any possibility of death resulting from condition related behaviours that are not suicidal in intent? 5.9 Is there evidence of assessment of levels of insight and awareness (and fluctuations in these levels) and their potential to contribute to suicide risk? 5.10 Is there evidence that the practitioner has assessed the nature and effectiveness of the service user s support networks? 5.11 Is there evidence of joint working with specialist substance misuse services, if appropriate?
Preventing suicide: A toolkit for community mental health 9 Standard 6 Family and carer involvement Audit procedure 6.1 Did the patient give consent for staff to share information with and make contact with family/carers? 6.2 If contacted, were they informed how to contact a member of the clinical team at any time? 6.3 If consent was refused and the family/carer was contacted anyway, was appropriate justification documented in the records? 6.4 Were family/carers given the opportunity to contribute to the risk assessment process? 6.5 Is there evidence that the discharge has been discussed with the client and their carers? 6.6 Is there evidence discharge was discussed and planned as early as possible with the client and carers? 6.7 Is there evidence that, following post incident multi disciplinary case reviews, information was shared and discussed with families of involved patients?
10 Preventing suicide: A toolkit for community mental health Standard 7 Discharge and transfer Audit procedure 7.1 Was the patient involved in creating this plan? 7.2 Do discharge plans specify arrangements for complying with treatment? 7.3 Were carers involved in creating this plan, if appropriate? 7.4 Is there evidence that service user was followed up within seven days of discharge/transfer to community team?
Preventing suicide: A toolkit for community mental health 11 Standard 8 Ligature point awareness Audit procedure 8.1 Has a ligature assessment been carried out in the outpatient waiting areas? 8.2 If any new ligature points were identified, have these been reported to estates for action? 8.3 Do you have any OUTSTANDING or OVERDUE estates requests relating to the management of identified ligature points?
12 Preventing suicide: A toolkit for community mental health Useful resources Crompton N & Walmsley P (2004) Community Mental Health Services in New approaches to preventing suicide, chapter 6. Cooper J & Kapur N (2004) Assessing Suicide Risk in New approaches to preventing suicide, chapter 2. Da Cruz D, Pearson A, Saini P et al (2010) Emergency Department Contact prior to Suicide in Mental Health Patients emj online, July. Best practice in managing risk. Department of Health, June 2007. Refocusing the care programme approach. Department of Health, 2008 National confidential inquiry into suicide and homicide by people with mental illness. Annual report. Department of Health/University of Manchester, July 2010. Hunt IM, Swinson N, Palmer B et al (2010) Method of suicide in the mentally ill: a national clinical survey. McAuliffe N & Perry L (2007) Making it safer: a health centre s strategy for suicide prevention. NPSA Ward Mangers Guide and Rationale documents NRLS 1133, NRLS 1133a. National Patient Safety Agency, 2009. Repper J, Perkins R (2004) Social inclusion and recovery a model for mental health practice. Bailliore Tindall. Suicide in Southwark a strategy for prevention. Southwark PCT, Public Health Directorate, October 2005. Windfuhr K, Bickley H, While D et al (2010) Non-resident suicides in England: a national study.
The NHS Confederation 29 Bressenden Place London SW1E 5DD www.nhsconfed.org/mhn Registered Charity no: 1090329 National Patient Safety Agency 4 8 Maple Street London W1T 5HD www.npsa.nhs.uk National Patient Safety Agency and Mental Health Network 2011. You may copy or distribute this work, but you must give the author credit, you may not use it for commercial purposes, and you may not alter, transform or build upon this work. INF29001