RationaleSuicides in mental health service settings may indicate a catastrophic system failure and can undermine public confidence in the mental health care system. They are tragic events that cause much grief and distress for families and friends, as well as for mental health professionals and other workers involved in their care, and for other consumers within the mental health service. Although suicides of people in the care of mental health services are not always preventable, it is acknowledged that there is scope for reducing some of these tragic events through improved systems of care.
Health Ministers agreed that 'suicide of a patient in an inpatient unit' is a sentinel event in health care, to be publicly reported by jurisdictions as one of a number of nationally agreed core sentinel events (see appendix 8). This data will be included in the National Sentinel Event Report due to be released by the Australian Council for Safety and Quality in Health Care by the end of 2005. 11
In addition to suicides in inpatient units, adverse events also include suicides occurring while mental health consumers are on day leave, or are absent without leave, and in the days and weeks immediately following discharge. This recognises that preventable suicides can occur as the result of omissions in care, for example as a result of lack of follow-up and continuity of care post-discharge. It is also argued that suicides occurring for periods up to a year following discharge from an inpatient unit are also serious events, particularly where consumers are in the care of community mental health services. Such suicides are commonly perceived by members of the community as a failure of the health care system.
Suicides are often preceded by suicide attempts and/or other acts of deliberate self-harm. However, not all self-harm behaviour is suicidal behaviour or related to suicidal thinking. Improved systems of assessment and management of deliberate self-harming behaviours may help to reduce suicides. A systems oriented approach to reducing suicides, suicide attempts and deliberate-self harm is needed, along with a non-punitive culture that rewards incident reporting and supports its use in continuous quality improvement.
The consultation (refer appendix 4) indicated that improved suicide assessment and management was a shared safety priority across the range of stakeholders consulted.
Strategies developed for this action plan have been conceived to be complementary to efforts under the National Suicide Prevention Strategy and State and Territory suicide prevention policies.Top of page
Table 1: Reducing suicide and self-harm in mental health services and related health service settings
- Reduced suicide in mental health services.
- Reduced suicide in acute health care services.
- Reduced suicide in the days immediately following discharge from inpatient care. 12
- Reduced suicide within 28 days following discharge from inpatient care. 13
- Reduced instances of suicide attempts in mental health services.
- Reduced instances of deliberate self-harm in mental health services.
- Reduced instances of suicide attempts within 28 days following discharge from inpatient care.
- Routine suicide risk assessment and management, and post-discharge follow-up within existing policies, protocols and clinical guidelines.
- Routine consideration of Coroner's recommendations for improving systems of care in mental health services to reduce suicides.
- Mental health services (including the interface with public and private facilities).
- Acute care services outside mental health services, particularly emergency departments.
- Interface between mental health services and primary care sector, such as general practitioners, and non-government organisations.
- Other relevant settings as applicable, such as ambulance services and other approved transport providers and police services.
Known problem areas
- Specialised mental health services (first day of admission, periods of leave, discharge planning, follow-up post-discharge, continuity of care between hospital and community based services and primary care services such as general practitioners and non-government organisations).
- Issues specific to accident and emergency hospital-based settings (triage, discharge, planning, timely access to mental health assessments and staffing/ resources/ workflow issues).
- Appropriate information and support for consumers and carers post-discharge, especially when current hospitalisation involves suicide attempt in care or prior to care, or where it is the first diagnosis of mental illness for a consumer.
- Absense of identified good practice in suicide risk assessment. Variability in protocols and application of protocols across hospitals/ services and jurisdictions.
- Communication across the jurisdictions.
- Over-reliance on junior/ trainee clinicians in emergency departments and mental health services.
- Risk factors related to the health service environment such as access to hanging points and belts, and other well documented risk factors. 14Top of page
- Identify and disseminate good practice in suicide risk assessment and management, and review existing protocols and clinical guidelines of mental health services and related health services. This will include examining good discharge planning, risk assessment, and outcomes measurement. This will include consideration of variations in good practice related to particular settings, eg child and adolescent mental health services.
- Identify good practice services/ leaders and facilitate their role in influencing clinical and service management change system-wide.
- Implement and use incident monitoring and management systems for monitoring instances of deliberate self-harm, suicide attempts and suicides.
- If a sentinel event of 'suicide in an inpatient unit' occurs ensure that the relevant service policy on open disclosure is followed and post suicide bereavement information resources are available to families and significant others. 15 Ensure appropriate processes are in place to support staff.
- Investigate, using tools such as root cause analysis, all suicides that occur whilst consumers are in the care of hospitals (mental health services and other parts of the hospital) and community components of public specialist mental health services.
- Investigate, using tools such as root cause analysis, all suicides that are known to have occured within one year post-discharge from acute care or specialist mental health service care.
- Develop education and training strategies for supporting services to use tools such as root cause analysis after suicides.
- Develop nationally consistent measures for recording, classifying and reporting of all suicides of mental health consumers in the care of mental health services and acute care, as well as for reporting of suicides within one year of discharge.
- Implement existing clinical practice guidelines for the management of deliberate self-harm. 16
- Ensure that systems are in place to automatically consider Coroner's findings, disseminate lessons, and ensure appropriate changes to systems.
- Evaluate changes in practice and outcomes.Top of page
Complementary/ linked strategies/ activities
- National Suicide Prevention Strategy
- Existing State and Territory suicide prevention strategies
- National Action Plan for Promotion Prevention and Early Intervention in Mental Health 2000.
- Australian Council for Safety and Quality in health Care, particularly national sentinel event reporting, Open Disclosure Standard.
- Existing State/Territory initiatives targeting areas identified in the above strategies, for example South Australian guidelines for reporting and managing sentinel events that include compulsory root cause analysis for suicide within 28 days of discharge.
- Implementation of Royal Australian and New Zealand College of Psychiatrists (RANZCP) Clinical Practice Guidelines for management of deliberate self-harm (adults).
- Australasian College for Emergency Medicine Guidelines for the management of deliberate self-harm in young people.
- Existing non-government initiatives, for example Lifeline's 'buddy' program to support consumers post-discharge from mental health services.
11 All jurisdictions have commenced to collect sentinel event data. Two jurisdiction have publicly reported - Department of Human Services (2004) Sentinel Events Program: Annual Report 2002-03, Victorian Government Department of Human Services,
Melbourne, May 2004 and NSW Health (2005) Patient Safety and Clinical Quality Program: First report on incident management in the NSW public health system 2003-2004, Sydney, January 2005.
12 Jurisdictions have differing protocols and information collection requirements. There is consensus that monitoring is needed but the time period for monitoring varies across jurisdictions from 5-28 days post discharge.
13 Agreed Phase 1 KPIs for public specialised mental health services include '28 day readmission'.
14 Refer to National Suicide Prevention Strategy documents and other evidence-based sources.
15 Some resources have been prepared under the National Suicide Prevention Strategy that may be appropriate here.
16 Australasian College for Emergency Medicine, Guidelines for the management of deliberate self-harm in young people and Royal Australian and New Zealand College of Psychiatrists, Guidelines for the management of deliberate self-harm in adults.