Preventing suicideA toolkit for communitymental health

Over a quarter of people who take their own life have been in contact with mental health services inthe previous year. While much improvement has been made over the last 15 years in reducing thesuicide 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 integralpart 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 beunderstanding of what took place previously and what support is presently available to thatindividual, 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 theirinpatient suicide prevention tool and in recognition that suicide prevention is not just an issue foracute services. Developed in cooperation with community mental health teams, this toolkit reflectsthe circumstances and needs of service users as they move between different parts of the healthsystem 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 ApplebyNational Director for Mental Health

Foreword

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

Contents

Preventing suicide: A toolkit for community mental health2

Overview and instructions

This section gives details of how to use the toolkit, including an explanation of theassessment tools and the use of case note review, and an example completed audit form andchecklist. The eight standards are then set out, and a list of useful resources. All thedocuments are available to download from www.nhsconfed.org/mhn

The standardsThe eight standards are organised to look at the process of admission through to discharge of aworking age adult. Accompanying these standards are detailed audit procedures which will help youmeasure 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, inorder to provide you with a more detailed context for each standard criteria.

Assessment – the general audit toolThe general audit tool provides an annual method of tracking and measuring the level of careprovided to patients at risk of suicide or self-harm. It provides a comprehensive view of the level ofadherence to the suicide prevention standards contained in the updated toolkit, and combines areview of trust policy, environmental and patient risk assessments, and the review of a small sampleof 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 aftercompleting 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 alsorecommended 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 awell functioning method of updating both front-line staff and the board on such matters, there is noneed to adopt a new practice.

Preventing suicide: A toolkit for community mental health 3

Example of a completed performance dashboard

Bar Chart Key:Standard 1 - GeneralStandard 2 - Risk assessmentStandard 3 - Care Programme Approach (CPA) patientsStandard 4 - Non-CPA patientsStandard 5 - Engagement and suicide awarenessStandard 6 - Family and carer involvementStandard 7 - Discharge and transferStandard 8 - Ligature point awareness

Example of a completed performance summary

Preventing suicide: A toolkit for community mental health4

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

The standards

Standard 1 General

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?

Audit procedure

Preventing suicide: A toolkit for community mental health 5

Standard 2 Risk assessment

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 andrisk 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?

Audit procedure

Preventing suicide: A toolkit for community mental health6

Standard 3 Care Programme Approach (CPA) patients

3.1 Does the care or other management plan reflect that the patient is allocated to CPA, ifappropriate?

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 thecommunity 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?

Audit procedure

Preventing suicide: A toolkit for community mental health 7

Standard 4 Non-CPA patients

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 riskassessment 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 tothe lead clinician in the community?

4.5 Is there evidence of the communication of a clear understanding of how care and treatmentwill 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?

Audit procedure

Preventing suicide: A toolkit for community mental health8

Standard 5 Engagement and suicideawareness

5.1 Is there evidence that the team employs the use of zoning boards and/or dailycommunication 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 serviceuser’s presentation?

5.4 Is there evidence that the practitioner has checked whether there is a family history of suicideor suicide attempts?

5.5 Is there any evidence that the clinician has discussed the client’s thoughts on suicide outsideof the risk assessment?

5.6 Is there evidence of assessment of physical health, medication and social circumstances, withassessment on their potential to contribute to suicide risk?

5.7 Is there evidence of assessment of recent loss/separation and family issues, with assessmenton their potential to contribute to suicide risk?

5.8 Is there evidence of assessment of any possibility of death resulting from condition relatedbehaviours that are not suicidal in intent?

5.9 Is there evidence of assessment of levels of insight and awareness (and fluctuations in theselevels) and their potential to contribute to suicide risk?

5.10 Is there evidence that the practitioner has assessed the nature and effectiveness of the serviceuser’s support networks?

5.11 Is there evidence of joint working with specialist substance misuse services, if appropriate?

Audit procedure

Preventing suicide: A toolkit for community mental health 9

Standard 6 Family and carer involvement

6.1 Did the patient give consent for staff to share information with and make contact withfamily/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 appropriatejustification 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?

Audit procedure

Preventing suicide: A toolkit for community mental health10

Standard 7 Discharge and transfer

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?

Audit procedure

Preventing suicide: A toolkit for community mental health 11

Standard 8 Ligature point awareness

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?

Audit procedure

Preventing suicide: A toolkit for community mental health12

Crompton N & Walmsley P (2004) ‘Community Mental Health Services’ in New approaches topreventing 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 MentalHealth 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 PatientSafety 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.

Useful resources

© National Patient Safety Agency andMental Health Network 2011.

You may copy or distribute this work, butyou must give the author credit, you maynot use it for commercial purposes, andyou may not alter, transform or buildupon this work.

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