Herts Draft Suicide Prevention Strategy



Draft for JCPB

HERTFORDSHIRE SUICIDE PREVENTION STRATEGY 2008 – 2011

CONTENTS

1. Executive Summary

2. Foreword

3. Introduction

4. Values and Principles

5. Background

6. Demographic Trends

7. Goals

7.1 High risk groups

7.2 Mental well-being

7.3 Availability of methods

7.4 Reporting in media

7.5 Research

7.6 Monitoring progress

8. Implementation

Appendix 1: Hertfordshire Suicide Audit 2007 – Annual Report

Appendix 2: Graph – Mortality from Suicide and Injury undetermined in

Hertfordshire 1993-2007

Appendix 3: HPFT Summary Report “Sharing Good Practice” (2007)

Appendix 4: References

Appendix 5: Action Plan 2008 to 2011 in full

Appendix 6: Partner Agencies

1. Executive Summary

This strategy has been produced by a range of organisations, working together on behalf of the people of Hertfordshire. It has been led by the Primary Care Trusts (PCTs) with the support of Hertfordshire Partnership NHS Foundation Trust (HPFT), mental health service user groups, carer groups, voluntary organisations and others.

It outlines the reasons why a suicide prevention strategy is necessary, and goes on to describe the County’s trends with regard to suicides in recent years.

The central section (section 7) shows the current situation, the broad aims and the specific actions planned in terms of the goals of the strategy – the most significant being about engaging more fully with the known high risk groups.

Finally, the plans for monitoring and reporting the progress of the strategy are presented.

Extra background information is to be found in the appendices.

2. Foreword

Hertfordshire’s suicide rate over the period of 1996 to 1998 was 8.75 per 100,000 in East & North Herts PCT area and 7.05 in West Herts PCT area. The target for the County is to reduce suicide rates to 6.7 per 100,000 in 2009, and 6.5 per 100,000 in 2010 and 2011 in both East and North Herts and West Herts PCTs.

Hertfordshire’s suicide rate has typically been below the national average, however; further improvements are possible and encouragement can be taken from the current downward trend in the County’s suicides, which reflects the national pattern.

It need not be stressed that when such tragic events occur, they are devastating in their impact on all those involved – families, friends and professionals.

A wide range of agencies and individuals have contributed to the development of this strategy, for which we are grateful (see appendix 6). Even wider involvement from such organisations as faith groups, schools, colleges, service providers, those bereaved by suicide, Probation, Network Rail, the train operating companies and Hertfordshire Highways Agency, will be necessary if it is to achieve its full impact.

Progress on implementing the strategy will be closely monitored and fully reported to partner agencies. If it remains a truly inter-agency project, we are confident that it will reach its objectives.

3. Introduction

“Suicide is a devastating event. Its emotional and practical consequences are felt by family and friends and the many statutory and voluntary agencies involved in the provision of health and social care. Although the rate of suicide in England is not high in comparison with other countries in the European Union, the figures remain disturbing. On average, a person dies every two hours in England as a result of suicide. It is the commonest cause of death in men under 35. It is the main cause of premature death in people with mental illness.”

(National Suicide Prevention Strategy for England – DoH (2002)).

The above statement was written in 2002, but remains as relevant and powerful today, underpinning suicide prevention as a key national priority for all health and social care services. A wide range of organisations have a role to play if Hertfordshire is to maximise its chances of preventing suicides.

This strategy therefore is based on a partnership between the agencies listed below:

• East and North and West Herts Primary Care Trusts (the lead agency)

• Hertfordshire Partnership NHS Foundation Trust (HPFT)

• Joint Commissioning Team

• Viewpoint

• Carers in Herts

Other statutory, private and voluntary sector organisations, including the Coroner’s Office, the Police and the Samaritans, are contributing to this work and the range of organisations involved is expected to grow as momentum develops.

Considerable knowledge and experience underpins this programme of work, including that held within HPFT which has used its own suicide prevention strategy for the past three years to provide the safest possible care to those for which it is responsible.

The strategy is also informed by robust data – national information which can be used for benchmarking purposes, and more local suicide audits which describe demographic trends and lessons from which we can learn.

It will:

• Enable a more concerted effort to be made between agencies to reduce suicides in the County

• Build on current initiatives making sure that good practice is shared

• Help agencies focus on those most at risk, as identified through audit

• Provide a framework and a reference point for other agencies and community representatives to join over the next 3 years

• Measure progress using accurate up-to-date information which can be widely reported

Implementation of the Strategy will be led and monitored through a new Hertfordshire Suicide Prevention and Mental Health Promotion Strategy Implementation Group which will oversee both the Mental Health Promotion and Suicide Prevention Strategies.

4. Values and Principles

The strategy sets out to reflect and demonstrate:

• The importance of providing mental health services (in both primary and secondary care), which are timely and accessible for all sections of the community we serve

• A belief that a significant proportion of suicides are preventable, so that a continuous reduction in numbers of suicides is achievable

• A recognition that causes of suicide are multi-factorial, ranging from subtle psychological patterns on an individual level to wide socio-economic influences

• An open and honest environment with a commitment to learning from those directly involved in suicides and “near misses” - individuals, carers, family, friends and staff – about what would have helped

• A culture of optimism and a determination to reduce the risk of suicide without any hint of complacency

• A commitment to supporting suicide “survivors” including staff, family and friends

• A willingness to tackle the stigma that still surrounds mental ill-health, so that those in need are more likely to seek help as appropriate

• An appreciation that suicide prevention is not the exclusive responsibility of any one sector of society, nor of health services alone.

• An openness to engage with voluntary organisations to facilitate reduction in suicide and an appreciation of the value and role of caring agencies who currently provide support to those at risk.

A Suicide Prevention Strategy needs to send carefully balanced messages to all those who may be touched by such an event about the preventability of suicides absolutely. Our target figure is not zero, so that our strategy does not assume that all suicides can be prevented. However, it does assume that continuous improvement is possible, and that we owe it to all those who will be affected by these events in future do all we can to reduce suicide.

5. Background

The improvements we intend to make in Hertfordshire need to be understood in an important national context. In the last nine years, there has been a much closer focus on suicide prevention in policy terms, much but not all of it about statutory mental health services.

The main national drivers are summarised below:

• National Service Framework for Mental Health (1999)

Standard 7 outlines how agencies including Mental Health Trusts are expected to work together to prevent more suicides. It stresses how this is likely to be most easily achieved in mental health services through improvements in many areas of general mental health services, including acute inpatient care, discharge planning, and effective operation of the Care Programme Approach, with users assessed as presenting the greatest risks receiving the highest levels of care.

• Saving Lives: Our Healthier Nation (1999)

This White paper underpins the messages in the National Service Framework. It introduces the national target of the death rate from suicide and undetermined injury being reduced by at least 20% by 2010.

• Safer Services: National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (1999)

This authoritative national report includes comprehensive data on suicide trends. It showed how the age profile had shifted in the 1990s, with a significant growth in suicides by young adult males (NB. This trend has not persisted in the 2000s). It contained findings which have been replicated since, such as the high proportion of cases where there had been contact with a mental health professional in the 7 days before the event, and the view of reporting professionals that around 20% of suicides in secondary care were preventable.

• An Organisation with a Memory (2000)

This described how through good systems of clinical governance, NHS Trusts can learn from adverse events and reduce the chances of their reoccurrence, rather than Public Inquiries and internal investigations into suicides continuing to highlight the same issues as causal factors to be addressed. It was influential in the creation of the National Patient Safety Agency, whose primary function is the dissemination of learning throughout the NHS in order to achieve safer services.

• Safety First: Five Year Report of the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (2001)

This report built on its comprehensive data to develop “Twelve Points to a Safer Service”.

• National Suicide Prevention Strategy for England (2002)

This provides a blueprint for local Strategies, so that our Strategy is organised in terms of the 6 Goals introduced here. It provides examples of local good practice, and national initiatives such as the “Mind out for mental health” anti-stigma campaign in 2002-2003 which targeted young people.

• Preventing Suicide: a Toolkit for Mental Health Services (2003)

This NIMHE document offers a method for mental health services to measure systematically the extent to which they are addressing Inquiry recommendations. It provides 8 auditable standards, and also offers an extensive range of references on good practice.

• Avoidable Deaths: 5 Year Report of the National Confidential Inquiry into Suicides and Homicides by People with Mental Illness (2006)

This latest report showed national improvements in preventing suicides within Mental Health Trusts, but also provided graphic evidence of avoidable deaths, challenging services to do more.

• NHS Performance Indicators

Both Mental Health Trusts and Primary Care Trusts must have in place a local system for suicide audit, generating actions to improve performance in this field.

Both also have a responsibility to contribute to the national target of reducing suicides by 20% between 1998 and 2010.

HPFT as a Mental Health Trust has other relevant targets such as that of following up within 7 days of discharge from acute inpatient units all those on Care Programme Approach, which includes all those deemed at risk of suicide.

The PCT “Vital Signs” target for both East & North Herts PCT and West Herts PCT is to achieve a suicide rate of 6.7 per 100 000 population in 2009 and 6.50 in 2010 and 2011.

6. Demographic Trends

6.1 General

Hertfordshire is a county of just over a million people, 87% of whom live in the 45 settlements of over 3,000 people. There is one city (St Albans) and a variety of market towns, industrial towns, new towns, commuter villages and rural villages. There are 10 district councils.

Hertfordshire’s recent (early 2008) unemployment rate was 1.3% for those claiming Job Seeker Allowance but 4.5% according to ILO definition (International Labour Organisation). There is a correlation between high unemployment levels and high suicide rates; this County’s unemployment rate is below the national average. Hertfordshire is part of the group called Prospering Southern England as classified by ONS (Office of National Statistics).

The recent national ‘credit crunch’ and financial crisis may well impact on employment and household income of local families (as well as nationally). The Strategy will ensure that the action plan develops to provide the necessary support to those affected by this.

6.2 Suicide Rates

Suicide rates are usually measured using the mortality from suicide and injury (and poisoning) of undetermined intent per 100,000 population.

Rates in Hertfordshire show a fall for East & North Hertfordshire PCT from 10.27 in 1993 to 6.14 in 2007. For West Hertfordshire PCT the fall is from 9.13 to 4.33.

However, because numbers are small, rates are generally calculated on a 3-year rolling average – as shown below.

[pic]

Three year rolling averages for East & North Hertfordshire shows the highest rates in Stevenage and Welwyn Hatfield and for West Hertfordshire in St Albans and Watford.

Note: The rates in all 10 Hertfordshire districts are less than the England Average.

[pic]

[pic]Gender Distribution

In Hertfordshire as nationally, the ratio of men to women over the past 10 years has remained between 3 to 1 to 4 to 1.

Age Distribution

Both nationally and locally there have been falls in suicide and undetermined injury mortality rates in young men, deaths often related to substance misuse.

Figures for 2003-2006 for Hertfordshire PCTs show the age-specific rates showing a higher than might be expected rate in the older 75 age group.

[pic]

East of England 2001-2006

Recent analysis of mortality from suicide and injury undetermined shows a wide variation between men and women in different age groups. The peak difference being in the 30-39 age group with four times as many men committing suicide than women. This ratio decreases in older groups.

Mortality rates for PCTs in the East of England show over the period 2001-2006 East and North Herts PCT having the lowest regional rate for males and persons.

Number of deaths from suicide and injury undetermined by age group. East of England 2001-2006.

[pic]

[pic]

Hotspots/Geographic Distribution

Plotting the site of suicides (which may or may not be near a person’s home) shows in 2007, higher rates in Stevenage, St Albans and Watford.

This pattern would be expected as these are three major centres of population in the County.

Findings from PCT Audit (2007) (see appendix 1)

• Age breakdown as follows:

|Under 30 years |30-40 years |40-50 years |50-60 years |Over 60 year |

| | | | | |

|5% |19% |26% |23% |28% |

• 31 of total of 36 cases were male

• 19 of 36 cases used hanging as the method

• Chronic physical illness was a factor in 12 of the 36 cases

Key Messages:

• The national suicide rate and the numbers for Hertfordshire are currently falling. Hertfordshire can be seen as reflecting broad national trends. However, the County’s position has been below the national average since at least 1998; this means that the national target of a 20% reduction by 2010 is especially demanding for us – nevertheless, it remains our aim.

• Likewise, the split between cases in HPFT and cases outside of secondary or specialist mental health care remains close to the national average at around a 30:70 ratio. This means that the relative performance of primary and secondary care is as expected, so that both areas of the NHS have an equal responsibility to contribute to further improvements.

• Considerable caution needs to be exercised in drawing conclusions from much of the other demographic data, where numbers are relatively small. The data does reinforce the message that males in the County are around three times more vulnerable to suicide than females, so that interventions need to be targeted at males and to be adapted to be acceptable to them. Again, the age trend is back to a picture of those in late middle age or older being especially vulnerable. Interventions need to reflect this, engaging with widespread problems of social isolation, bereavement and loss, pensioner poverty and chronic illness.

7. Goals

This section outlines – for the 6 areas of the strategy prescribed by the Department of Health – the current position, the broad 3 –year aims and finally the actions planned by April 2011.

7.1 Goal 1: To reduce risks in key high risk groups

7.1.1 Current situation

For Hertfordshire, the main high risk groups for suicide are similar to those found nationally.

Males are significantly more at risk of suicide in this County than females, and particular attention needs to be paid to those in middle age or later life. This is a new development from the concern felt locally and nationally in the past decade that young males were the highest risk group. New policy and strategic thought must reflect this change.

Hertfordshire as a whole is relatively well placed to develop an effective suicide prevention strategy for the future, with its history of partnership working and its relatively low suicide rate compared to the national average.

In primary care, in recent years there has been a greater emphasis on early identification of depressive illness leading to effective treatment. The Quality and Outcomes Framework for GPs has facilitated better monitoring of those with severe mental illness. Practice Based Commissioning groups have begun to develop alongside HPFT Enhanced Primary Mental Health Services delivering the Improved Access to Psychological Therapies initiative, which will improve services for those with depression and other neurotic disorders who do not meet criteria for secondary care services.

A wider range of psychological as well as medical treatments are being made available, thus enhancing patient choice.

Primary Care Trusts as commissioners are increasingly aware of their responsibilities to vulnerable groups. In addition, commissioners of specialist services such as those for people with substance misuse problems have set up more accessible services, such as the Drugs Intervention Programmes (DIP) for those with drug and/or alcohol problems who offend.

In primary care, the Quality and Outcomes Framework for GPs has provided a lever for improving standards of patient care; it is possible that it can be used further to ensure earlier detection and treatment of those at risk for suicide (above all, those with depression), together with more use of Significant Event Audits to learn lessons when suicides do occur.

Emergency services, educational establishments, representatives of those who have mental health problems and their carers, and the voluntary sector increasingly recognise that they have a role to play in a suicide prevention strategy. The University of Hertfordshire has created the post of a mental well–being officer for students with emotional problems. The police are contributing information about suicide hotspots. The Coroner’s office is providing information to the ongoing county suicide audit, and continues to look beyond its formal legal role and to contribute to the wider thinking about how to prevent such incidents.

The Chaplaincy services which have been established in local trusts provide services to patients from diverse backgrounds and support from faith organisations can play a crucial role at times of illness or bereavement.

Those under the care of Hertfordshire Partnership NHS Foundation Trust (HPFT) make up around one third of all County suicides, which means that whilst they are a minority, the rate of suicide by those under the care of HPFT is much greater than the overall County rate.

HPFT data reveals that there have been no suicides in the Child and Adolescent Mental Health Services in the last 5 years, and none in Specialist Learning Disabilities Services with the exception of one individual who was in prison, being assessed by the Learning Disability Forensic Service.

The suicides occur across all adult mental health services – there are a small number carried out each year by inpatients; some individuals are under the care of Community Mental Health Teams (CMHTs) and Specialist MH Teams for Older People (SMHTOP), and there are some individuals receiving low intensity outpatient care.

Alcohol and drug abuse can also lead to increased risk. There are currently both statutory and non-statutory specialist Drug and Alcohol Services across Hertfordshire. Most alcohol detoxifications currently take place in the community although some are undertaken on medical wards where high risk of physical complications have been identified. Many services have traditionally concentrated on drug users, and problem drinkers remain an at risk group needing particular focus.

The main factors which are helping prevent suicides in mental health services are as follows:

1. On acute inpatient units, ligature point awareness and risk management is maintained by the training programme and a strong patient safety culture is led by ward managers and modern matrons.

2. On acute inpatient units, close adherence to policies on supportive observations of service users and on managing patients who go absent from units without leave.

3. On acute inpatient units, environmental audits carried out by the Health and Safety department, checking escape routes and security systems.

4. In Crisis Assessment and Treatment Teams, a concentration of staff with the greatest expertise in clinical risk assessment and management, operating in the critical area where decisions are made as to whether to admit individuals at high risk or whether they can be treated at home.

5. The Early Intervention in Psychosis Service has developed considerably in the past 2 years, and has a target of providing services to 450 service users by June 2009. Young people (especially males) with a new diagnosis of psychotic illness remain a high risk group for suicide, and it is likely that the development of this service has already assisted in preventing suicides.

6. The Trust has a clear policy and performance target on following up those most at risk within 7 days of their discharge from acute inpatient care, which is a performance target. This period is one of high risk for suicide first identified by the National Confidential Inquiry into Suicides and Homicides Report “Safety First” (2001). The policy is well known and performance in this area is good.

7. In recent years the Trust has established a Mental Health In-reach Service at HMP The Mount, Hertfordshire’s only prison. Numbers of prison suicides nationally are generally regarded as too high, with prisoners on remand a particularly high risk group. Whilst HMP The Mount might be predicted to have a relatively low risk for suicide as it is a category C prison, which does not hold prisoners on remand, the In-reach Team are well placed to help it maintain its good safety record.

8. The Trust’s one day training course on Clinical Risk Assessment and Management has to be attended at least once every 3 years by all front line staff, It was revised in April 2008 to reflect the latest DoH guidance on “Best Practice in Managing Risk” (June 2007). Assessment and management of suicide risk is covered on the day and staff are given other sources of information on the subject to follow up.

9. There are systems for staff to learn from actual incidents and near misses through 7 day reports and other investigations, through the Risk Department’s newsletter and through practice governance groups.

10. The Board and Executive team are kept informed of major incidents and suicide trends through reports to the Patient Safety and Risk Management committee.

11. The Trust has followed its own Suicide Prevention Strategy 2005- 2008, with annual action plans monitored by its Suicide Prevention Group

12. Progress has also been measured through the internal suicide prevention audit, conducted annually, which examines cases where suicide risks have been safely managed as well as cases with a fatal outcome. Results are fed back in detail to teams and are well received because they are a means of promoting good practice in this sensitive area, and this is welcomed by staff.

7.1.2 Three Year Aims

Those presenting at A and E departments across the County after incidents of deliberate self-harm are a high risk group for suicide. HPFT and West and North and East Hertfordshire’s Acute Hospital Trusts need to work together to ensure that the responses to these individuals are compliant with best practice as contained in the NICE guidelines on the management of self-harm, building on the harm minimisation project in HPFT.

Those with dual diagnosis (defined for the purpose of this document as the presence of mental health problems and drug and/or alcohol problems) are a high risk group for suicide (and sudden unexplained death). At present, in HPFT, their care is co-ordinated within mental health services whilst they may also receive treatment for their substance misuse in the Community Drug and Alcohol Teams or via the voluntary sector. Those with alcohol problems can be difficult to engage and keep in treatment, and as a result need a more comprehensive set of services county-wide, with an emphasis on accessibility, effective treatment, and good care co-ordination.

Additional funding has been made available in 2008-09 for brief interventions in alcohol harm reduction. This might be further developed county-wide.

More needs to be done to prevent suicides by older males, and another aim of this Strategy is to develop a full network of bereavement services across the county for all who may need them. At present, such services are often linked to specialist groups, such as children or those suffering with terminal illness. Well publicised stigma-free bereavement services for all need to be developed, offering not only advice and support but effective counselling where needed.

Such developments will require a review of current contracts in the voluntary sector, with the aim of commissioning bereavement services in a co-ordinated way.

The main aims for HPFT over the next 3 years are as follows:

1. Improve patient safety including suicide prevention within acute inpatient units through a variety of measures under the heading of “Addressing Acute Concerns”. Currently acute inpatient care is under considerable pressure, with bed occupancy rates consistently above 100% and the proportion of detained inpatients increasing. Extra capital and revenue investment in these units is planned in order to make units safer and more therapeutic. Trends in major incidents including suicides are being carefully monitored, and any decisions about bed numbers in future will be informed by this data.

2. Provide a more efficient and co-ordinated response to the mental health needs of those presenting out of hours through development of the “Hospital at Night” service. This involves merging of A and E mental health liaison, Crisis Assessment and Treatment Teams (CATT) and aspects of the role of junior doctors, to make sure these service users are promptly and proficiently assessed, with resources then being easily accessed. Those at risk of self-harm or suicide often present through these routes, and they will benefit from these service improvements.

3. Review referral pathways to the Crisis and Treatment Teams (CATT) to ensure that there are no barriers for service users in crisis to receive a service. This work will include the development of a referral protocol with the Voluntary Sector.

4. Continue to develop and strengthen transition pathways between services and between care groups, especially for service users transitioning from Child and Adolescent Mental Health Services to Working Age Mental Health and from there to Mental Health Services for Older People.

5. Continue to implement the policy on 7 day follow up of those discharged from acute inpatient care who are most at risk including those identified as at risk of suicide. 100% compliance with this policy remains a Trust target.

6. Fully develop the Early Intervention in Psychosis Service to the size required by commissioners, namely 450 service users by 1st July 2009, including outreach into student populations. This is expected to increase the chances of preventing suicides by those newly diagnosed with a psychotic illness, especially young males, by providing them with more effective care and treatment at an earlier stage.

7. Significantly develop Enhanced Primary Care Mental Health Teams and expand services under the banner of “Improving Access to Psychological Therapies”, so that those in primary care who may be at risk of suicide (especially those with depression), are treated earlier and more effectively.

8. Maintain the good record of preventing suicides in Child and Adolescent mental health services. In particular, the new purpose built inpatient adolescent unit at Forest House will be well designed to ensure patient safety in a more therapeutic environment than previously.

9. Ensure that, when reconfiguring services, unnecessary internal boundaries (which are known to make it harder sometimes to manage patients safely), are avoided wherever possible.

10. Strengthen the relationships between older people’s inpatient services and local bereavement services including CRUSE, so that those admitted who have been bereaved have good access to counselling through the voluntary sector as well as good personalised inpatient care.

11. Work with generic older peoples’ services and local organisations such as Age Concern Hertfordshire to highlight their supportive role.

12. Improve the assessment and treatment of the physical health problems of older mental health service users in particular, with physical conditions and their medical treatments being routinely monitored, and clarity in every case between primary and secondary care clinicians about medical responsibility.

13. Maintain the good record of preventing suicides in inpatient services for people with learning disabilities such as Tertiary Assessment and Treatment Services (TATS) and Specialist Residential Services (SRS) at Harperbury, through a culture of full compliance with the Trust clinical risk assessment and management policy and procedures, and good reporting of incidents so that they are investigated with lessons learnt. This will be supported by high levels of clinical psychology input, especially for those with patterns of persistent self-harm.

14. Achieve National Treatment Agency targets with respect to the performance of Community Drug and Alcohol Teams, especially in retaining service users in treatment. Service users with substance misuse problems have high levels of both suicide and accidental death – sometimes the two are hard to distinguish – and these risks are reduced when they engage effectively in treatment. The objectives of the service include both short waiting times and retention in treatment. Some problem drug users will be on CPA which would further improve the chance of retaining them in treatment with a successful outcome.

15. Develop the role of the mental health inreach team at HMP The Mount, with more support to prison staff through the mental health awareness training programme, including its module on deliberate self-harm and suicide.

16. Make full use of the newly created Clinical Risk Trainer/Manager post, to support staff in the complex task of managing clinical risks effectively with service users and carers. This will be through delivering a more comprehensive programme of risk training to staff, with both introductory and advanced elements, and providing expert advice to staff over the most complex and challenging cases.

17. Make available to staff the most validated risk assessment tools, starting with the Beck Hopelessness Scale which has particular relevance for the assessment of suicide risk.

18. Achieve level 2 of the NHS LA risk management standards for Mental Health Trusts in November 2008 and maintain it thereafter. This year the NHS LA inspection has stimulated the Trust into making many improvements in the way it ensures patient safety with considerable attention to suicide prevention, with policies revised to cover the relevant areas and systems improved for gathering evidence of policy compliance and training to assist staff in this.

19. Build stronger partnerships with carers in the ways they work together with professionals to manage risks including suicide risks. A new section on engaging with carers has been added this year to the revised Clinical Risk policy, and new training programmes will emphasise the skills and attitudes required to work effectively with carers in this way.

20. Refine the “Learning from Adverse Events” policy, especially in the area of post-incident support to both staff and carers. After suicides, if this is not well handled, staff can feel driven into defensive practice. Such caution can inhibit both learning from and recovery from such tragic incidents. An atmosphere of openness must be fostered between professionals and carers and families.

21. Continue to use the annual mandatory internal suicide prevention audit to elicit and share good practice.

22. Help staff make the 11 principles of the recovery approach more meaningful in practice. The principles which are about attitudes of optimism and hope can be especially important in enabling strong therapeutic relationships to be established with service users who are suicidal.

23. Work with primary care to develop better recording of self-harm presentations and to help primary care in providing and signposting to appropriate support.

24. To identify problem drinkers using recognised tools e.g. Audit, FAST, PAT and SASQ and undertake on the spot interventions and signposting to more specialist services if necessary.

Key aims for other agencies include:

1. Working with local employers and other organisations to reduce the impact and stress incurred by those affected by redundancy, and/or reduction of household income associated with the current economic downturn and financial climate. To work with Herts Chamber of Commerce for Herts companies and awareness of those who worked in financial sector in the City of London and staff in related industries which have been affected.

2. Individuals recently released from prison are known to be at higher risk of suicide. Prisoners released into Hertfordshire mainly come from prisons in Bedfordshire and Essex. Work across geographical boundaries with probation services for those with sentences greater than 10 months and with DIP (Drug Intervention Programme) and Community Drug and Alcohol Teams (CDAT) for those with a known drug problems in prison will hopefully have a positive impact.

3. Promoting information and other support for survivors of suicide, both within primary care and through HPFT.

4. Army leavers are another vulnerable group and as such national policy is in place to ensure robust pathways to support services for those with Post Traumatic Stress Disorder, and other mental health issues. Viewpoint will work with the local Territorial Army Centres to provide support for reservists and to provide training on mental health issues and suicide risk awareness.

5. Look at whether national trends linking LGBT (lesbian, gay, bisexual and transsexual) concerns around inclusion and suicide bear any relevance in Hertfordshire by establishing improved data.

6. For Mental Health Service Providers to work more closely with the police to ensure that the most appropriate pathway is taken, and that inappropriate arrests are not made at times of crisis. It will also be important to work with police to build on the mental health service-user led training currently run by Viewpoint available to frontline staff.

7.1.3 Action Plan (2008-2011)

|Goal 1 |Action |Lead agency |Date for completion |

| |1. Establish systems for gathering full data set of those|PCT |April 09 |

| |presenting at A and E Departments after incidents of | | |

| |deliberate self-harm and attempted suicide. | | |

| |2. Ensure compliance in A and E with NICE guidance on |PCT/JCT |April 09 |

| |management of deliberate self-harm. | | |

| |3. Explore ways of checking that deliberate self-harm is |PCT |June 09 |

| |effectively managed in primary care. | | |

| |4. For those with dual diagnosis, build on local |PCT/JCT |Ongoing |

| |initiatives to ensure equal access county-wide to | | |

| |effective treatment for alcohol abuse. | | |

| |5. For the bereaved, ensure support and counselling are |PCT/JCT |Ongoing |

| |equitably available county-wide. | | |

| |6. Maximise use of Quality and Outcomes framework in |PCT |Ongoing |

| |primary care, to ensure learning from incidents and | | |

| |effective detection and treatment of those vulnerable for| | |

| |suicide (especially those with depression). | | |

| |7. Fully functioning Early Intervention in Psychosis |HPFT |June 09 |

| |service. | | |

| |8. Begin Hospital at Night Service. |HPFT |Dec 08 |

| |9. Extra capital and revenue investment in acute |HPFT/JCT |April 09 |

| |inpatient units. | | |

| |10. Significant development of Enhanced MH primary care |HPFT |April 09 |

| |and Improving Access to Psychological Therapies. | | |

| |11. Local links set up between older people’s mental |HPFT |April 09 |

| |health services and bereavement services. | | |

| |12. Work with employers to develop redundancy and |PCT |April 10 |

| |retirement information | | |

| |13. Work with the Territorial Army to provide awareness |Viewpoint |September 09 |

| |training. | | |

| |14. Work to improve crisis access and referral pathways |Herts Mind Network/HPFT |April 09 |

| |15. Provide support groups for LGBT (lesbian, gay, |Herts Mind Network |Ongoing |

| |bisexual and transsexuals) | | |

| |16. Gain through audit a better understanding of those |PCT |Ongoing |

| |who attempt suicide and how best to provide sustainable | | |

| |support | | |

7.2 Goal 2: To promote mental well-being in the wider population

7.2.1 Current situation

The PCTs have led on the development of a Mental Health Promotion Strategy for Hertfordshire, which sets out wide ranging plans to enhance mental health in its widest sense through initiatives in the health, employment and education sectors. The intention is to nurture a culture where good mental health is seen as an essential feature of good general health for all, with all stakeholders and members of the public having a shared responsibility to achieve these joint aims.

There is a tradition of using World Mental Health Day to promote positive images of mental health, often with a focus on the aspirations of those from ethnic minority groups.

Hertfordshire Cruse and West Herts Hospital Trust are currently running a pilot scheme. The progress of this will be used to influence future actions in the prevention of suicide.

The University of Hertfordshire is developing a healthy campus project and as part of this are using new technologies such as blogging to communicate with students and provide avenues for support.

7.2.2 Three Year Aims

As already stated, we need to do more to address the pressures on older males in the county, and consideration will therefore be given to developing publicity materials targeted at them, emphasising that it is understandable for people facing stresses such as poverty, unemployment or retirement, chronic physical ill health and/or chronic pain, loneliness and bereavement to have feelings of depression, anxiety or despair.

Encourage volunteering for mental health charities and others. This has a two-fold benefit of providing a valuable resource for voluntary organisations and of providing meaningful activity for those in retirement to keep them in social contact, thereby reducing the risk of social isolation.

Alongside the publicity, relevant services must also be in place, such as the bereavement services mentioned above in 7.1.2.

Work should be done to promote sensible drinking, as binge drinking can be a contributory factor in some cases of suicide.

It should not be forgotten that suicides in younger males increased significantly in the early 1990s, and publicity campaigns accompanied by the development of confidential helplines appear to have contributed positively to the elimination of this trend in the past decade. In Hertfordshire we aim to learn from the tragic Bridgend experience of multiple youth suicides, and will consider whether an initiative – for example, Papyrus – is needed, in order to make sure that young adults can access emotional support where necessary. The Samaritans are currently piloting a text support service, the information that comes from this should be used to inform service developments in Hertfordshire.

7.2.3 Action Plan (2008-2011)

|Goal 2 |Action |Lead agency |Date for completion |

| |1. To support existing plans in multi-agency |PCT |Ongoing |

| |mental health promotion strategy around reducing | | |

| |stigma, preventing social exclusion and | | |

| |supporting vulnerable groups. | | |

| |2. To promote and support the development of |PCT/Viewpoint/ JCT |June 09 |

| |services for young adults. | | |

| |3. To provide volunteering opportunities, |CVS and others. |Ongoing |

| |targeting the retired population. | | |

7.3 Goal 3: To reduce the availability and lethality of suicide methods

7.3.1 Current situation

There is good evidence that steps to reduce the availability and lethality of suicide methods do have a positive impact on suicide rates – whether this be the ending of carbon monoxide as a gas in car exhausts, or the creation of blister packs for tablets such as paracetamol to be harder to take quickly in large quantities.

Method of suicide for the years 2001 to 2006 is as follows:

|method |E and N |West |Total |

|Drowning |8 |3 |11 |

|Hanging, strangulation, suffocation |96 |98 |194 |

|Jumping/falling |9 |12 |21 |

|Object related |7 |4 |11 |

|Other or unspecified |9 |10 |19 |

|Poisoning by drugs |45 |69 |114 |

|Poisoning by other means |11 |18 |29 |

|Shooting |5 |5 |10 |

|Jumping or lying before moving object |6 |2 |8 |

|Crashing vehicle |1 |0 |1 |

|Fire |0 |1 |1 |

|Total |197 |222 |419 |

In Hertfordshire, hanging has become the most common method for suicide; it is not possible to inhibit access to this method across the County, particularly in wooded and other public access areas.

Access to this method in more controlled and monitored environments is more achievable, for example, across mental health inpatient units run by HPFT, there is a culture of vigilance towards ligature points, supported by regular checks and by a mandatory ligature awareness training programme for inpatient staff.

There are systems in place to reduce persons overdosing on prescribed drugs. These include 7-day dispensing and regular review of prescribed medication and blister packs. Risk assessment for suicide is part of the management of the depressed person. The new Primary Care Mental Health teams should help to reduce attempted suicide and suicide using prescribed drugs.

The Samaritans are currently undertaking work with Network Rail and train operating companies nationally, to look at safety issues on the railways. Some Mental Health First Aid Training has taken place and work should be undergone to develop this amongst employees most likely to come into contact with those at risk.

7.3.2 Three Year Aims

Hertfordshire’s Suicide Audit Group now monitors for suicide hotspots, checking whether any particular sites in the county are gaining a reputation as places to make suicide attempts. No significant pattern has yet emerged; if it does, at the earliest stage we would plan to take steps – such as working with the Samaritans to install a phoneline, or increase the height of surrounding walls if this would reduce access to a high risk site

In the past, at risk individuals have sometimes been prescribed medication in significant quantities which they have then taken as a fatal overdose. Recent audits in HPFT indicate that it is now well understood that the toxicity and amount of the drugs prescribed should be carefully considered when treating those at risk of suicide.

It will be important to use the ongoing county-wide suicide audit to gain greater understanding of some of these issues, such as the numbers of deaths by poisoning that use prescribed drugs and the numbers that buy the drugs over the counter.

It is proposed to audit prescribing patterns further in primary care – paying attention not only to the number of days of the prescription, but also whether all prescriptions for anti-depressants are clinically indicated.

Through local Samaritan input the Implementation Group will aim to mirror good national practice with Network Rail, and support any national initiatives as far as possible.

Viewpoint’s current work with mental health first-aiders will be evaluated with a view to looking at a possible roll-out.

HPFT to look at availability of training in Suicide Interventions skills, and if not currently available to work with stakeholders to develop training.

7.3.3 Action Plan (2008-2011)

|Goal 3 |Action |Lead agency |Date for completion |

| |1. Through audit, continue to monitor location |PCT |Ongoing |

| |of suicides in-County, taking action to install | | |

| |phone boxes etc, where necessary. | | |

| |2. Agree role of community and PCT pharmacists |PCT |April 09 |

| |in ensuring the safest prescribing practice. | | |

| |3. Work with Network Rail to ensure safety of |JCT/ Samaritans |Ongoing |

| |all Network Rail assets. | | |

| |4. Assess viability of MH Awareness training for|Viewpoint/ HPFT/ University|April 09 |

| |people likely to come into contact with people |of Hertfordshire | |

| |at risk of suicide e.g. Network Rail staff, Vol | | |

| |Org workers | | |

7.4 Goal 4: To improve reporting of suicide behaviour in the media

7.4.1 Current situation

When suicides are reported in detail in local and national media, there is often concern that such publicity may lead to further such incidents, by communicating graphically how a particular method may be used, or by contributing to a misguided notion of the perceived attraction or even “glamour” of such events.

As a result, voluntary concordats with the local press have at times been sought in order to achieve more sensitive reporting, but none are currently in place in Hertfordshire.

In addition, attempts have been made to influence the teaching of journalism to students and to make prospective journalists aware of the considerable influence on public attitudes, for good or ill, that they can have, but with little lasting effect.

In Hertfordshire as elsewhere, articles about suicides may still be insensitive to the feelings of families and others involved, and may also encourage the view that for every suicide someone or other still alive must be held responsible.

In recent years, HPFT and other local mental health organisations have attempted to influence this distorted media agenda by offering more positive stories to the press about mental health, and by challenging or responding to other stories to promote a more balanced view.

7.4.2 Three Year Aims

We aim to continue to build relationships with the local press, using the experience of the Coroner’s office to exert more control than previously. The Communications Departments of the PCTs and of HPFT have an important role to play in this.

It will be important to both monitor coverage as it occurs, to proactively seek more responsible reporting, and actively to correct stories that are misleading persistently and consistently.

Opportunities to influence future journalistic attitudes will continue to be explored, through input to schools of journalism or through establishing voluntary codes of behaviour with local newspapers.

We will use the guidance “Sensitive Coverage Saves Lives” compiled by the Mediawise Trust and the publication “What’s the Story? Reporting Mental Health and Suicide”.

A more concerted effort to provide positive news stories about depression, mental health and emotional problems in general, to the local press and radio will be made. As stated above, this will support the mental health promotion strategy, and will help challenge the view that mental health problems and the chains of events that lead to suicides are always “someone else’s business”.

We will also aim for a higher profile for such subject matter on local radio, adding to the current mental health item presented weekly by HPFT.

We will hold a launch event for the Suicide Prevention Strategy to highlight good practice, engage further stakeholders and give a positive media image.

7.4.3 Action Plan (2008-2011)

|Goal 4 |Action |Lead agency |Date for completion |

| |1. Support bid by Viewpoint for project to |Viewpoint |November 08 |

| |monitor local reporting of mental health | | |

| |issues. | | |

| |2. Pursue voluntary code of conduct with |Viewpoint |June 09 |

| |local press. | | |

| |3. Use HPFT and PCT Communications |HPFT/PCT |Ongoing |

| |Departments to promote good news stories in | | |

| |local media. | | |

| |4. Samaritans to share national experience |Samaritans |Ongoing |

| |of improving media reporting of suicide. | | |

7.5 Goal 5: To promote research on suicide and suicide prevention

7.5.1 Current situation

Through the University of Hertfordshire and HPFT, there are some recent research projects which have extended our knowledge of this area, such as the work of Professor Hawley on clinical risk assessment tools, and of Dr Kouimtsidis on effective care planning and treatment of those with substance misuse problems. A current national audit of bereavement services is being undertaken which will influence future commissioning decisions.

7.5.2 Three Year Aims

Our goals in regard to research are:

1. To encourage local participation in locally initiated research and/or multi-site projects.

2. To facilitate research by providing funding for appropriate projects.

3. To commission research where specific topics might be identified through the county audit.

7.6 Goal 6: To improve monitoring of progress towards the “Saving Lives: Our Healthier Nation” target to reduce suicides by at least 20% from 1998 to 2010

7.6.1 Current situation

Section 5 of this document demonstrates that as a county, Hertfordshire has sufficient information available to monitor progress towards this target over the next three years. It should be stressed that considerable care needs to be taken in interpreting suicide data, because different definitions and catchment populations can easily lead to figures that are not equivalent being directly compared.

It is also important to appreciate that 3 year averages are the best way to report trends, and therefore that there can be a considerable time lag before the most recent data is available.

Our contribution to the national target is to aim to reduce suicides by Hertfordshire residents from 7.9 per 100 000 population in 1996-1998 to 6.7 per 100,000 in 2009 and 6.5 in 2010 and 2011 for both East & North and West Herts PCTs respectively.

7.6.2 Three Year Aims

The County Suicide Audit Group has met to set up the ongoing audit process and now to establish the strategy. The current Suicide Audit and Prevention Working Group will become an implementation group. It has been agreed that it will merge with the Mental Health Promotion Strategy Implementation Group as both groups had representation from the same organisations. Annual reports will be provided to partner agencies, and foremost to the Strategic Commissioning Group led by the Joint Commissioning Team who report to the Joint Commissioning Partnership Board.

The audit itself has a major role to play in measuring progress. In order to do this fully, it will need to agree with GPs that Serious Event Audits will be carried out for each primary care suicide.

7.6.3 Action Plan (2008-2011)

|Goal 6 |Actions |Lead agency |Date for completion |

| |1. Report from Suicide Prevention Group to SCG. |PCTs |May 2009 |

| |2. Confirm group responsible for monitoring |PCTs |Dec 08 |

| |progress towards target. | | |

| |3. Provide annual reports on progress of |PCTs |annual |

| |strategy (including latest data against target) | | |

| |to relevant groups. | | |

8. Implementation

Implementation will be led and monitored by the PCTs reporting to the Strategic Commissioning Group.

It is planned that representatives of:

• PCTs

• Joint Commissioning Team

• HPFT

• Probation Service

• Mental health service users

• Carer organisations

• Police

• Transport Police

• Coroner’s office

• Third sector mental health providers

and others will contribute to the strategy and its implementation over the next three years.

When suicides occur they touch many lives, and it will be important that the strategy and action plan continue to grow and be open to new ideas if it is to have its maximum impact.

Appendix 1

Hertfordshire Suicide Audit 2007

Annual report

1. About this report

Hertfordshire Primary Care Trusts (PCTs) are jointly responsible with Hertfordshire County Council for securing the provision of appropriate care for all those with mental ill health in Hertfordshire. This includes action to reduce the overall rate of death by suicide in the County. Best practice guidance, including the Mental Health National Service Framework (NSF) (1999) and the NHS plan (2000) is available to support local planning and service delivery. Measures by mental health services to achieve a reduced risk of suicide are also set out in the 'National suicide prevention strategy for England' and 'Preventing suicide: A toolkit for mental health services'.

The aim of this report it to inform relevant stakeholders of the trends surrounding this cause of mortality in the population and to develop a local action plan and strategy in the form of a multi agency approach for the prevention of suicides and undetermined injury. Other initiatives supporting this work are being undertaken in the local implementation of the Standards included in the NSF for Mental Health and through the Primary Care Trusts’ Mental Health Promotion Strategy.

National context

The White Paper Saving lives: Our Healthier Nation (1999) outlined a commitment by the government of a target to nationally reduce deaths from suicide and undetermined injury by at least one fifth by 2010. This is supported by Standard Seven of the NSF for Mental Health.

Standard Seven of the NSF for Mental Health says that local health and social care communities should prevent suicides by delivering on the other six standards "and in addition... develop local systems for suicide audit to learn lessons and take any necessary action." The National Institute for Mental Health in England (NIMHE) publications ‘Suicide audit in Primary Care Trust localities: A tool to support population based audit of suicides and open verdicts’ (2006) and ‘Suicide audit in Primary Care Trust localities: A whole systems approach’ (2006) set out a best practice methodology for carrying out suicide audits and collecting information from the audits to inform local, regional and national suicide prevention strategies.

The National Confidential Inquiry into Suicide and Homicide by People with a Mental

Illness (NCI) has been collecting data since 1996 and has published its most recent report Avoidable Deaths (2006) which highlighted a number of steps for Mental Health services to take. This body only captures information on people who have been in touch with secondary care mental health services in the 12 months prior to the suicide event and therefore only captures approximately 25% of the suicides that occur. It has been documented that the audit tool mentioned will enable PCTs to supplement the knowledge obtained from the NCI by adding more detailed information about the 75% of people who die by suicide and who are not in contact with mental health services.

Local context

In Hertfordshire a process for county wide audit of suicides was agreed in 2004 between the Joint Commissioning Team, Hertfordshire Partnership Foundation Trust (HPFT) and Hertfordshire Primary Care Trusts. This is supported by the Coroner and the East of England Strategic Health Authority (EoE SHA).

A process of robust audit and “learning from adverse events” policy is in place within the local Mental Health services provider organisation and a strategy for suicide prevention forms part of the Local delivery plan and the responsibility of the PCT who will be leading on coordinating any future audits.

Aims

The purpose of this report is to provide a baseline to assist the development of future audits and establish a system for collecting relevant information on suicides to inform local, regional and national suicide prevention strategies with the aim of substantially reducing mortality rates by 2010 (from the 'Our healthier nation' baseline, 1995 - 1997).

Methodology

Where possible the methodology in the Suicide audit in Primary Care Trust localities tool has been used to inform the data collection process in this report. The Trust has also had the advice and expertise of local Public Health consultants and Mental Health service providers.

Information was collected from a number of sources; Coroner’s reports (with verdicts in 2007 so far), Serious Untoward Incidents (SUIs) reported to the PCTs and the data being collected on suicides from the local provider of mental health services. Information from medical notes returned to the PCT from GPs following the deaths were also included in the audit. It has been difficult to include detailed information on people committing suicide in the county but who are resident outside.

It is important to note that the Coroner’s Office has now set up an audit form completing data each time a suicide or open verdict is recorded. The PCT will collect these monthly.

An average sized PCT with a population of 100,000 people will have 10-15 suicides or undetermined injury deaths per annum. Therefore it is likely that on average there will be 1 or 2 each month which will need to be audited by the PCT. Part of the action plan to aid future data collection is to design a system to trigger a Significant Event Audit (SEAs) within General Practitioner (GP) surgeries As part of the key action areas identified in the guidance for suicide audits, steps will be taken to address this with GP practices so that information will be available for future audits. The two Hertfordshire PCTs have a population of approximately 1 million.

2. Findings

Demographics

The information collected in this audit relates to 44 cases and the following table outlines the percentages of people in the following age categories. The average age is 52 years old and there were no deaths in the under 25 age group.

Table 1.1

|Under 30 years old |30-40 years old |40-50 years old |50-60 years old |Over 60 year old |

|5% |19% |26% |23% |28% |

From the 44 cases looked at in total only 36 have primary care data.

Table 1.2

The following table shows the local area of registered home address in all 44 cases

|Local Area |Total |

|Ware |2 |

|Hemel |3 |

|St Albans |7 |

|Stevenage |5 |

|Hitchin |1 |

|Hertford |3 |

|Berkhamstead |1 |

|Hatfield |1 |

|Hoddesdon/Broxbourne/Cheshunt/Waltham Cross (East Herts) |5 |

|Watford |2 |

|Radlett & Borehamwood |2 |

|Welwyn |3 |

|Potters Bar |1 |

|Bishops Stortford |2 |

|Out of county addresses |6 |

Occupation of Suicide Cases 2007

Table 1.3

|Caretaker |4 |

|Driver (one unemployed) |3 |

|Accountant (one retired) |2 |

|Other group: Travellers |2 |

|Welder |1 |

|Computer design engineer |1 |

|Car Trimmer |1 |

|Secretary |1 |

|Refuse Worker |1 |

|Underwater videographer |1 |

|Carpenter |1 |

|Plant fitter |1 |

|Teacher/voluntary worker |1 |

|Company Director |1 |

|Electrician |1 |

|Window cleaner |1 |

|IT Programmer |1 |

|Regional Accounts Manager |1 |

|Security Officer |1 |

|Pensions Consultant |1 |

|Contract Manager |1 |

|Officer Worker |1 |

|Unemployed |1 |

|Retired housewife |1 |

|Retired telephonist |1 |

|Retired shop assistant |1 |

|Agricultural builder (retired) |1 |

|Chartered Mechanical Engineer (retired) |1 |

From the data collected on 35 cases, 8 people were registered as unemployed or retired.

Coroner related information

In the data examined under Coroners comments out of the 36 cases examined, 8 had left suicide notes. Hanging was the most frequent method chosen, found in 19 of 36 cases.

Contact with Primary Care

Again there is no clear over all pattern. There is evidence of contact but most were related to physical issues.

There were some difficulties when examining the data available which made matching the data with individual service user’s difficult. It does provide some baseline to build from in future audits.

Where recorded, 13 of the individuals had no diagnosis of mental health in the previous 12 months. Two thirds of suicides cases in Hertfordshire are not under the care of secondary mental health services at the time of the suicide and 75% of people who die by suicide are not in contact with mental health services nationally.

Chronic Illness

From the Primary Care data on 36 cases 12 were shown to have chronic illness recorded in their records. Over 50% of all cases in this report are 50 years older or more and it is expected that some chronic disease would be present; however at this time it is unclear how far these factors were contributory factors.

Mental Health Services

There was no data received in 24 of the 36 cases. In one case the CPN visited the day before, in two other cases, CPN visits were made but the interval is not recorded. In one case there was a 2 month interval and in another there was a 7 month interval. Overall therefore it is impossible to comment on trends.

3. Mortality rates in Hertfordshire from suicide and undetermined injury

In a previous data collection exercise by the public health department at the PCT the following information was found for the period 1993-2007.

Male mortality from suicide and injury undetermined was higher than female mortality throughout the period examined. Rates have decreased overall in the final 3-year period (2005-2007), except for the local authorities of Watford and East Hertfordshire females and, to a small extent, in St. Albans’ males. In Stevenage the rate has decreased since 2002-2004 but is still higher than the East and North Hertfordshire PCT average.

Due to small numbers in the data, 3-year averages were used to examine trends in order to smooth the trend line, freeing it from some of the random or chance variation; by Primary Care Trust (PCT) and Local Authority (LA). These figures can be seen in Appendix A. and the information can be compared with the information below for national and regional figures.

4. National and regional figures, and local targets for 2008/9 – 2010/11

Data gathered from the Office of National Statistics has shown that population estimates over the last three years current as of October 2007 estimate that the national average figures for England are 6.2 and 5.8. These figures are for male and female, all ages and are based on per 100,000 population.

Indicators produced show figures for Hertfordshire over the coming years in line with the 2010 national target.

| East and North Hertfordshire |2009 |2010 |2011 |

|Age standardised death rate per 100,000 population from Suicide and Injury of |6.70 |6.66 |6.62 |

|Undetermined Intent | | | |

| West Hertfordshire |2009 |2010 |2011 |

|Age standardised death rate per 100,000 population from Suicide and Injury of |6.66 |6.63 |6.60 |

|Undetermined Intent | | | |

5. Limitations

The number of suicides in the audit is not a full year so it is difficult to make direct comparisons of actual against target for 2007. The final figure for calendar year 2007 will be confirmed once all the Coroner’s cases for that year are complete and have verdicts. This report incorporates all coroner’s cases from 2007 including those not registered with GP.

On this occasion the group were unable to obtain any data from SEAs, and it was reported that there were some issues regarding the details recorded in the GP medical notes as well as the limitation of information available if the individual was not in contact with mental health services. Auditing the GP notes directly for each case was considered the best method in the absence of SEAs to obtain the primary care data required.

6. Further considerations

Further to the analysis of the findings within this audit, it has been highlighted that other factors may need to be examined in the future such as those surrounding social circumstances and other cases of suicide in family members and recent bereavement. The report Avoidable Deaths suggests that a significant proportion of those who died by suicide were misusing drugs and alcohol. As these finding relate to 25% of these deaths, this is also a consideration for those that have not been in contact with mental health services for primary care.

7. Recommendations

The Suicide Audit Group (SAG), which is a multi disciplinary team of staff involved in the delivery of Mental Health services in Hertfordshire, will refine the datasets used and the processes involved in data collection for the period 2008-09. It is recognised that the data capture needs to be further developed for future audits.

It has been suggested that in addition to guidance provided by the SAG that representatives from the local criminal justice system are approached for their input to future audits as well as the local police.

8. Action Plan

The SAG will devise a mechanism for reviewing the process of audit, its findings and the monitoring of any agreed actions. The following actions will be implemented and monitored by the SAG:

• Develop an action plan based on the key findings within this report. The key findings are:

➢ Majority of suicides occurred in the over 40s, with 28% over 60 years.

➢ Highest numbers occurred in St Albans, Stevenage and East Herts.

➢ A considerable number of people were unemployed or retired (8/35)

➢ One third of people had a chronic illness (12/36)

• Agree a prevention strategy for Hertfordshire suicides and undetermined injury events for presentation at the Joint Commissioning Partnership Board meeting.

• PCT Clinical Governance lead to work with practices to design a system to trigger a SEA following a suicide reported by the Coroner’s Office.

Report prepared by the Hertfordshire Suicide Audit Group

March 2008

Appendix 3

HPFT Suicide Prevention Audit 2007 – Sharing Good Practice

1. The 2008/9 suicide prevention audit examined 10 suicide cases from 2007 and 10 “high risk cases” that have been safely managed.

We found that compliance with national standards was very good for:

• Completion of clinical risk assessments.

• Follow up of high risk inpatients within 7 days (and where necessary 48 hours).

Compliance with national standards was good (but could be improved) for:

• Risk assessments should clearly inform practice

• High risk cases should be on Enhanced CPA.

• Service users with dual diagnosis should be identified and provided with effective well coordinated care and treatment.

• Wherever possible, staff should work in partnership with carers to manage risks.

2. There is no doubt that this audit confirmed a very wide range of good practice. Some of the key features were:

• Good use of a sufficient range of available resources, tailored according to changing needs.

• Accessible, responsive services.

• Staff who are knowledgeable and vigilant, and optimistic about their chances of intervening effectively.

• Good proactive communication between staff – both within HPFT and between this Trust and other agencies.

3. In addition, the audit noted details of good practice shown below. Some of these may be hard to interpret out of context and some relate to good care generally rather than specifically suicide prevention, but they are given here as prompts to teams about what is working well.

➢ Update of the risk review between medical and nursing staff collaborating closely.

➢ Daily changes to care plan in response to the assessment.

➢ Daily medication monitoring but allowing service user to keep full prescription and therefore working with service user’s wishes.

➢ Not discharging service user from care prior to the weekend.

➢ Responsive to service user desires.

➢ Co-working between care co-ordinator and psychologist.

➢ Not allowing a gap between psychology assessments and commencement of treatment.

➢ Facilitating early discharge by involvement with CATT while on the ward.

➢ Using HONOS since August 2007.

➢ Not relying on formal overall care plan when care needed to be assessed and needs changed on a daily basis – e.g. flexibility within a framework.

➢ Evidence of good contact and support to carer and client.

➢ Review by community teams at daily handovers.

➢ Evidence of relatives expressing satisfaction.

➢ Good liaison with family.

➢ Good rapport with GP.

➢ Good links with Adult Care Services to assess for Home Care.

➢ Review of diagnosis when indicated.

➢ Variety of ways of communicating especially with relatives, i.e. email and mobile text messaging.

➢ Collaboration with family regarding property and accommodation.

➢ Actively knowing the service user’s history regarding high and low points and anniversaries during the year.

➢ Respite admission where possible.

➢ Access to CPN and duty workers at all times.

➢ Change in referral process.

➢ Contact by phone to all DNA’s, even out of hours.

➢ Vigilant contact set up as a structure with service user and family members.

➢ Open honest discussion on a regular basis regarding self harm.

➢ Quick referral to consultant for a review.

➢ Good links with home environment especially when not family home.

➢ 24 hours telephone contact with Turning Point.

➢ Comprehensive letter to GP.

➢ Well Being Depot Clinic.

➢ Professionals meetings.

➢ Arranging funding for Detox and Rehab.

➢ Knowledge of the Adult Protection Register.

➢ Dual diagnosis trained identified worker.

➢ “Good practice relies on people going the extra mile”.

➢ “Helps to have Clinical Supervision after a meeting with a service user at risk”

Appendix 4

References

1. Department of Health (1999) National Service Framework for Mental Health. London : Department of Health.

2. Department of Health (1999a) Saving Lives: Our Healthier Nation. London: The Stationery Office.

3. Appleby L., Shaw J., Sherratt J., Amos T., Robinson J., McDonnell R., McCann K., Parsons R., Burns J., Bickley H., Kiernan K., Wren J., Hunt I., Davies S. and Harris C. (2001) Safety First: National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. London: Department of Health.

4. An Organisation with a Memory. Report of an expert group on learning from adverse events in the NHS chaired by the Chief Medical Officer. Department of Health, London 2000.

5. .uk

6. drinkaware.co.uk

Appendix 5

Action Plan 2008 to 2011

GOAL 1

|Action |Lead agency |Date for completion |

|1. Establish systems for gathering full data set of those presenting|PCT |April 09 |

|at A and E Departments after incidents of deliberate self-harm and | | |

|attempted suicide. | | |

|2. Ensure compliance in A and E with NICE guidance on management of |PCT/JCT |April 09 |

|deliberate self-harm. | | |

|3. Explore ways of checking that deliberate self-harm is effectively|PCT |June 09 |

|managed in primary care. | | |

|4. For those with dual diagnosis, build on local initiatives to |PCT/JCT |Ongoing |

|ensure equal access county-wide to effective treatment for alcohol | | |

|abuse. | | |

|5. For the bereaved, ensure support and counselling are equitably |PCT/JCT |Ongoing |

|available county-wide. | | |

|6. Maximise use of Quality and Outcomes framework in primary care, |PCT |Ongoing |

|to ensure learning from incidents and effective detection and | | |

|treatment of those vulnerable for suicide (especially those with | | |

|depression). | | |

|7. Fully functioning Early Intervention in Psychosis service. |HPFT |June 09 |

|8. Begin Hospital at Night Service. |HPFT |Dec 08 |

|9. Extra capital and revenue investment in acute inpatient units. |HPFT/JCT |April 09 |

|10. Significant development of Enhanced MH primary care and |HPFT |April 09 |

|Improving Access to Psychological Therapies. | | |

|11. Local links set up between older people’s mental health services|HPFT |April 09 |

|and bereavement services. | | |

|12. Work with employers to develop redundancy and retirement |PCT |April 10 |

|information | | |

|13. Work with the Territorial Army to provide awareness training. |Viewpoint |September 09 |

|14. Work to improve crisis access and referral pathways |Herts Mind Network/HPFT |April 09 |

|15. Provide support groups for LGBT (lesbian, gay, bisexual and |Herts Mind Network |Ongoing |

|transsexuals) | | |

|16. Gain through audit a better understanding of those who attempt |PCT |Ongoing |

|suicide and how best to provide sustainable support | | |

GOAL 2

|Action |Lead agency |Date for completion |

|1. To support existing plans in multi-agency mental health promotion|PCT |Ongoing |

|strategy around reducing stigma, preventing social exclusion and | | |

|supporting vulnerable groups. | | |

|2. To promote and support the development of services for young |PCT/Viewpoint/ JCT |June 09 |

|adults. | | |

|3. To provide volunteering opportunities, targeting the retired |CVS and others. |Ongoing |

|population. | | |

GOAL 3

|Action |Lead agency |Date for completion |

|1. Through audit, continue to monitor location of suicides |PCT |Ongoing |

|in-County, taking action to install phone boxes etc, where | | |

|necessary. | | |

|2. Agree role of community and PCT pharmacists in ensuring the |PCT |April 09 |

|safest prescribing practice. | | |

|3. Work with Network Rail to ensure safety of all Network Rail |JCT/ Samaritans |Ongoing |

|assets. | | |

|4. Assess viability of MH Awareness training for people likely to |Viewpoint/ HPFT/ |April 09 |

|come into contact with people at risk of suicide e.g. Network Rail |University of | |

|staff, Vol Org workers |Hertfordshire | |

GOAL 4

|Action |Lead agency |Date for completion |

|1. Support bid by Viewpoint for project to monitor local reporting |Viewpoint |November 08 |

|of mental health issues. | | |

|2. Pursue voluntary code of conduct with local press. |Viewpoint |June 09 |

|3. Use HPFT and PCT Communications Departments to promote good news |HPFT/PCT |Ongoing |

|stories in local media. | | |

|4. Samaritans to share national experience of improving media |Samaritans |Ongoing |

|reporting of suicide. | | |

GOAL 6

|Goal 6 |Actions |Lead agency |Date for completion |

| |1. Report from Suicide Prevention Group to SCG. |PCTs |May 2009 |

| |2. Confirm group responsible for monitoring |PCTs |Dec 08 |

| |progress towards target. | | |

| |3. Provide annual reports on progress of |PCTs |annual |

| |strategy (including latest data against target) | | |

| |to relevant groups. | | |

Appendix 6

Partner Agencies

The following Organisations have taken an active role in the development of this Strategy and as such we would like to acknowledge their contribution:

Carers in Herts

Cruse Bereavement Care

East of England Ambulance Service

Hertfordshire Fire and Rescue Service

Hertfordshire Joint Commissioning Team

Hertfordshire Partnership Foundation NHS Trust

Hertfordshire’s Primary Care Trusts

Herts Mind Network

Rethink

Samaritans, Herts/Essex

Turning Point

University of Hertfordshire

Viewpoint

West Herts Hospitals NHS Trust

It is hoped through the implementation of the Strategy that further agencies will become involved.

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APPENDIX 2

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