Suicide and Deliberate Self Harm – Prevention Guidelines

Deliberate self-harm refers to an intentional act of causing physical injury to oneself without wanting to die.

Suicide is the intentional taking of one‘s own life

Ward environments should be assessed by staff regularly to ensure that safety features of the ward are enhanced and that materials that patients may use to self-harm or suicide are not accessible for patients.

1. Eliminate structures that are capable of supporting a hanging object such as exposed utility pipes, sprinkler heads, clothing & towel hooks.

2. Ensure that door-locking mechanisms, patient monitors, alarms, and CCTV are functional.

3. Remove items that can be used as hanging or strangulation devices such as drapery cords, belts, shoe laces, ties, handkerchief, bathrobe sashes, drawstring pants, bras, straps & clothing (belts & neck ties) & ladders.

4. Keep out of reach of the patient; items that can be used in an attempted suicide such as drugs, alcohol, sharp instruments (razors/blades), bolts on the inside of doors, & cleaning fluids.

5. Instruct visitors not to bring in restricted items without staff review.

6. Avoid leaving portable cleaning & maintenance equipment unattended.

7. Use beds closest to nursing stations.

1. Monitor patients who have co-morbid diagnoses that increase the risk of suicide such as depression and substance abuse.

2. Patient with high suicidal risk

3. Use continuous 1:1 observation protocol for very high risk patients

a. Keep patients at arm‘s length at all times.

b. Staff observers should not be engaging in other duties.

c. Patients should be repeatedly assessed for suicidality every xx.

d. Change the observation staff person to avoid burnout, wandering concentration, and to allow patients to interact with different people.

4. If ever a patient expresses suicidal ideation, take it seriously and further explore thoughts for level of intent, and presence of a concrete plan.

5. Monitor patient‘s behavioural signs and symptoms in addition to self-report indicators of suicidality.

6. The medical team should review such patients as frequently as required.

7. Nurses have a key role to play in reducing self-harm and suicides and should carry out the following:

7.1. Care Planning/ Risk identification

7.1.1. On admission an assessment / care plan should be completed to include all risk including risk of suicide or self-harm and the degree of risk 7.1.2. The nurses should ensure that the risk is fully recorded as follows: a. Feelings of hopelessness b. Suicidal ideas and plans c. Expressions of suicide intentions d. History of Self harm and suicidal attempt e. Loneliness and social isolation

f. Family history of suicides g. Difficult circumstances such as bereavement, financial difficulties or other family problems h. Withdrawal from alcohol or drugs 7.2. Ensure that all involved Staff are informed of a patient with a suicide risk 8. Where risks are identified in the assessment/care plan, preventive actions must be taken promptly: 8.1.1. Observations

a. Patients with suicidal risks should be observed constantly. b. The frequency of observation should be determined by the degree of risk identified in the care plan. c. Be aware of certain signs which may indicate that a patient may wish to commit suicide (E.g. suicidal threat, closing bank accounts, refusing to eat or drink) d. Regular discussions with patients in order to identify suicidal thoughts e. Accompany/supervise patients when they are away from the ward area or being transported to other hospital / clinics f. Be aware that the suicidal risk may increase after commencement of treatment in patients with depressed 8.1.2. Monitor the patient‘s safety needs Do not leave the drug tray within reach of the patient and make sure that daily medication is swallowed a. Remove straps and belts that can be used for suicides b. Do not allow the patient to lock themselves inside

c. Keep this type of patient in areas of the ward that are easy to observe (near the nurse‘s duty room) d. Make sure that someone accompanies patient to the bathroom

e. Encourage the patient to talk about their suicidal plans/ methods f. Encourage verbal communication of suicidal ideas

g. Appreciate the patient‘s his positive qualities

h. Prevent drug misuse i. Ensure that on discharge the patient will not be homeless j. Ensure physical illnesses are dealt with before discharge 9. Patient/Family Information a. Lead the patient/relative to understand their care plan on admission and at appropriate intervals b. Medication or other treatment and observations should be explained properly to the patient/relative c. To identify a supporting person from the staff and ensure that the patient knows that they can approach this person with any concerns d. Improve relationships with the family, friends and carers and educate them regarding identification of early signs and expressions of suicidal ideas. They also need to be informed of how to contact any support group (medical staff, social worker, community mental health team support, 1926 line or ward nurses) when needed and they can bring the patient back to the hospital whenever necessary.

1. If nursing staff are aware that a patient has self-harmed or committed suicide they should do the following: 1.1. Deliberate Self Harm

a. Do not delay treatment or transfer because it is a self-inflicted injury b. Notify the medical officer and consultant responsible for the patient c. Complete an accident/ incident form 1.2. Committed Suicide

a. Do not delay treatment or transfer because it is a self-inflicted injury b. Follow the standard medico-legal procedure c. Notify the medical officer and consultant responsible for the patient d. Notify the Director through SGNO e. Complete an accident/ incident form