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Suicide prevention

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What is covered

This interactive flowchart covers setting up suicide prevention partnerships in community and residential custodial and detention settings. It explains how the partnerships should develop a strategy and plan to:
  • raise awareness
  • reduce access to methods of suicide
  • support people bereaved or affected by suicide
  • prevent suicide clusters
  • reduce the potential harmful effect of media reporting.
It also covers training for gatekeepers.
This interactive flowchart should be read in conjunction with Public Health England's Local suicide prevention planning: a practice resource.

Updates

Updates to this interactive flowchart

9 September 2019 Suicide prevention (NICE quality standard 189) added.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on preventing suicide in community and residential custodial and detention settings in an interactive flowchart

What is covered

This interactive flowchart covers setting up suicide prevention partnerships in community and residential custodial and detention settings. It explains how the partnerships should develop a strategy and plan to:
  • raise awareness
  • reduce access to methods of suicide
  • support people bereaved or affected by suicide
  • prevent suicide clusters
  • reduce the potential harmful effect of media reporting.
It also covers training for gatekeepers.
This interactive flowchart should be read in conjunction with Public Health England's Local suicide prevention planning: a practice resource.

Updates

Updates to this interactive flowchart

9 September 2019 Suicide prevention (NICE quality standard 189) added.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Suicide prevention (2019) NICE quality standard 189

Quality standards

Suicide prevention

These quality statements are taken from the suicide prevention quality standard. The quality standard defines best practice for reducing suicide and helping people bereaved or affected by suicide and should be read in full

Quality statements

Multi-agency suicide prevention partnerships

This quality statement is taken from the suicide prevention quality standard. The quality standard defines best practice for reducing suicide and helping people bereaved or affected by suicide and should be read in full.

Quality statement

Multi-agency suicide prevention partnerships have a strategic suicide prevention group and clear governance and accountability structures.

Rationale

By working together, local organisations can combine their expertise and resources to implement a range of interventions to prevent suicide including addressing risk factors such as self-harm.
Partnerships should have a strategic suicide prevention group to identify priorities and manage the overall strategic direction. Organisations that have a key role in suicide prevention should have senior level representation on the strategic suicide prevention group. Although local structures are likely to vary, the group may coordinate the work of a wider network of representatives from specific services and organisations to implement the local suicide prevention strategy.
To promote understanding, partnerships should involve people with personal experience of a suicide attempt, suicidal thoughts and feelings, or a suicide bereavement. Clear terms of reference and governance and accountability structures will improve effectiveness and sustainability.

Quality measures

Structure
a) Evidence that multi-agency suicide prevention partnerships have a strategic suicide prevention group attended by senior level representatives.
Data source: Local data collection, for example, membership list including job titles and responsibilities and attendance registers.
b) Evidence that multi-agency suicide prevention partnerships have clear governance and accountability structures.
Data source: Local data collection, for example, terms of reference.
c) Evidence that multi-agency suicide prevention partnerships support people with personal experience of a suicide attempt, suicidal thoughts and feelings, or a suicide bereavement, to be involved in the partnership.
Data source: Local data collection, for example, programme of induction and support for people with personal experience who are involved in the partnership.
Outcome
a) Rate of emergency hospital attendance or admission for intentional self-harm.
Data source: Public Health England’s Suicide Prevention Profile includes data on the age-standardised rate of emergency hospital admissions for intentional self-harm in local authority areas. NHS Digital’s Hospital Episode Statistics includes data on A&E attendances for self-harm.
b) Rate of self-harm in the community.
Data source: Local data collection, for example, community or school surveys. NHS Digital’s survey of the mental health of children and young people in England includes questions on self-harm and attempted suicide. Data on episodes of self-harm in primary care are likely to be available from primary care electronic health care record systems.
c) Suicide rate.
Data source: Public Health England’s Suicide Prevention Profile includes data on the rate of suicide in local authority areas for different population groups (based on Office for National Statistics source data).

What the quality statement means for different audiences

Lead organisations such as local authorities and residential custodial or detention providers set up a multi-agency suicide prevention partnership with a strategic suicide prevention group that includes senior representatives from key organisations. Lead organisations ensure that representatives on the group can make decisions and commit resources on behalf of their organisation, and have skills and knowledge in line with Health Education England’s Self-harm and suicide prevention competence frameworks.
Lead organisations ensure that people with personal experience of a suicide attempt, suicidal thoughts and feelings, or a suicide bereavement who are involved in the partnership can access a programme of induction and support. They identify clear leadership for the partnership and ensure it has clear terms of reference, based on a shared understanding that suicide can be prevented. The terms of reference should:
  • clarify local partnership structures, including working arrangements between the strategic suicide prevention group and any wider network or partnership subgroups
  • identify clear governance and accountability structures, including oversight from local health and care planning groups such as the health and wellbeing board
  • clarify links between suicide prevention partnerships in the local community and those in custodial settings, particularly in relation to managing prisoners and detainees in the community.

Source guidance

Preventing suicide in community and custodial settings (2018) NICE guideline NG105, recommendations 1.1.1, 1.1.2 and 1.1.4

Definitions of terms used in this quality statement

Multi-agency suicide prevention partnership
Suicide prevention requires work across a range of settings targeting a wide variety of audiences. Given this complexity, the combined knowledge, expertise and resources of organisations across the public, private and voluntary sectors is essential. A wide range of representatives working with adults, children and young people may be brought together to contribute to a multi-agency suicide prevention partnership.
Strategic suicide prevention group
A strategic suicide prevention group in the community could include representatives from the following:
  • clinical commissioning groups
  • local public health services
  • healthcare providers
  • social care services
  • voluntary and other third-sector organisations, including those used by people in high-risk groups
  • emergency services
  • criminal justice services
  • police and custody suites
  • employers
  • education providers
  • people with personal experience of a suicide attempt, suicidal thoughts and feelings, or a suicide bereavement.
A strategic suicide prevention group in a residential custodial or detention setting could include representatives from the following:
  • governors or directors
  • healthcare staff (including physical and mental health)
  • other staff
  • pastoral support services
  • voluntary and other third-sector organisations
  • escort custody services
  • liaison and diversion services
  • emergency services
  • offender management and resettlement services
  • people with personal experience of a suicide attempt, suicidal thoughts and feelings, or a suicide bereavement, to be selected according to local protocols.
[NICE’s guideline on preventing suicide in community and custodial settings, recommendations 1.1.3 and 1.1.5 and expert opinion]

Equality and diversity considerations

Multi-agency suicide prevention partnerships should make reasonable adjustments to ensure that people with additional needs such as physical, sensory or learning disabilities, and people who do not speak or read English, or who have reduced communication skills, can participate in the strategic suicide prevention group. People should have access to an interpreter (including British Sign Language) or advocate if needed.

Reducing access to methods of suicide

This quality statement is taken from the suicide prevention quality standard. The quality standard defines best practice for reducing suicide and helping people bereaved or affected by suicide and should be read in full.

Quality statement

Multi-agency suicide prevention partnerships reduce access to methods of suicide based on local information.

Rationale

Reducing access to common methods of suicide and to places where suicide may be more likely to occur can be an effective way of preventing suicide. A range of measures can be used to interrupt people’s plans, giving them time to stop and think, or making it more difficult for them to put themselves in danger. An understanding of local information will help suicide prevention partnerships prioritise the methods and places to focus on locally.

Quality measures

Structure
a) Evidence that multi-agency suicide prevention partnerships collect and analyse local information on methods of suicide and locations.
Data source: Local data collection, for example, data sharing protocols and a rapid intelligence gathering process.
b) Evidence that multi-agency suicide prevention partnerships identify how they will reduce access to methods of suicide.
Data source: Local data collection, for example, local suicide prevention action plan.
c) Evidence that multi-agency suicide prevention partnerships review progress in reducing access to methods of suicide at least annually.
Data source: Local data collection, for example, local suicide prevention action plan progress reports.
Outcome
a) Number of suicides by methods identified in the local suicide prevention action plan.
Data source: Local data collection, for example, rapid intelligence gathering. Detailed information on methods should not be included in the published suicide prevention action plan.
b) Number of suicides in high-frequency locations.
Data source: Local data collection, for example, rapid intelligence gathering. Detailed information on locations should not be included in the published suicide prevention action plan.
c) Suicide rate.
Data source: Public Health England’s Suicide Prevention Profile includes data on the rate of suicide in local authority areas for different population groups (based on Office for National Statistics source data).

What the quality statement means for different audiences

Multi-agency suicide prevention partnerships gather and analyse information from a range of sources to understand local patterns in suicide method and location. The partnership uses this information to prioritise the methods and locations to focus on. It includes these priorities in the suicide prevention action plan, identifies actions and regularly reviews progress.
The partnership supports partner organisations to ensure that they comply with national guidance on issues such as providing and maintaining safer cells in residential custodial or detention settings and restricting access to painkillers. The partnership also facilitates data sharing protocols between organisations to support timely analysis of data and actions to reduce access to methods of suicide for people in high-risk groups.
People in the community and in custody know that organisations are working together to prevent suicide.

Source guidance

Preventing suicide in community and custodial settings (2018) NICE guideline NG105, recommendations 1.6.1, 1.6.2 and 1.6.3

Definitions of terms used in this quality statement

Reducing access to methods of suicide
Suicide prevention partnerships should ensure local compliance with national guidance:
Reduce the opportunity for suicide in locations where suicide is more likely, for example by erecting physical barriers (see Public Health England's Preventing suicide in public places: a practice resource). Also consider other measures such as:
  • providing information about how and where people can get help when they feel unable to cope
  • using CCTV or other surveillance to allow staff to monitor when someone may need help
  • increasing the number and visibility of staff, or times when staff are available
  • working with planners who have responsibility for designing bridges, multi-storey car parks and other structures that could potentially pose a suicide risk.
[NICE’s guideline on preventing suicide in community and custodial settings recommendations 1.3.2, 1.6.2, 1.6.3 and 1.6.4]
Local information
Suicide prevention partnerships should use local data including audit, Office for National Statistics and NHS data, as well as rapid intelligence gathering, to:
  • identify emerging trends in suicide methods and locations
  • understand local characteristics that may influence the methods used
  • determine when to take action to reduce access to the methods of suicide.
[NICE’s guideline on preventing suicide in community and custodial settings recommendation 1.6.1]

Media reporting

This quality statement is taken from the suicide prevention quality standard. The quality standard defines best practice for reducing suicide and helping people bereaved or affected by suicide and should be read in full.

Quality statement

Multi-agency suicide prevention partnerships have a local media plan that identifies how they will encourage journalists and editors to follow best practice when reporting on suicide and suicidal behaviour.

Rationale

Irresponsible reporting of suicide and suicidal behaviour may have harmful effects, including potentially increasing the risk of suicide. By promoting best practice, partnerships can encourage responsible reporting, which can help prevent suicide clusters and avoid further distress being caused to those bereaved or affected by suicide.

Quality measures

Structure
a) Evidence that multi-agency suicide prevention partnerships have a local media plan that identifies how they will encourage best practice in reporting on suicide and suicidal behaviour.
Data source: Local data collection, for example, a partnership media plan.
b) Evidence that multi-agency suicide prevention partnerships have a named lead for the local media plan.
Data source: Local data collection, for example, description of partnership roles and responsibilities.
c) Evidence that multi-agency suicide prevention partnerships work with other organisations such as the Samaritans to give feedback to local media journalists and editors about reporting on suicide and suicidal behaviour.
Data source: Local data collection, for example, a feedback log. This may include information on feedback given by other organisations such as the Samaritans.
Outcome
a) Number of local media reports of suicide or suicidal behaviour that do not meet best practice criteria.
Data source: Local data collection, for example, monitoring records.
b) Suicide rate.
Data source: Public Health England’s Suicide Prevention Profile includes data on the rate of suicide in local authority areas for different population groups (based on Office for National Statistics source data).

What the quality statement means for different audiences

Multi-agency suicide prevention partnerships in the community develop a plan for liaising with local media organisations that encourages a positive relationship and promotes best practice when reporting on suicide and suicidal behaviour. Partnerships identify a lead to coordinate the local media plan. Partnerships work with organisations such as the Samaritans to provide feedback to editors and journalists if a report is not consistent with best practice guidelines.
Multi-agency suicide prevention partnerships in residential custodial and detention settings liaise with local media through the Ministry of Justice, if relevant, and encourage Ministry of Justice press officers to follow best practice when reporting on suicide and suicidal behaviour.
Local media journalists and editors work with the local suicide prevention partnership and other organisations such as the Samaritans to increase awareness of best practice and improve reporting standards.

Source guidance

Preventing suicide in community and custodial settings (2018) NICE guideline NG105, recommendations 1.10.1, 1.10.2 and 1.10.4

Definitions of terms used in this quality statement

Best practice when reporting on suicide and suicidal behaviour
This includes:
  • using sensitive language that is not stigmatising or in any other way distressing to people who have been affected
  • reducing speculative reporting
  • avoiding presenting detail on methods
  • providing stories of hope and recovery including signposting to support.
[NICE’s guideline on preventing suicide in community and custodial settings recommendations 1.10.2 and expert opinion]

Involving family, carers or friends

This quality statement is taken from the suicide prevention quality standard. The quality standard defines best practice for reducing suicide and helping people bereaved or affected by suicide and should be read in full.

Quality statement

Adults presenting with suicidal thoughts or plans discuss whether they would like their family, carers or friends to be involved in their care and are made aware of the limits of confidentiality.

Rationale

Families, carers and friends can help to support a person who has suicidal thoughts or plans. They can also provide valuable input to an assessment of the person’s needs to help keep them safe. Involving families, carers or friends can be complex so, providing the person has mental capacity, it is important for them to discuss who they would or would not like to be involved if there is a concern over suicide risk. The person should have the opportunity to discuss information sharing and their right to confidentiality so that they are aware of the circumstances in which confidential information may need to be disclosed to family, carers or friends.

Quality measures

Structure
a) Evidence of local arrangements to provide training on information sharing and confidentiality based on the Department of Health and Social Care's consensus statement on information sharing and suicide prevention to practitioners in contact with adults presenting to health or care services with suicidal thoughts or plans.
Data source: Local data collection, for example, staff training records.
b) Evidence of local processes to ensure that adults presenting with suicidal thoughts or plans discuss whether they would like their family, carers or friends to be involved in their care.
Data source: Local data collection, for example, local service protocol.
c) Evidence of local processes to ensure that adults with suicidal thoughts or plans are made aware of the limits of confidentiality.
Data source: Local data collection, for example, local service protocol.
Process
a) Proportion of adults presenting with suicidal thoughts or plans who discuss whether they would like their family, carers or friends to be involved in their care.
Numerator – the number in the denominator who discuss whether they would like their family, carers or friends to be involved in their care.
Denominator – the number of adults presenting with suicidal thoughts or plans.
Data source: Local data collection, for example, audit of patient records.
b) Proportion of adults presenting with suicidal thoughts or plans who are made aware of the limits of confidentiality.
Numerator – the number in the denominator who are made aware of the limits of confidentiality.
Denominator – the number of adults presenting with suicidal thoughts or plans.
Data source: Local data collection, for example, audit of patient records.
Outcome
a) Proportion of assessments for adults who presented with suicidal thoughts or plans who wanted their family, carers or friends involved, that involved family, carers or friends.
Numerator – the number in the denominator that involved family, carers or friends.
Denominator – the number of assessments for adults who presented with suicidal thoughts or plans who wanted their family, carers or friends involved.
Data source: Local data collection, for example, audit of patient records.
b) Proportion of family members, carers or friends of adults who presented with suicidal thoughts or plans who are satisfied with information sharing about suicide risk.
Numerator – the number in the denominator who are satisfied with information sharing about suicide risk.
Denominator – the number of family members, carers or friends of adults who presented with suicidal thoughts or plans.
Data source: Local data collection, for example, survey of family members, carers or friends of adults who presented with suicidal thoughts or plans.
c) Suicide rate.
Data source: Public Health England’s Suicide Prevention Profile includes data on the rate of suicide in local authority areas for different population groups (based on Office for National Statistics source data).

What the quality statement means for different audiences

Service providers (such as general practices, hospitals, ambulance services, mental health trusts, prisons and social care providers) ensure that processes are in place for adults presenting with suicidal thoughts or plans to discuss whether they would like their family, carers or friends to be involved in their care, and to make them aware of the limits of confidentiality.
Providers ensure that if the person wants their family, carers or friends involved in their care, the nature of their involvement, including how and when information is shared with them, is agreed. Providers ensure that staff are trained and aware of the Department of Health and Social Care’s consensus statement on information sharing and suicide prevention.
Health and social care practitioners (such as A&E practitioners, paramedics, first responders, GPs, nurses, social workers, mental health professionals and allied health professionals) discuss with adults presenting with suicidal thoughts or plans whether they would like their family, carers or friends to be involved in their care. They also make them aware of the limits of confidentiality. If the person wants their family, carers or friends involved, health and social care practitioners ensure they agree how they will be involved and when information will be shared with them.
Commissioners (such as local authorities, clinical commissioning groups and NHS England) commission services that discuss with adults presenting with suicidal thoughts or plans whether they would like their family, carers or friends to be involved in their care. They also make them aware of the limits of confidentiality.
Adults who contact a health or care service and feel suicidal discuss whether they would like their family, carers or friends to be involved in their care. If they want their family, carers or friends to be involved, they agree how they will be involved and when information will be shared with them. They are also told about confidentiality and when it may be necessary to share information with their family, carers or friends.

Source guidance

Definitions of terms used in this quality statement

Adults with suicidal thoughts or plans
Adults who disclose suicidal thoughts or plans when asked about suicide ideation and intent.
[Expert opinion]
Limits of confidentiality
If a person is at imminent risk of suicide, there may be sufficient doubts about their mental capacity to consent to information about their risk of suicide being shared. In these circumstances, a professional judgement will need to be made, based on an understanding of the person and what would be in their best interest. This should take into account the person’s previously expressed wishes and views in relation to sharing information with their family, carers or friends.
The judgement may be that it is right to share critical information. If the purpose of the disclosure is to prevent a person who lacks capacity from serious harm, there is an expectation that practitioners will disclose relevant confidential information, if it is in the person’s best interest to do so. Disclosure may also be in the public interest because of the far-reaching impact that a suicide can have on others.

Equality and diversity considerations

Services that support adults with suicidal thoughts or plans should make reasonable adjustments to ensure that people with additional needs such as physical, sensory or learning disabilities, and people who do not speak or read English, or who have reduced communication skills, can use the service. People should have access to an interpreter (including British Sign Language) or advocate if needed.
Health and social care practitioners should ensure that adults who temporarily lack mental capacity to consent to information sharing are asked if they want their family, carers or friends to be involved in their care as soon as they are able to give consent.

Supporting people bereaved or affected by a suspected suicide

This quality statement is taken from the suicide prevention quality standard. The quality standard defines best practice for reducing suicide and helping people bereaved or affected by suicide and should be read in full.

Quality statement

People bereaved or affected by a suspected suicide are given information and offered tailored support.

Rationale

Children, young people and adults who are bereaved or affected by a suspected suicide are themselves at increased risk of suicide. Providing support after a suspected suicide can reduce this risk, especially when tailored to the person’s needs. It is important to identify people who may need support as soon as possible so that they can be given practical information and access support if, and when, they need to.

Quality measures

Structure
a) Evidence of local arrangements to use rapid intelligence gathering to identify people who may be bereaved or affected by a suspected suicide.
Data source: Local data collection, for example, data sharing agreements and reporting arrangements.
b) Evidence of local processes to give information to people bereaved or affected by a suspected suicide and to ask if they need help.
Data source: Local data collection, for example, a local protocol.
c) Evidence of local services that can provide support to people bereaved or affected by a suspected suicide.
Data source: Local data collection, for example, service specifications and a local directory of information on the services available.
Process
a) Proportion of people bereaved or affected by a suspected suicide who are given information.
Numerator – the number in the denominator who are given information.
Denominator – the number of people bereaved or affected by a suspected suicide.
Data source: Local data collection, for example, audit of case records.
b) Proportion of people bereaved or affected by a suspected suicide who are asked if they need help.
Numerator – the number in the denominator who are asked if they need help.
Denominator – the number of people bereaved or affected by a suspected suicide.
Data source: Local data collection, for example, audit of case records.
c) Proportion of people bereaved or affected by a suspected suicide who access tailored support.
Numerator – the number in the denominator who access tailored support.
Denominator – the number of people bereaved or affected by a suspected suicide.
Data source: Local data collection, for example, monitoring information from local support services.
Outcome
a) Proportion of people bereaved or affected by a suicide who are satisfied with information and support.
Numerator – the number in the denominator who are satisfied with information and support.
Denominator – the number of people bereaved or affected by a suicide.
Data source: Local data collection, for example, survey of people bereaved or affected by a suicide.
b) Number of suicides among people bereaved or affected by a suicide.
Data source: Local data collection, for example, rapid intelligence gathering.

What the quality statement means for different audiences

Multi-agency suicide prevention partnerships carry out rapid intelligence gathering to identify children, young people and adults who may be bereaved or affected by a suspected suicide. Partnerships ensure that coordinated processes are in place across partner organisations to provide information to people who are bereaved or affected by a suspected suicide, to ask them if they need additional help and to signpost them to support if needed.
Partnerships ensure that information and signposting to support is offered to people who are bereaved or affected by a suspected suicide as soon as possible and then at subsequent opportunities to ensure that people can access support when they need it.
Service providers (such as police, hospitals, ambulance services, prisons, general practices, funeral directors, coroners’ offices, employers and education providers) ensure that processes are in place to provide information to people who are bereaved or affected by a suspected suicide (including health and care practitioners and first responders), to ask them if they need additional help and to signpost them to support if needed.
Providers ensure that information and signposting to support is offered to people who are bereaved or affected by a suspected suicide as soon as possible and then at other opportunities to ensure that people can access support when they need it.
Practitioners (such as police officers, GPs, nurses, paramedics, mental health practitioners, prison staff, funeral directors, coroner’s office staff and human resource managers) provide information to people who are bereaved or affected by a suspected suicide, ask them if they need additional help and signpost them to support if needed. Practitioners who respond to a suspected suicide or provide support to people bereaved or affected by a suspected suicide, are aware of how they can access support to help them cope, if they need it.
Commissioners (such as local authorities, clinical commissioning groups and NHS England) commission services that provide support after a suspected suicide with the capacity and skills to meet the needs of the local population, including children and young people. They also commission services that provide information to people who are bereaved or affected by a suspected suicide, ask them if they need additional help and signpost them to support if needed.
Children, young people and adults who are bereaved or affected by a suspected suicide are given practical information, such as an information booklet, and asked if they want any other help. If they do, they are put in touch with a support service.

Source guidance

Preventing suicide in community and custodial settings (2018) NICE guideline NG105, recommendation 1.8.2

Definitions of terms used in this quality statement

People bereaved or affected by a suspected suicide
Children, young people and adults who are bereaved or affected by a suspected suicide may include relatives, friends, classmates, colleagues, other prisoners or detainees, as well as first responders and other professionals who provided support.
[NICE’s guideline on preventing suicide in community and custodial settings, recommendation 1.8.1]
Information
Practical information expressed in a sensitive way that helps people to cope and signposts to other services, such as Public Health England’s Help is at hand guide.
[Expert opinion and NICE’s guideline on preventing suicide in community and custodial settings, recommendation 1.8.2]
Tailored support
Support that is focused on the person’s individual needs. As well as professional support, it could include:
[NICE’s guideline on preventing suicide in community and custodial settings, recommendation 1.8.3]

Equality and diversity considerations

Information for people bereaved or affected by a suspected suicide should be in a format that suits the person’s needs and preferences. It should be accessible to people who do not speak or read English, and it should be culturally appropriate. For people with additional needs related to a disability, impairment or sensory loss, information should be provided as set out in NHS England's Accessible Information Standard.
Services that provide support after a suspected suicide should ensure that staff have the skills and knowledge to support children and young people who are bereaved or affected. Services should also ensure that they provide support for people from black, Asian, other minority ethnic groups and people with religious beliefs in a culturally sensitive way.
Services that provide support after a suspected suicide should make reasonable adjustments to ensure that people with additional needs such as physical, sensory or learning disabilities, and people who do not speak or read English, or who have reduced communication skills, can use the service. People should have access to an interpreter (including British Sign Language) or advocate if needed.

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Effective interventions library

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Implementation

NICE has produced resources to help implement its guidance on:

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

Gather and analyse information

Rationale

Good information is essential for planning, monitoring success and improving the strategy and plan for all settings. The committee agreed that the information should come from different sources to get a clear picture of what is happening. But they also agreed that it is important to make sure the local data collected is as reliable as possible, so that the strategy and plan is as effective as possible.
Although the evidence was limited, the committee agreed with an expert that more rapid and frequent information gathering (rapid intelligence gathering) is important, for example for early detection of suicide clusters.
The committee also agreed that because analysing information on suicides may expose staff to some distressing material, training and support is essential to help them cope.

Impact

Gathering and analysing data may involve some additional resources. But most multi-agency suicide prevention partnerships have some work already in place. So we do not expect this will have a significant resource impact.

Gatekeepers

People in groups that have contact, because of their paid or voluntary work, with people at risk of suicide. People in these groups may be trained to identify people at risk of suicide and refer them to treatment or supporting services as appropriate.
They may include: health and social care practitioners, criminal justice and detention settings staff, police and emergency services, people who provide a paid or voluntary service for the public, faith leaders, railway and underground station staff, and staff in educational institutions.

High suicide risk

High suicide risk means that the rate of suicide in a group or setting is higher than the expected rate based on the general population in England. Groups at high risk can include: young and middle-aged men, people who self-harm, people in care of mental health services, family and friends of those who have died by suicide, people who misuse drugs or alcohol, people with a physical illness, particularly older adults, people in the LGBT community, people with autism, people in contact with the criminal justice system, particularly those in prisons, people in detention settings, including immigration detention settings, and specific occupation groups (see Suicide by occupation, England: 2011 to 2015 Office for National Statistics).
These include high buildings such as multi-storey car parks, railways and bridges and places where other means of suicide are accessible, such as medical, veterinary or agricultural settings where human or animal drugs may be readily available (see Public Health England's Preventing suicides in public places: a practice resource).

Set up partnerships

Rationale

Approximately 6,000 people take their own life each year in the UK. The risk of suicide in the UK prison population is considerably higher than among the general population. The number of people dying by suicide in custodial or other detention settings such as prisons, immigration detention centres, young offender institutions and police custody has increased over the past decade.
Many local agencies can be involved in preventing suicide in the community. Although the evidence was limited, the committee felt strongly that these agencies need to work together to focus on the most effective and cost-effective interventions. By combining expertise and resources, partnerships can cover a much wider area more effectively and implement a range of activities.
Likewise, different services within residential custodial and detention settings can be more effective if they work together in a local multi-agency partnership and with similar partnerships in the community.

Impact

Improved communication and information sharing between statutory agencies and community organisations may have resource implications. For example, the costs of staff time, communication, interventions and the meetings associated with multi-agency teams.
But multi-agency partnership working is already enshrined in the Department of Health and Social Care's suicide prevention strategy for England, updated in the Suicide prevention: third annual report. As a result, multi-agency suicide prevention partnerships have been set up in most community and residential custodial and detention settings, so no additional costs are expected.
These include high buildings such as multi-storey car parks, railways and bridges and places where other means of suicide are accessible, such as medical, veterinary or agricultural settings where human or animal drugs may be readily available (see Public Health England's Preventing suicides in public places: a practice resource).

Suicide clusters

A series of 3 or more closely grouped deaths linked by space or social relationships. In the absence of transparent social connectedness, evidence of space and time linkages are needed to define a cluster. In the presence of a strong demonstrated social connection, only temporal significance is needed. (Adapted from Public Health England's Identifying and responding to suicide clusters and contagion: a practice resource).

Develop a strategy

Rationale

Some evidence and expert opinion showed that having a strategy for how to connect local organisations can help prevent suicide in community and residential custodial and detention settings. (For general reasons why we have made the recommendations see set up partnerships: rationale and impact.)
If the strategy has clear leadership and is based on what is currently happening in the area or setting, it is likely to be effective. This involves gathering data on suicide rates and sharing best practice. A strategy may also help to ensure organisations are prepared to respond to a suicide.
Expert opinion showed that when partnerships share knowledge and experience, this is of greater benefit than working individually. It may include collaborating with neighbouring organisations in the same setting to develop a shared strategy.

Impact

Improved communication and information sharing between statutory agencies and community organisations may have resource implications. For example, the costs of staff time, communication, interventions and the meetings associated with multi-agency teams.
But the Department of Health and Social Care's suicide prevention strategy for England advocates multi-agency partnerships, and suicide prevention strategies have been set up in most community and residential custodial and detention settings. So no additional costs are expected.

Develop and implement an action plan

Rationale

Having a detailed action plan based on local knowledge and clear leadership can help prevent suicide in the community and in residential custodial or detention settings. The plan will be effective if it is based on knowledge of what is happening in the area or setting, involves stakeholders and is adaptable. (For general reasons why we have made the recommendations see set up partnerships: rationale and impact.)

Impact

Multi-agency suicide prevention action plans have been set up in most community and residential custodial and detention settings, so no additional costs are expected. For example, Public Health England's Suicide Prevention Atlas shows which local authorities have suicide prevention plans.

Raise awareness

Rationale

Many people who take their own lives are not in contact with mental health services and may not necessarily be in contact with a GP, so opportunities for clinical interventions can be limited. Non-clinical interventions, such as telephone or text helplines or volunteer-run face-to-face talking are important to support people with suicidal thoughts and keep them safe.
There is increasing demand for non-clinical interventions but little evidence on the benefits. Research is needed to evaluate how effective they are. (The committee made the following research recommendation: 'How effective and cost effective are non-clinical interventions to reduce suicidal behaviours?')
The committee agreed that awareness-raising activities and messages, tailored to people's needs and circumstances, can help get rid of common misconceptions about suicide and self-harm and let people know where they can go for help. They also agreed that increasing local awareness of suicide and the support available is likely to encourage people to seek help. But there can be a fine line between helpful and potentially harmful messages. (The committee made the following research recommendation: 'How effective and cost effective are interventions to support people in the community who are bereaved or affected by a suicide?' )
In residential custodial and detention settings, they agreed that extra support during particularly vulnerable times, such as 'early days', might reduce the risk of suicide. Peer support, along with measures such as the provision of 'safer cells', might also help to act as deterrents. But there is a lack of evidence and more research is needed to evaluate the effectiveness of different interventions in a range of custodial settings. (The committee made the following research recommendation: 'What interventions are effective and cost effective in reducing suicide rates in custodial and residential settings?' )

Impact

Increasing local awareness of suicide and the support available could encourage more people to seek help and so increase health and social care costs.

Reduce access to methods of suicide

Rationale

The committee agreed that it is important to identify local suicide trends, including common methods and places where suicide is more likely, such as bridges and railway stations. That way action can be taken to reduce people's access to both the methods and places.
Physical barriers like fences and netting could reduce the number of suicide deaths in places where suicide is more likely because it makes it more difficult for people to put themselves in danger. Evidence showed that if a barrier stops a person from taking their life in one place they will not automatically go somewhere else and try again.
Similarly, compliance with national guidance, for example on safer cells in custodial settings (see the Ministry of Justice's Quick-time learning bulletin: safer cells) and restrictions on painkiller sales in the community can act as an effective deterrent.
The committee agreed that, despite the lack of evidence, it may be worth thinking about implementing these measures because they can sometimes give people time to stop and think – and so may prevent deaths. The presence of staff at high risk locations may also give people a chance to reconsider, as well as being a source of timely support.

Impact

Where physical barriers or other measures are needed this may have a resource impact in terms of staff time and construction and maintenance costs. NICE has an implementation tool to help determine the cost effectiveness of different interventions.

Support people bereaved or affected by suicide

Rationale

The committee agreed that people affected by a suspected suicide may, as a result, be at risk of harming themselves. This includes family members and friends of people who have died, as well as first responders.
The committee heard that bereavement support can reduce this risk, especially when tailored to the person's needs. People who had bereavement support were also likely to experience lower levels of depression and anxiety. Some of these benefits were based on personal accounts because the evidence was limited.
Some services have been developed locally to provide this type of support. But because there is very little evidence on the benefits, local authorities are reluctant to commission such services. Research is needed to build an evidence base on these interventions for people in the community so that effective and cost-effective statutory and voluntary services can be developed. (The committee made the following research recommendation: 'How effective and cost effective are interventions to support people in the community who are bereaved or affected by a suicide?')

Impact

The committee recognised that providing support for people affected by suicide may be cost effective from a societal perspective, when the costs of productivity losses are taken into account. However, because of the lack of evidence this supposition needs to be treated with caution.

Prevent suicide clusters

Rationale

Suicide clusters can emerge quickly and unexpectedly. But an expert told the committee that if the right systems are in place then it is possible to reduce the likelihood of further deaths.
This was supported by the committee's own experience. An expert also explained to the committee that the police and the coroner's office need to notify agencies as soon as possible when a suspected suicide is being investigated. That is because an inquest to confirm cause of death is usually only held 6 to 12 months after the event. This is too late to prevent new suicide deaths if a cluster is developing.
Residential custodial and detention settings have a duty to undertake and learn from reviews of incidents of self-harm to prevent future occurrences and make custody safer.
Based on this information and their own experience, the committee agreed that rapid intelligence sharing is important.

Impact

Improved communication and information sharing between statutory agencies and community organisations may have resource implications. For example, the costs of staff time, communication, interventions and the meetings associated with multi-agency teams.

Reducing the potential harmful effects of media reporting

Rationale

Irresponsible reporting of suicide may have harmful effects, including potentially increasing the risk of suicide.
Reports of the method used in a suspected suicide seems to increase the risk of other people copying the suicide – so-called copycat suicides. And inaccurate media reporting upsets people bereaved by suicide. So steps to encourage responsible reporting could prevent further suicide deaths.
Although there was little evidence on personal experiences of suicide or suicidal behaviour shared through social media, the committee agreed that the guidance given to the media should also apply to social media.
To combat the harmful effects of irresponsible reporting, the committee agreed that it is important to promote best practice and also monitor media coverage.

Impact

Providing training for journalists may have cost implications. But better reporting generally has beneficial outcomes.

Training

Rationale

Some evidence showed that training improves people's knowledge about suicide, the risks and how to prevent it. The committee agreed that it may be effective to train a range of people involved with both the public and with occupational groups known to be at high risk of suicide. That way they can help spread general prevention messages and encourage people at risk to talk and seek help.
But UK evidence on the effectiveness of gatekeeper training is limited and there are only a few specific training programmes available. Training for all gatekeepers is important because it may help to identify more people at risk of suicide. But research is needed to evaluate how effective it is. (The committee made the following research recommendation: 'How effective and cost effective is gatekeeper training in preventing suicides?')

Impact

Training can be costly. But it is expected to be made available through existing continuous professional development programmes, so the costs for professionals and organisations could be minimised. For example, Health Education England has developed generic and specialist competencies for people working with adults and children with suicidal behaviour or ideas and for non-specialists working in community settings.

Glossary

(reduced access to time out of cell and purposeful activity, usually as a result of short staffing or serious incidents)

Paths in this pathway

Pathway created: September 2018 Last updated: September 2019

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