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Preventing suicideA toolkit for ambulanceservices

Overview and instructions 2

The standards 4

Standard 1 Consent and capacity 4

Standard 2 Intervention and care 5

Standard 3 Suicide prevention 6

Standard 4 Family or carer contact 7

Standard 5 Appropriate medication 8

Standard 6 Follow-up care 9

Standard 7 Post-incident review 10

Standard 8 Training of staff 11

Useful resources 13

Contents

Preventing suicide: A toolkit for ambulance services2

Overview and instructions

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

The standardsThe eight standards contained in the toolkit reflect changes in practice that have occurred in ambulance services in the last six years. The standards are organised to look at the process ofadmission through to discharge of a working age adult. Accompanying these standards are detailedaudit procedures which will help you measure your current practice and identify areas forimprovement.

It is necessary to read through each of the standards prior to commencing the general audit tool, inorder to provide you with a more detailed context for each standard criteria.

Assessment – the general audit toolThe general audit tool provides ambulance service providers with an annual method of tracking andmeasuring the level of care provided to patients at risk of suicide or self-harm. It provides acomprehensive view of the level of adherence to the suicide prevention standards contained in theupdated toolkit, and combines a review of trust policy, environmental and patient risk assessments,and the review of a small sample of patient records. It is recommended that the general audit tool isused on an annual basis.

The general audit tool contains:

• a performance summary and performance dashboard that are automatically generated aftercompleting responses to each of the questions

• audit questions relevant to each of the eight standards

• an action plan that lists all actions that have not reached 100 per cent compliance in the sample of inpatient case notes reviewed.

It is recommended that the general audit tool is undertaken on an annual basis. It is alsorecommended that organisations print the performance summary worksheet to provide both front-line staff and the board with regular feedback on the level of care. However, if your trust has awell functioning method of updating both front-line staff and the board on such matters, there is noneed to adopt a new practice.

Preventing suicide: A toolkit for ambulance services 3

Example of a completed performance dashboard

Bar Chart Key:Standard 1 - Consent and capacityStandard 2 - Intervention and careStandard 3 - Suicide preventionStandard 4 - Family or carer contactStandard 5 - Appropriate medicationStandard 6 - Follow-up careStandard 7 - Post incident reviewStandard 7 - Training of staff

Example of a completed performance summary


Standard 1 Consent and capacity

Standard 2 Intervention and care

Standard 3 Suicide prevention

Standard 4 Family or carer contact

Standard 5 Appropriate medication

Standard 6 Follow-up care

Standard 7 Post-incident review

Standard 8 Training of staff

The standards

Standard 1 Consent and capacity

Issues of consent,capacity and mental ill health in theassessment andtreatment of people whoself harm should beunderstood andaddressed by allhealthcare professionals.

1.1 Is there an up-to-date policy/guidance which encompassesconsent to treatment issues and the Mental Capacity Act?

1.2 Does relevant policy/guidance include that all treatmentsshould be explained to the patient unless being delivered in an emergency?

1.3 Is there a policy/guidance in place detailing what staff shoulddo if a patient who lacks capacity or who has not had a capacityassessment completed refuses treatment/transportation?

1.4 Do clinicians know how to access an emergency assessmentunder the Mental Health Act where required?

1.5 Is there evidence that capacity was assessed?

1.6 If the patient was deemed not to have capacity to consent totreatment, did consultation take place with the lasting powerof attorney or court appointed deputy, as appropriate?

1.7 If the patient was deemed not to have capacity to consent to treatment, were the reasons for this recorded in the clinical record?

1.8 Is it recorded that actions taken were in the patient's bestinterests?

Criteria Audit procedure


Standard 2 Intervention and care

Specific personal,cultural, religious orother factors that need to be considered whenexamining or treating the individual areascertained and informthe care given.

2.1 Is there a policy/guidance in place detailing how staff shouldaccess face-to-face and telephone interpreters?

2.2 Is it detailed within policy/guidance that the relatives of thepatient should not be used as interpreters except in the case of medical emergency?

2.3 Is there a policy/guidance detailing procedures regardinggender-specific care and chaperoning, as appropriate?

2.4 Does the policy/guidance dictate that patients are offered achoice of assessment and treatment from male and femalestaff, as appropriate?


People who have self-harmed will betreated with the samecare, respect and privacyas any patient.Healthcare professionalstake full account of thelikely distress associatedwith self-harm.

2.5 Are there methods of collecting data regarding patientexperience in place?

2.6 Are there examples of how patient experience information hasbeen used to inform clinical development within service?

2.7 Is this monitored within trust clinical governance processes?

2.8 Is there evidence of complaints received by patients whoreceived treatment for self-harm?

2.9 Is there evidence of what action was taken in response tothose complaints?

Ambulance crews will collect data andascertain information,which will be passed onto A&E department staffto inform the initialassessment andtreatment plan.

2.10 Is there a policy stating that ambulance staff should obtain allsubstances and/or medications found at the scene of anemergency call and pass these on to A&E department staff?

2.11 Is the scene of the incident recorded?

2.12 Are poisons or equipment used for self-harm recorded?

2.13 Is the environmental context where the incident took placerecorded?

2.14 If significant others were present, are their views recorded?

2.15 Is the outcome of the capacity assessment recorded?

2.16 Is there a record of treatments given or offered?


Standard 3 Suicide prevention

Issues of consent,capacity and mental illhealth in the assessmentand treatment of peoplewho self harm should be understood andaddressed by allhealthcare professionals.

3.1 Do all ambulance staff have access to the JRCALC Suicide andSelf-harm Risk Assessment Tool?

3.2 Is the quality of assessments audited as part of the trust'sannual audit programme?

3.3 Are there examples of how practice has been improved inresponse to audit outcomes?

3.4 Is the audit process monitored within trust clinical governanceprocesses?

3.5 Is there a process in place for staff to access specialistprofessionals for advice when assessing children, young adultsand older persons over the age of 65, who have self-harmed?

3.6 Is there evidence that this information has been disseminatedto staff and is monitored?

3.7 Is there evidence that a risk assessment was carried out?

3.8 Are risk assessments completed in full?

3.9 Is there documentation that a copy of the assessmentinformation has been passed to the patient's GP?

3.10 Is there documentation that a copy of the assessmentinformation has been passed to any relevant mental health services?



Standard 4 Family or carer contact

Healthcare professionalswill provide emotionalsupport, help andinformation aboutsources of help ifnecessary to anyrelatives/friends/carerspresent.

4.1 Is information on crisis and advice organisations, socialservices departments, independent advocacy services,patient/carer's support groups etc available, as appropriate?

4.2 Is there a process in place for provision of support tocarers/relatives, as appropriate?

4.3 Is there a policy/guidance to obtain consent from the patient to involve family/carers in gatheringinformation/contributing to assessment of a patient who has self-harmed, as appropriate?



Standard 5 Appropriate medication

Adequate anaesthesiaand/or analgesia shouldbe offered to people whohave self-injuredthroughout the processof suturing or otherpainful treatments.

5.1 Is there evidence that auditing of appropriate medication ismonitored within trust clinical governance processes?

5.2 Is there evidence that any instances of adequateanaesthesia/analgesia not being given are subject toappropriate management action?


Ambulance staff willhave access to advice andinformation at all times.

5.3 Is there a policy to ensure that TOXBASE and National PoisonsInformation Service (NPIS) is available to ambulance crews at all times?


Standard 6 Follow-up care

People who repeatedlyself harm should beoffered advice on therisks of self harm andadvice on minimisation,self management andcoping strategies.

6.1 Is there a clinical protocol detailing what advice to give topeople who self-harm?

6.2 Does this information include:• details for when harm minimisation advice is and is not

appropriate (for example, for those who harm themselves by self-poisoning)?

• details of advice for those who self-poison?• details of who should deliver advice to those who self-poison?• instructions on how to advise those who inflict superficial

injuries regarding wound care, how to obtain appropriate sterile dressings and equipment and how to deal with scar tissue?

• alternative coping strategies?



Standard 7 Post-incident review

Services should haveaccess to a dedicatedself-harm servicesplanning group whichincludes A&Edepartment staff, generalpractitioners, ambulancestaff and mental healthservices.

7.1 Is information available about how to complain and askquestions if a patient is unhappy with their treatment?

7.2 In the terms of reference for Post Incident Review Groups isthere evidence of:• multidisciplinary working• details for cross-organisational audit• incorporation of patient views and action taken in response

to satisfaction survey data• examination of performance data, incidents and complaints

and action taken in response to this• plans for, and records of cross organisational training• practice and service development activity• the development and implementation of joint protocols• mechanisms for providing formal feedback and information

to trust-boards and commissioners

7.3 Is there a policy to ensure that family/carers are included inpost incident reviews?


All incidents of seriousself-harm or suicide in the community areinvestigated under therelevant primary careorganisation and whereapplicable, mental healthservices’ serious incidentprocedure.

7.4 Does the serious incident policy include:• involvement of parents/carers in the investigation process?• support for parents/carers in the investigation process?• psychological support mechanisms for staff?• process for learning and disseminating lessons?• process for governance and reporting to trust board and

commissioners?

The psychological effectsexperienced by staffshould be a component ofall major incident plans.

7.5 Is there evidence that staff support was addressed?


Standard 8 Training of staff

Staff who have contactwith people who self-harm are providedwith regular training.

8.1 What proportion of relevant clinical staff have receivedtraining to equip them to understand and care for people whohave self-harmed in the last three years?

8.2 Is there a policy regarding the provision of clinical supervisionto staff who care for those who self-harm?

8.3 What proportion of currently employed clinical staff havereceived clinical supervision in the last month?

8.4 What proportion of relevant non-clinical staff have receivedtraining to equip them to understand and assist people whohave self-harmed?


Clinical staff who havecontact with people whoself-harm are providedwith appropriate trainingto equip them tounderstand and care for people who have self-harmed.

8.5 Does the training course for clinical staff cover:• patient involvement?• the problems faced by people who self-harm when they have

contact with services?• an exploration of some of the meaning of and motives for

self-harm?• capacity and consent in relation to self-harm?• risk assessment for suicide and self-harm?• early management?• the impact of cultural issues on self-harm?• carers issues?• the content of the NICE guideline?• specific issues relating to the safeguarding, care and

assessment of asylum seekers, children, young adults and older persons over the age of 65?

Non-clinical staff whocome into contact with people who self-harm (includingreceptionists, domestic staff, securitystaff etc) should beprovided with basictraining to equip them to understand and assist people who haveself-harmed.

8.6 Does the training course for non-clinical staff cover:• basic awareness of mental health issues? • the problems faced by people who self-harm when they have

contact with services? • an exploration of some of the meanings of and motives for

self-harm? • risk awareness? • safety issues relating to the care environment in relation

to those who have self harmed and are at risk of further self-harm?


Ambulance crews shouldbe trained to dealeffectively with incidentsof self-harm.

8.7 Does the training course include:• retrieval of substances/medications from the scene? • initial assessment? • the management of self-poisoning? • when and how to access TOXBASE and NPIS telephone service? • the use of IV Naloxone in the event of opioid overdose?



New horizons: towards a shared vision for mental health. Department of Health, 2009. Available atwww.dh.gov.uk/en/Publicationsandstatistics/Publications

Clinical practice guidelines 2006. Joint Royal Colleges Ambulance Liaison Committee. Available atwww.jrcalc.org.uk

Self-harm. The short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care. Clinical Guideline 16. National Institute for ClinicalExcellence, 2006. Available at www.nice.org.uk

National suicide prevention strategy of England. Annual report on progress 2008. National MentalHealth Development Unit, 2009. Available at www.nmhdu.org.uk

Better services for people who self-harm. Quality standards for healthcare professionals. Royal Collegeof Psychiatrists, 2006. Available at www.rcpsych.ac.uk

Useful resources

© National Patient Safety Agency andMental Health Network 2011.

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

The NHS Confederation29 Bressenden Place London SW1E 5DDwww.nhsconfed.org/mhn

Registered Charity no: 1090329

National Patient Safety Agency4–8 Maple StreetLondonW1T 5HDwww.npsa.nhs.uk

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