Preventing Suicide and Deliberate Self Harm
Laying the Foundations: Identifying Practice Examples
Project Report
12. Suicide Review Committee, Lothian Primary Care NHS Trust, Edinburgh
Target Group
The Suicide Review Committee reviews suicide incidents among patients in secondary care services - people under the care of psychiatric services at the time of death. Any suicide within Royal Edinburgh Hospital, the hospitals at Rosslynlee and Herdmanflat, and day care and out-patient facilities is reported to the Committee, as well as the suicide of anyone who has received care services from community-based Trust staff.
Issues
The aim of the review process is to identify learning points and to improve the quality of care.
Services/approach
The committee consists of local psychiatric consultants plus other health professional representatives.
If a suicide has happened, the Review Committee will meet with the team responsible for the person at the time of death. The team would consist of staff working for the Trust, and staff from the local authority or voluntary organisations working with the patient. The review will examine the care received by the person up to their death. The Review Team will ask for a history of the situation, a description of what led up to the death, mechanisms for supporting relatives following bereavement, and support for workers and other patients.
The mechanics of the process are covered by the Trust suicide review policy which covers everything regarding the suicide from the time that it happens until 'closure'.
At the end of the meeting, agreement will be sought as to the learning experiences. A report will be circulated to the responsible medical officer and review team members. The Review Team meets every six weeks to review all recent reports. The report will also be fed back to Trust management through the Trust's system for clinical effectiveness and clinical governance.
Safety issues will also be acted upon separately - there is a mechanism for reporting such issues as the need for collapsible curtain rails or other action immediately to the Trust.
It is often discovered that the team did everything that is reasonable to prevent suicide. It is often difficult to know how the care team could have intervened differently to prevent the suicide from taking place. Even if the person is known to be at risk, it is difficult to know when they might commit suicide.
In the past, the responsible medical officer conveyed the outcome of the meeting to relatives, but the Committee may change this practice, as it may be easier for the relatives if someone independent of the care team undertook this task.
In Lothian, service providers are looking at how to re-shape emergency and crisis responses, as well as develop the idea of one-stop shops to make it easier for people to access services in general.
Key features
For further information, contact:
Dr Diana Morrison
Royal Edinburgh Hospital
Morningside Place
Edinburgh, EH10 5HF
Tel 0131 537 6249