The beguilingly simple steps to reduce suicides
This week, we marked world suicide prevention day. Suicide is a preventable tragedy, a global public health problem that has increased in recent decades. The World Health Organisation suggests that, globally, there has been a 60 per cent rise in suicide over the past 45 years, with a current rate of about one death every 40 seconds. In some nations, suicide has become one of the leading causes of death, and in the US, the majority of fatal gunshot wounds are self-inflicted. Suicide is more common than homicide.
With such macabre statistics, it’s not surprising that suicide prevention has, in many nations, become a public health priority. At the heart of this effort is identifying and understanding risk factors. Our attempts to prevent hinge on our ability to predict.
Having non-punitive mechanisms for reporting and investigating suicidal behaviours improves our ability to predict. Such an open and systematised approach to reporting and analysis leads to improved risk identification and the implementation of comprehensive strategies grounded in the local experience.
In one of my previous roles within the National Health Service in the UK, I was responsible for investigating all suicides and attempted suicides undertaken by people using mental health services in Lancashire.
The first case I ever investigated involved a young man of about 20 years old who had been hospitalised for severe depression.
This was the patient’s first psychiatric hospitalisation, and his parents were understandably apprehensive about having him admitted. On his first night at the hospital, the patient phoned his parents complaining that he was being bullied and that there was a general lack of care and attention from the staff.
Early the next morning the parents called the ward to speak to their son. A nurse went to get him, but he wasn’t in his room. After a fruitless search of the hospital and its grounds, the police were notified. Later that day the hospital ward received a report that a young man fitting their missing patient’s description had died from injuries sustained after throwing himself from the roof of a local bus station.
One of the issues that came to light while investigating this case was that the patient had not received a risk assessment. Such assessments are standard, providing the clinical team with an idea about the level of risk patients pose to themselves or others. A tragic irony, in this case, is that a suicide note was later discovered, and this melancholic farewell to loving parents had been written on the back of a blank risk assessment form.
Could this suicide have been prevented? In retrospect, the answer is nearly always yes. In this case, had the risk assessment been undertaken the patient may have been placed under observation and prevented from leaving the ward. We could have stopped the inquiry there and simply played the blame game. However, our systematic investigation technique required that we also consider the broader context. For one thing, the ward was understaffed and the risk assessment training for staff had lapsed.
Delving deeper, we also discovered that this particular hospital had experienced a spike in suicide attempts and completions every April going back as far as records existed.
Effective prevention is born of open reporting and adopting incident investigation techniques
Our case was also an April case. It transpired that April was the time of year when lots of the hospital’s staff took holidays. This mass exodus in April was due to a policy stipulating that leave not taken before April 30 could not be carried over into the next financial year. Identifying this systemic issue was more useful than pointing the finger at a valuable staff member. Among other things, a simple change to the annual leave policy ensured that the risk of similar future suicides was greatly reduced.
Effective prevention is born of open reporting and adopting incident investigation techniques that focus on systems and broader context. In the absence of such an approach, suicide can be misreported (accident/misadventure etc), under-reported and under investigated. Preventing suicide is saving lives. “And whoever saves one life it would be as if he saved the life of all humankind” (Quran 5:32).