Most people who attempt to end their life, don’t actually want to die; they just cannot stand the pain of living at that particular moment. By simply treating patients with compassion and empathy, and validating how they are feeling, we can decrease the amount of pain they are in at that moment. And in doing so, help to decrease their feelings of suicidality. 

Each patient who expresses suicidal thoughts should have an individualised care plan (safety plan), tailored to their own needs. Care plan details should be put on patient’s notes as necessary and accommodated as best possible. The plans should involve Primary Care Mental Health Teams as appropriate.

View and download the template safety plan.

Practices should provide information to patients on their website about being suicide aware. Information should be kept up to date throughout the year.

An example of this could be: 

We are in the process of becoming a Suicide Aware Practice.
We are trying to improve the access to our services for people having thoughts of hurting themselves or ending their life. All our staff have had training in suicide prevention and so you can reach out to anyone at the surgery and ask for help.
We also provide support for anyone affected by the death of someone by suicide. Please contact the surgery if you feel you need help.
If you are having any current thoughts about suicide, then during the hours of 8am-6.30pm Monday to Friday please contact the surgery urgently by...
Outside of these hours you can...

• Call 111 and ask for a mental health practitioner
• Text HANTS to 85258
• Contact the Samaritans on 116123 or visit www.samaritans.org
• Safehavens can provide emotional and practical support to people experiencing mental health crises.
  • Your local Safe haven is...
  • Their phone number is...
  • They are located at...
  • Their opening hours are...

You can access all of the most up to date information at Hampshire and Isle of Wight Healthcare NHS Foundation Trust's 'Help in a crisis' page.

Appropriate changes should be made to increase access to patients experiencing mental health crisis:

• Protocols should be in place to support patients seeking help in mental health crisis, making this as easy and effective as possible.
• Mental health crisis needs to be seen urgently same day – or at least assessed same day

A mental health crisis should be seen as no different from an acute physical health problem and, ideally, a patient in crisis should be assessed the same day. In primary care, mechanisms should be put in place to show that practitioners will support patients in crisis and to make access to care as easy as possible.

Sharing feelings of suicide with anyone can be difficult, particularly to people you don’t know. This should be considered across practice staff. For example, receptionists could ask:

‘Is this for your physical health or mental health?’ If the answer is ‘mental health,’ then the follow-up question could be ‘Is this a same-day urgent issue or routine?’ The feedback groups supported this approach as a less invasive way of accessing the help they need.

Every GP practice will have differing mechanisms for its patients to book appointments. However, it is vitally important that someone having a mental health crisis is assessed urgently, similar to any acute physical health problem. Practices should therefore have protocols in place to ensure patients in mental health crisis receive prompt care.

People with living experience reported difficulty asking for help when in mental health crisis. They even reported that they were unsure if Primary Care could provide support in mental health crisis.

By displaying suicide aware information in waiting rooms and clinical areas, patients will hopefully be encouraged to reach out to Primary Care staff for help and support. 

Posters have been developed with people with living experience, download here.
 

Where possible, offer patients continuity of care. Continuity does not have to be with a GP, it can be with other appropriate members of the healthcare team. Some possible suggestions are:

• Offer appointments with the same clinician where possible.
• Appointments can be booked by the clinician themselves, especially if worried about risk. If you feel a patient needs to be seen, book the appointment for them there and then.
• Involve Primary Care Mental Health teams to help with continuity if appropriate.
• If continuity is not possible, use IT systems to ensure crisis care plans are readily available to all members of staff. Put alerts on patient’s notes about how best to help them when they are in crisis e.g. prefers to wait in car, prefers face to face, note safety plan, grounding helps/doesn’t help etc.

GP Practices should share their bypass numbers with relevant services including Community Mental Health Teams (CMHT), Crisis teams, NHS111 and emergency services (inc. Police and Ambulance) to improve communication between services. Secondary care and emergency services will be able to communicate any concerns more effectively thus hopefully avoiding missed electronic and paper correspondence. Be aware that practices also need to obtain the bypass numbers of each of these services to facilitate timely communication.

Practices can use, where appropriate, their in-house Primary Care Mental Health team Multidisciplinary Team meetings to facilitate communications between secondary care teams. 

It can be difficult to know how and when to involve friends and family members in the care of someone at risk of crisis and suicide. Information in the clinical training provides clinicians with guidance about how and when they can involve family members and the legalities behind breaking confidentiality in a patient’s best interests in this circumstance.

Primary care should ensure: 

• Compassion and an empathetic approach is extended to the friends and family who are involved in the patient’s care
• Appointments are offered to friends and family registered in the practice to ensure they are being supported for their own wellbeing

In collaboration with Zero Suicide Alliance, the Department of Health and Social Care (DHSC) has produced SHARE, a guide to support healthcare professionals who may need help understanding when they can share information in relation to suicide prevention. This covers consent, confidentiality, information sharing, and the relevant laws, rules, and regulations. The main principles are to: 

• Seek consent to share information
• Have regard to the law, rules and regulations
• Always act in the patient’s best interest
• Record all discussions an activities
• Ensure service user confidentiality is respected
   

All clinical staff should take the 50-minute suicide aware practice training for clinical staff. This training discusses:

• facts and language that should be used when talking about suicide.
• assessing risk of suicide and potential risks factors for deaths by suicide.
• living experience feedback of patients experiences of Primary Care when they or their loved ones have had thoughts of suicide, or have died by suicide.
• how we can help in Primary Care, including the use of safety planning.
• postvention; what to do in the event of a death by suicide, either in patients or staff.

In addition to this, it is recommended that all clinical staff complete the following short training:

• Free online suicide awareness training from the Zero Suicide Alliance
• NHS Suicide Awareness – E-Learning established by NHS Hampshire and Isle of Wight (module 1 and 2)

All staff should be aware of the best practice guidance for safety assessment, formulation and management.

All non-clinical staff should take the short suicide aware practice training for non-clinical staff. This training:

• explains what the Suicide Aware Practice scheme is and why it is important.
• highlights the importance of asking about suicidality if there is concern, emphasising that asking about suicide does not increase the risk of suicide.
• discusses the importance of escalating any concern to appropriate team members.

In addition to this, it is recommended that all non-clinical staff complete the following short training:

• Free online suicide awareness training from the Zero Suicide Alliance
• NHS Suicide Awareness Website – E-Learning established by NHS Hampshire and Isle of Wight ICB (module 1)

The suicide prevention training outlined above should be embedded into all inductions (including locums) to ensure all new or temporary staff are aware of protocols.

All staff should be aware of the suicide prevention information hub and be encouraged to use it. All staff should have a shortcut on their desktop that leads them to the Suicide Prevention online information resource. Information will be therefore readily available when needed.

Clinical and dispensary staff need to consider safety when prescribing to patients with a past and/or a current history of suicidal thoughts and/or self-harm.

Self-poisoning is the second most common cause of death by suicide. The most common medication for a mood disorder is a Selective Serotonin Reuptake Inhibitors (SSRIs), which is not without risk, especially in younger people. Z- drugs, benzodiazepines, tranquillisers, beta-blockers, opiates, and other antidepressants come with risk. Consider the following points to mitigate risks:

Dependence Or Withdrawal Symptoms

Healthcare professionals should provide verbal and written information about the medicine’s name, purpose, side effects, how to safely store as well as where to contact if there are any problems. Helpful guidance can be found in these documents:

• Medicines associated with dependence or withdrawal symptoms: safe prescribing and withdrawal management for adults
• Self-harm: assessment, management and preventing recurrence

Safer prescribing and dispensing

The recommendations in this section apply to all healthcare professionals.

When prescribing medicines to someone who has previously self-harmed or who may self-harm in the future, healthcare professionals should take into account:

• The toxicity of the prescribed medicines for people at risk of overdose (for example, opiate-containing painkillers and tricyclic antidepressants (TCAs)) 
• Their drug and alcohol use
• The risk of use, and possible interaction with prescribed medicines
• The person's wider access to medicines prescribed for themselves or others
• The need for effective communication where multiple prescribers are involved.

Note - TCAs are now more often used for conditions other than depression such as analgesia or migraine prophylaxis. Therefore, the patient’s mental health may not be at the forefront of a consultation when initiating this medication. However, practitioners should discuss the harms of TCAs in overdose with patients with a past or current history of self-harm or suicidal ideation.

Read the STOMP and STAMP principles behind the pledge.

Use shared decision making to discuss reducing the access to means to suicidal thoughts. Regarding medicines consider: 

• Reducing the amount prescribed e.g. weekly prescriptions
• Consent for carers to oversee medication
• Ask them to return unwanted medicines
• Ensure regular reviews of medications

Consider carrying out a medicines review after an episode of self-harm:

• Take into account the pharmacokinetic properties of medicines, for example, half-life, risk of toxicity and the concurrent use of medicines such as benzodiazepines and opiates.
• If necessary, contact the National Poisons Information Service for further advice.
• For people with learning disabilities, neurodivergence including autism or both, the NHS England STOMP-STAMP principles may be useful.

Healthcare professionals should use consultations and medicines reviews as an opportunity to assess self-harm if appropriate. For example, asking about thoughts of self-harm or suicide, actual self-harm, and access to substances that might be taken in overdose (including prescribed, over- the-counter medicines, herbal remedies and recreational drugs).

Special considerations:

• Practitioners should alert patients to the possible increase in suicidal ideation when initiating anti-depressants and ensure adequate follow up is booked immediately if there are concerns.
• Practitioners should be aware that the use of beta-blockers, especially in younger people, should be avoided if possible in patients with a history of self-harm or suicidal ideation as there is an increased risk of harm in overdose.

Clinical staff should be trained in delivering safety plans to patients expressing suicidal thoughts as evidence suggests safety plans help with suicide prevention.

• Covered in the clinical PowerPoint training
• All patients with thoughts of suicide should have a safety plan

A safety plan is an agreed set of strategies, activities, people to help and organisations to contact when in crisis. It should:

• be co-created with the patient
• have immediate and long-term strategies
• be put somewhere safe and accessible and to be USED when in crisis

Information and guidance on safety planning can be found here. In its most simple form, a clinician can ask a patient: ‘What are you going to do to keep yourself safe between now and when you are seen next?’

The following are some examples that can be suggested but are in no way exhaustive:

• Reasons for living e.g. positivity, photos
• Things to lift/calm mood e.g. yoga, meditation
• Ways to make the situation safer e.g. identify distress triggers, change environment
• Distractions e.g. keeping busy through activities and mind
• Sources of support e.g. family, friends, specialist support (e.g. Safe Havens, 111, Samaritans, text SHOUT).

A safety plan template can be found here.
A safety plan specifically for the use with children and young people us to the age of 35 can be found here.
A safety plan for prescribing can be found here.

Suicide Prevention champions are there to be advocates for the Suicide Aware practice scheme, the patients and the team. 

Practices should ideally have at least two champions per practice and ensure that there is both a clinical and non-clinical champion. Both champions need to proactively advocate the scheme, ensuring staff and patients are aware of suicide prevention and postvention.

• Champions can be responsible for ensuring the Suicide Aware scheme is completed to an adequate standard by using the checklist to utilise completion.
• Champions are to be advocates of the scheme and of patients in mental health crisis.
• Champions can be used to actively reach out to people who may be affected by a death by suicide in the practice. This could be registered family members of people who die by suicide, or staff members affected by the event, to ensure they receive prompt support.

Clinical champions should:

• Be a sounding board for other team members who may need advice and support regarding individual patients.
• Help with postvention in the event of a death by suicide; especially organising the “in-house debrief”.

Non-clinical champions could be any member of practice staff who have the right skills to do it, including practice managers, receptionists and other members of the supporting team. They are expected to:

• Ensure that all staff do the training and are encouraged/reminded to complete the training.
• Proactively initiate postvention protocols in the event of a death by suicide.
• Ensuring the checklist has been completed to an adequate standard. 

You may be notified of a death by suspected suicide by the police, by the Coroner’s Office, or by a colleague/friend. The Coroner’s Office will make contact with the GP practice as part of their investigation into the events leading up to the death. You will be asked to provide any information that you have relating to the healthcare of that individual. 

Immediate Action (within 24 hours)

Please be mindful of when the news about a possible suicide is communicated with team members.

• People may find the news of a possible death by suicide distressing for several reasons.
• Ensure the news is delivered with empathy and compassion and takes into consideration the individuals workload for the day. E.g. finding out in the middle of a busy duty morning is unlikely to be appropriate. 

Please be mindful that any member of staff can be affected by a possible death by suicide, including clinical and non-clinical staff.

• Proactively identify any staff members who may have been affected and provide empathetic and effective support. Please ensure anyone bereaved/affected is aware of the Cruse Support after Suicide Service.
• Phone call/visit the bereaved family, if appropriate. Extend sympathies and offer referral to Cruse.
• Put a flag on the system for any linked family members, to ensure compassionate approach and bereavement by suicide support (Cruse) is discussed at next consultation.
• Be aware that people bereaved by (suspected) suicide are at significantly greater risk of suicide/suicidality than people bereaved by other means.
• In the case of a death of a patient who is under 18 years of age, the GP will be invited to attend the Joint Agency Response (JAR) meeting. This takes place usually within 24 hours of a notification.

Action within 2-3 days

• A debrief of the case may be useful to clarify what happened and allow staff members to discuss the situation. 
• Ensure it is done in a compassionate and non-judgemental manner that does not reinforce stigma or feelings of blame.
• Staff should be reminded of suicide bereavement services i.e Cruse Support after Suicide.
• Reminding staff to see their own GP for support can be useful and should be encouraged. 

Longer Term

• Offer support in the lead-up to and around the Inquest. 
• Remind families that they are able to self-refer (or be referred with consent) to the Cruse Support after Suicide service, even if they have been discharged from the service (i.e. referral is open at any time). 
• Remind families of other ongoing support that is available to them, e.g. SOBS which provides peer support.

Useful Links:

• Survivors of bereavement by suicide (SOBS)
• Samaritans media team

You may be notified about the death of a colleague by the Police, by the Coroner’s Office, or by a colleague/friend. The Coroner’s Office will make contact with the GP practice as part of their investigation into the events leading up to the death. You will be asked to provide any information that you have relating to the healthcare of that individual. 

Immediate Action (within 24 hours) 

• Immediately identify any staff members who may have been affected and provide empathetic and effective support. Please ensure anyone bereaved/affected is aware of the Cruse Support after Suicide Service. Ensure you are addressing the bereaved family’s wishes. 
• Consider carefully any media/comms you put out about the death of the colleague, ensuring that you are working with the bereaved family’s wishes. The Samaritans media team can provide helpful support at this time. 
• Suicide Aware champions (or other suitable staff members) could possibly call/visit to the bereaved family, if appropriate, to extend sympathies.
• Flag on the system linked family members, to ensure a compassionate approach and referral to bereavement by suicide support (Cruse Support After Suicide) is discussed at next consultation. 
• Be aware that people bereaved by (suspected) suicide are at significantly greater risk of suicide/suicidality than people bereaved by other means. 
• Suicide Aware Champions to ensure colleagues have a point of contact for support and advice. 

Action within 2-3 days 

• A discussion amongst staff to allow them to discuss and reflect on the situation may be useful.
  • This will be different to the discussion of the death of a suspected suicide of a patient as details are unlikely to be known.
  • Ensure it is done in a compassionate and nonjudgemental manner that does not reinforce stigma or feelings of blame.
• Staff should be reminded of suicide bereavement services i.e Cruse Support after Suicide.
• Reminding staff to see their own GP for support can be useful and should be encouraged.
• Monitor the wellbeing of all staff and consider flexible work options if necessary and possible.
• Consider a memorial and make sure it follows best practice.

Longer term

Offer support to staff in the lead up to and during the inquest. There are resources available that can be helpful for professionals and bereaved people:

• Coroners Courts Support Service
• A Guide to Coroner Services for Bereaved People
   

A death by suicide can affect clinicians in a way that no other death does. It can lead to feelings of guilt, feelings of blame and deliberating over what a clinician could have done to prevent the death. 

It is important to remember that when there is a death by suicide NO ONE IS TO BLAME.

Primary Care can be an isolating place at times so remember to reach out to others if you need.

• Connect with people around you:
  • Avoid isolation which allows you time to ruminate.
  • Try speaking to family, friends and colleagues about your feelings.
• Soothe yourself:
  • Acknowledge your feelings and feel okay to express your emotions. It helps to know what enables you to relax and to make sure you do it.
  • Be kind to yourself. Self-criticism and impatience won’t help you feel better.
  • Treat yourself as you would treat a good friend or your patients. Try to have patience regarding your own difficulties. Some people might like to use relaxation, mindfulness or gentle exercise as healthy coping mechanisms.
• Look after your emotional health - Some clinicians have reported that it was helpful to read articles, papers or books related to suicide and other clinicians’ experiences in similar situations. For example, there is a book called ‘Working in the Dark’ by Campbell and Hale (2017) who theorise about the nature of suicide and why it can leave such distress in people that survive, including clinicians.
• Look after your physical health – Sleep, eat regular meals, stay hydrated, keep physically active. Reduce or limit alcohol consumption, ‘self-medicate’ or ’overdo it’ (sport, work, other activities). Keeping a healthy day-to-day routine will help reduce tiredness and emotional exhaustion.
• Seek support and be aware of the Cruse Support after Suicide Service to which you can self-refer. This service is completely confidential and you can contact them anonymously.
• Going for a walk with a friend, or some similar activity, might also be an invaluable distraction if you are feeling preoccupied and unable to stop thinking about the death. Some professionals also noticed the benefits of talking to a therapist, in a safe and confidential setting.
• Identify any triggers and avoid reminding yourself of the incident to limit distress.
• Consider making temporary adjustments to your work patterns - it may be helpful taking some time away from work to recover and you should consider if a temporary adjustment to your clinical duties is desirable. A referral to Occupational Health might help put necessary measures in place if you need ongoing adjustment to your work pattern to support your recovery and to deliver safe patient care.
• Be aware that people bereaved by (suspected) suicide are at significantly greater risk of suicide/suicidality than people bereaved by other means. It is important to recognise this and look after yourself.