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1.1.11 Suicide and Self Harm Policy

Contents

  1. Introduction and Purpose
  2. Standards and Procedures
  3. Threats of Self Harm / Actual Self Harm or Suicide
  4. Assessing Risk Factors and Developing Management Plans
  5. Involvement of Other Agencies and Professionals
  6. Identifying Factors Indicating Risks for Potential and Actual Harm
  7. Identifying the Opportunities for Potential and Actual Harm
  8. Addressing Risk Factors in a Child’s Best Interest
  9. Reporting and Recording Requirements
  10. Secure Welfare Service
  11. Incident Reporting Systems
  12. Considerations for Best Practice
  13. Related Policy Documents and Procedures

    Appendix 1: Responsibilities of Staff where there is a Young Person at Risk of Suicide or Self Harm in residential Services

    Appendix 2: Flowchart - Suicide and Self Harm for Residential Services

    Appendix 3: Residential Services - Essential Information Form

    Appendix 4: Residential Services - Pre Admission Health Questionnaire

    Appendix 5: Self Harm and Suicide Risk Assessment for Residential Services

    Appendix 6: Room Safety Policy

    Appendix 7: Residential Services - Events Notification


1. Introduction and Purpose

This policy has been developed to provide information and detail practice requirements regarding the management of children and young people who engage in self-harming behaviours or threats of suicide. The purpose of this advice is to:

  • Provide a framework for self-harm and suicide risk management;
  • Provide information about reducing the risks of injury or death and ensuring the safety and wellbeing of clients;
  • Outline the reporting requirements;
  • Reduce the level of uncertainty and stress for practitioners in managing clients who self-harm and express potentially suicidal behaviour.

Within the spectrum of children and young people who are currently being ‘looked after’ some are particularly vulnerable to risks from a range of actions and behaviours associated with self-harm. These include those who:

  • Threaten to self-harm, including threats of suicide;
  • Actual self-harm;
  • Engage in self-mutilation (self-cutting, blood letting);
  • Express suicidal ideation;
  • Attempt suicide.

Often these types of actions and behaviours are associated with adolescence but they can also be displayed by young children. Given the level of harm that can result from these actions and behaviours, working with and responding to these behaviour requires specific, intensive and strategic planning and casework. Two major considerations in responding to and managing self - harming behaviours and threats of suicide are harm reduction and duty of care.


2. Standards and Procedures

Many children and young people who come into the ‘looked after’ system have experienced significant trauma in their lives and are often highly vulnerable. It is likely that these children will sometimes have multiple and complex needs and significant behavioural and emotional difficulties, which can lead to acting in ways that place themselves in situations of high risk. This can particularly apply where a child is placed out of home care.

The ‘Residential Care Audit’ (2001) identified that children placed in residential care can be particularly vulnerable. The audit identified that 22 per cent of children in residential care had engaged in self-harming behaviours or threats of suicide. Added to this, the audit identified a high level of mental health diagnoses and higher levels of substance abuse than the general population. Residential care clients were also found to lack age appropriate skills necessary for independent living and to have increased levels of aggressive and challenging behaviour at younger ages.


3. Threats of Self Harm / Actual Self Harm or Suicide

Threats of self harm and actual self-harm involved a range of actions, along a continuum, from statements to self-arm to a display of self-harming behaviours, to suicide. In definition self-harm requires not only the threat of self-infliction of injury (to varying degrees of intent), but also importantly, an awareness of motive. The issue of awareness of motive is significant because it is what distinguishes self-harming behaviours from other types of behaviours often associated with and grouped as adolescent risk taking and experimental behaviours.

Children in the Child Protection system can present with significant behavioural and emotional difficulties and a lack of self-care. Experimental and risk-taking behaviours can frequently become extreme and result in significant levels of harm. This through does not equate to every child who engages in extreme risk-taking behaviour intentionally wanting to self-harm. Some displays of behaviours such as self-cutting, self-strangulation or deliberately placing oneself in harms way, can be relatively easy to define as an act of self-harm. Other types of high risk activities, which result in harm, may be more difficult to define as either intended acts of self-harm or experimental risk-taking behaviour, for example, substance use of reckless behaviour.


4. Assessing Risk Factors and Developing Management Plans

The reasons why children and young people in the ‘looked after’ system present with self-harming behaviours are often complex and varied but generally related to a combination of factors which include:

  • Past experience of and on-going trauma;
  • Significant and continuing stressors in their lives;
  • Inadequate or poorly developed emotional or behavioural capabilities;
  • Absence of self-care;
  • Emerging or diagnosed psychiatric or psychological disorder;
  • Lack of appropriate support networks;
  • Lack of other coping mechanisms to moderate or address the behaviours.

For practitioners identifying the potential likelihood or probability of self-harm requires an assessment of a range of factors indicating risk and need and an assessment of the risk opportunities. This assessment will form the basis for determining a risk management plan and if possible should include correctly identifying underlying causal factors. To formulate a risk management plan requires the coordinated and collaborative input of a number of professionals who may be involved or have expertise to offer.


5. Involvement of Other Agencies and Professionals

Children and young people who display self-harming or suicidal behaviours may already have involvement with other services that have expertise to offer in addressing or reducing such behaviours. If a child or young person is not involved with such services, practitioners should consider making referrals or seek consultation with such services as part of the best interests planning.

The involvement of these services on a consultancy basis or as part of the care team in developing intervention strategies and case management plans is essential to attaining the best outcomes for the child or young person involved. It is essential that other agencies and professionals acknowledge that they have a significant role in assisting to formulate intervention strategies and implementing agreed management plans as part of joint working.


6. Identifying Factors Indicating Risks for Potential and Actual Harm

Factors which indicate risk of self-harm or suicide include:

  • Previous threats, attempts or acts of self-harm or suicide;
  • Preoccupation with or idealisation of self-harm or suicide;
  • History of self-harm or suicide within the family;
  • Ongoing and presenting psychological or emotional functioning, including marked changes in presentation such as depression, flat affect, mood deterioration (or elevation), high levels of anxiety or unrest, impulsivity;
  • Psychological and psychiatric history;
  • Stressors present in a child or young person’s life, including current events and occurrences;
  • Lack of individual coping strategies and internal mechanisms to deal with distressing or traumatic events;
  • Withdrawal, isolation, separation or alienation from networks such as family, peers, social groups and school;
  • Excessive involvement in high risk activities such as reckless actions endangering life, substance use etc;
  • At discharge from a Psychiatric inpatient unit services.


7. Identifying the Opportunities for Potential and Actual Harm

Opportunities for potential and actual harm include:

  • Whether there is a plan to self-harm or suicide;
  • Where there are means available to carry out self-harm or suicide;
  • A significant event or incident occurred with which the child has not coped well with or, in the past has self-harmed as a response to such an event;
  • Other factors present which could increase the possibility or desire to follow through with self-harm or suicide, such as access to substances of drugs, involvement with others who self-harm;
  • Lack of or reduced contact and monitoring from regular supports;
  • Comments indicating an intention to self-harm or suicide.


8. Addressing Risk Factors an a Child's Best Interest

Where it is known that a young person engages in threats of self-harm or actual self-harm, as identified during pre-admission assessment, it is essential the risk management process in put into action. This should be completed in consultation with all professionals and services involved and recorded on the correct paperwork (see appendices). Interventions and responses may be required to:

  • Ensure the immediate and on-going safety of the child;
  • Reduce the harm or prevent it from re occurring;
  • Provide the basis for a management plan which supports and promotes addressing harmful behaviours and the underlying causes;
  • Decide whether the child or young person can be safely maintained and supported in their current placement;
  • Take appropriate decision making action, such as consult with or report self-harming behaviour to the line manager, or service manager, or other involved professionals who can provide advice and direction.

Chronic or entrenched patterns of self-harming behaviours can be triggered by a specific event but are more likely to be related to psychological functioning. Often this internal component can make it more difficult to predict or map when an episode may occur. Where the self-harming behaviour may be chronic or on-going there may be reoccurring behaviours or conduct in a child or young persons presentation which signal a self-harming episode is imminent. A risk management plan in this case would include:

  • Identifying the signs that may indicate when an episode of self-harm is more likely;
  • Utilising formulated assessment tools which may assist in gauging and monitoring behavioural patterns, for example, to ascertain when levels of anxiety or stress may be heightened. These tools may be provided by specialist services such as CAMHS;
  • Developing strategies to reduce, prevent, or avoid the conditions and times in which the self-harming behaviours may regularly occur, that is, planned structured activities at those times;
  • Developing a knowledge of what strategies could be employed to end the self-harming episode;
  • Providing the client with alternative strategies if they feel they cannot stay safe, such as telephoning help-line numbers, over 16yrs can access the mental health crisis team;
  • Assessing if the child or young person can be supported through the event;
  • Deciding whether the child or young person can be safely maintained and supported in their current placement;
  • Consider taking child to Accident and Emergency.

Risk management and crisis prevention planning for high-risk children and young people will require review on a frequent basis, sometimes daily or weekly depending on the degree of risk. In such cases it is likely that the care and placement planning process will need to include additional and frequent planning meetings held between the care team.


9. Reporting and Recording Requirements

Accurate and timely recording on the child or young person’s files of all incidents related to self-harm is important as this information assists in developing, formulating and reviewing the suicide and self harm plan for those who engage in self-harm actions or behaviours.


10. Secure Welfare Service

Where a child or young person is exhibiting high-risk behaviour, which cannot be managed in a community setting, a placement in secure welfare may be appropriate. Secure welfare is a locked facility which provides containment and time limited intervention until a point where the risk has become manageable. Requests will need to be submitted to Service Manager and Assistant Director for consideration where significant risks have been identified as unmanageable.


11. Incident Reporting Systems

Incident reporting is an Ofsted requirement and involves completing an incident report and appropriate documentation. Incidents and risk assessments are graded according to the actual impact on children, young people and staff involved. Most incidents of actual self-harm or attempted suicide will require a critical incident report to be completed and reviewed and updated as appropriate.

Prior to admission to a residential home all children and young people should undergo an initial risk assessment to determine suitability for a residential or respite placement. As part of this assessment the manager will identify from case records if there is any indication of a risk of self harm. This will include a verbal reference to self harm even if an act of self harm does not occur.

Where self harm is indicated at point of admission the risk assessment needs to be completed to reflect intervention strategies agreed with all agencies and professionals involved. Where there is considered to be an increased risk of self-harm then the individual crisis management plan will indicate those action which are to be taken to minimise the risk.

The individual crisis management plan is to be reviewed every 28 days or sooner if an incident occurs which increases the risk of self harm. Where a specific event has led to an assessment that the risk of an episode of self harm is more likely then the worker should complete the specific management plan. This plan sets out how the team will manage the increased risk down through increased vigilance and support.

In all cases where a baseline assessment is undertaken then a chronology of significant events is to be inserted into the front of the recording file. Completion of the record enables patterns and theses to be identified quickly. It is important to note that this process is in addition to the requirements to provide a running record, completion of an incident form and notification under Schedule 2.


12. Considerations for Good Practice

Self-harming behaviours and acts of self-harm by children and young people can have a distressing and traumatic impact on all those involved in ensuring their safety and wellbeing. When working with children and young people who self-harm or are at risk of suicide, practitioners should familiarise themselves with the services that are available to provide support and debriefing in the event of a critical incident.

In situation where practitioners are involved with a child who is actively self-harming or suicidal, they should, in consultation with other members of the care team, ensure there is a plan to manage the negative effects such as distress of grief, that an incident of self-harm or suicide may cause other workers, family members and other children and young people.

Consideration needs to be given to the provision of appropriate training and information to all staff involved in working with children and young people at risk of self-harm and suicide.

It is recommended that all staff complete training in risk assessment and working with young people who display and present risk in suicide and self harm behaviour. This training will need to be reviewed and updated annually through refresher training.


13. Related Policy Documents and Procedures

Critical Incident Policy

Self Harm Procedure

E learning - Working with Suicide and Self Harm


Appendix 1: Responsibilities of Staff where there is a Young Person at Risk of Suicide or Self Harm in Residential Services

Introduction

Reducing the risks of self harm and suicide is a matter of highest priority and should take precedence over all other matters. It is considered as a safeguarding function, which all staff must take personal and collective responsibility for.

Responsibilities

Person first receiving information that a young person may be at risk of self harm or suicide

  • Take immediate action to ensure the safety of the young person;
  • Inform shift leader on duty of any concerns and consult on appropriateness of opening Suicide and Self Harm paperwork.

Shift Leader

  • Manage immediate response to include frequency of checking is sufficient, room safety policy has been implemented correctly and that medical attention has been sought where necessary;
  • Inform all staff on duty;
  • Notify on call manager or assistant manager of risks presented and regular updates as appropriate, particularly where there is significant increase in risks being displayed or identified;
  • Ensure Suicide and Self Harm paperwork for the young person involved has been started and that details are shared in handover meetings and include details of support plan in place;
  • Ensure support plan is implemented throughout the shift and sufficient actions have been taken to ensure the safety of the young person;
  • Complete and update Daily Supervision and SS14’s to detail the young person’s mood, behaviour and responses to the risk management plan in place;
  • Work in collaboration with the management team to address any quality issues and shortfalls, including recommendations to homes’ managers for policy and procedure changes to be considered;
  • In consultation with on call manager or assistant manager, to initiate any referral to Safeguarding Board or Ofsted.

Key Worker

  • Ensure monthly summaries and individual crisis management plans are updated to reflect implementation of plans for young people at risk of suicide and self harm;
  • Identify individual work in consultation with management team to reduce risks of self harm and suicide;
  • Inform other professionals including Social Workers, YOS workers, CAHMS and where appropriate family members.

On Call Manager

  • Oversee shift leaders response to plans for young people at risk of suicide and self harm to ensure correct actions are taken to safeguard young people and manage process and address any shortfall;
  • Contact line manager to provide relevant information and updates as agreed;
  • Read and sign report by initiating member of staff;
  • Ensure daily supervision and support record is completed, signed and dated;
  • Close suicide and self harm pack when appropriate.

Team Manager

  • Notify Head of Service as appropriate following information received from homes manager/assistant manager or shift leader.


Appendix 2: Flowchart - Suicide and Self Harm for Residential Services

Click here to view Flowchart - Suicide and Self Harm for Residential Services


Appendix 3: Residential Services - Essential Information Form

Click here to view Residential Services - Essential Information Form


Appendix 4: Residential Services - Pre Admission Health Questionnaire

Click here to view Residential Services - Pre Admission Health Questionnaire


Appendix 5: Self Harm and Suicide Risk Assessment for Residential Services

Click here to view Self Harm and Suicide Risk Assessment for Residential Services


Appendix 6: Room Safety Policy

Click here to view Room Safety Policy


Appendix 7: Residential Services - Events Notification

Click here to view Residential Services - Events Notification

End