1. Suicide Prevention, Learning and Support - our new Trust strategy
Simon Sherring, Deputy Director of Nursing
Dr Nicola Byrne, Deputy Medical Director

2. Overview
Background
principles
drivers
ambitions

3. Background: the ‘Zero suicide’ opportunity to improve both safety + our shared experience
Identify
existing good work to share and areas we can improve
Improve
how we learn from incidents and support each other
Strengthen
our partnership working with each other, patients, carers + communities
Engage
all our staff with QI, given the importance of this subject to us all

4. Strategy principles
Everyone in the Trust has something to contribute to this work
Suicide prevention, learning and support are all connected
We need to achieve better, safer care for all - regardless of perceived risk
We need to work with patients, carers, our multi-agency partners and communities
A Quality Improvement (QI) approach will be used to test and refine new initiatives

5. Starting point – what does the evidence say?
International + national evidence; London and our local borough data
Trust learning: 2016 review found that amongst suicide deaths in SLaM
the majority had diagnoses of mood disorders
secondary diagnoses (inc. substance misuse) often poorly documented
clinical record keeping sometimes poor
concerns over quality of communication between staff + our multiagency collaboration were recurring themes

6. National Confidential Inquiry

7. NCISH report 2018 More emphasis should be placed on:
Building relationships
Gathering good quality information
Families and carers should have as much involvement as possible in the assessment process

8. Learning from suicide related claims – a thematic review of NHS Resolution data (2018)
Main areas of concern
Serious Incident investigations - quality of analysis + recommendations
Inconsistencies in how coroners work in relation to Prevention of Future Deaths reports + the mechanisms to ensure recommendations acted on
Lack of both family involvement + staff support after a suicide death

9. Four drivers to our strategy to reduce suicide
Healing relationships
Procedural safety
Shared learning
Effective partnership working

10. Healing relationships – secondary drivers
An organisational ‘Just culture’ with Trust's 5 commitments lived at all levels
Development of care process models
Better safety planning + self-harm management
More consistent identification and management of mood disorders and substance misuse

11. Procedural safety – secondary drivers
Mindful transitions of care
Consistent operational processes
Clear channels of communication
An electronic record (ePJS) supporting better assessments + information sharing
Safe medicines management
Safe staffing numbers and skill mix
Environmental safety

12. Shared learning – secondary drivers
All staff engagement in suicide prevention
Shared learning from incidents, involving carers
All staff having competency in suicide prevention
Provision of bereavement support for carers and support for staff

13. Effective partnership working
Routine involvement of patients and carers in service design and our QI work
Active involvement in local borough multi- agency suicide prevention plan work
SLP collaboration

14. How will we measure success? - Prevention
Number of self-harm incidents and suicide deaths amongst patients under our care
Benchmarking against local population, London and national data

15. How will we measure success? - Learning
How confident are staff to raise concerns?
How good are we at learning from incidents?
Where can we learn from successes nationally?

16. How will we measure success? - Support
How well do we support staff in the aftermath of a patient death?
How well do we work with and support carers after a loved one’s suicide?

17. Action! – 3 month milestones
1.       Engage staff; eNews; Maud; video; World Mental Health day
2.       Improve awareness of information sharing with carers
3.       Establishment of 6 monthly Grand Round Learning Stories
4.       Provide information on bereavement support on our website

18. Action! - 6 month milestones
Introduction of 48 hr check-ins after discharge from wards
Analysis of ‘Place of Safety’ data – IoPPN research
Develop our data strategy
Pilot a suicide bereavement support group for anyone to access in the community

19. Action! – 9 -12 month milestones
Medicines audit of Trust suicide deaths
Development of Learning Stories from SUIs
Involvement in all 4 borough local multi-agency work
Review management of self-harm - NCISH self-assessment tool kit
Develop new integrated care plans for wards

20. Meanwhile, all the good work going on already across the Trust continues…
Here is Shelia Woodward (on the far right of the photo) leading a team of volunteers at Cannon Street station promoting mental health awareness, information and resources. The team are spreading the message that if you are struggling with your mental health you are not alone, there is always hope and there are people and services ready to help you.

21. More information
@nicbyrnepsych