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Welcome

A suicide prevention event in Cheshire & Merseyside

10th September 2015, World Suicide Prevention Day

#wspd15 #zerosuicide @CMPHN @Mersey_Care

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Professor Louis Appleby

Director, National Confidential

Inquiry

Chair, National Suicide Prevention

Strategy (England)

World Mental Health Day 2015

• 800,000 suicides per

year worldwide

• 16 million self-harm

episodes per year

• Second leading cause of

death in 15-29 year olds

Suicide rate, England 1995-2013

Source: ONS ICD 10 codes X60-X84 (for 10 year olds and over), Y10-Y34 (for 15 year olds and over), excluding Y33.9 -

where the coroner's verdict was pending up to 2006. ICD 9 codes E950-E959 (for 10 year olds and over) and E980-

E989 (for 15 year olds and over), excluding E988.8.

• Record low in

2006-7

• Rise from 2008,

linked to

recession

Suicide rates in NHS areas 2011-13

Colour-coded, highest rates = darkest

National Suicide Prevention Strategy 2012:

• Reduce risk in high risk groups

• Tailor approaches to improve mental health in

specific groups

• Reduce access to the means of suicide

• Support for those bereaved by suicide

• Support media in delivering sensitive approaches

to suicide

• Support research, data collection and monitoring

Six actions

Suicide rates in England, by age and gender

0

5

10

15

20

25

10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75+

Age Group

Age specific death rate per 100,000 population

male

female

Source: ONS ICD10 X60-X84 (for 10 year olds and over) and Y10-Y34 (for 15 year olds and over)

• Rates in men 3

x higher

• Highest rates in

men 40-54

years

• Higher in over

75s

Suicides per week following discharge

• Peak of risk in

first 1-2 weeks

after hospital

discharge

• 14% deaths

occur before

first follow-up

• Linked to lack

of care plans

Suicide under crisis resolution/home treatment,

England

71

108

153

156

177187

207

179193 195

226

183

162 155

142 122104 100

9099

71 67

0

50

100

150

200

250

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Nu

mb

er o

f p

atie

nts

Year

CR/HT In-patient

• Suicide

under CRHT

now 3 x in-

patient care

• 37% within a

week

• 43% living

alone

Suicide risk & number of GP consultations in

previous 12 months

12.3

7.8

1.67

• Suicide linked

to frequent GP

consultation

• 12-fold increase

with attendance

x 2 per month

• Risk also high

in non-attenders

Bergen et al 2012, Lancet

Life expectancy in men who

self-harm vs the general

population

• 50%+ of those who

die by suicide have

a history of self-

harm

• Risk of suicide

increased 30-50 fold

in the year after self-

harm

Self-harm and suicide

0

100

200

300

400

500

600

700

800

<18 years <20 years <25 years <=25

Num

ber

of

suic

ide d

eath

s

Age groups

UK

70

160

500

700

Suicide in children and young people:

deaths per year (England; UK)

Suicide in children and young people

In care or

custody

History of

abuse

Copycat

clusters

Social media

Alcohol/drugs

Bullying

Self-inflicted deaths in prison custody,

England & Wales

0

20

40

60

80

100

120

140

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Rates per 100,000 prisoners

• Currently 80

deaths/year

• Rates fell

post-2004

• Recent rise

Suicide after prison release

0

10

20

30

40

50

60

70

80

90

1 2 3 4 5 6 7 8 9 10 11 12 13

Time from release (28 day periods)

Source: Pratt et al, Lancet 2006

No.

suicides

• Risk remains high

on release

• Highest risk in first

month

• Importance of

“through the gate”

services

Patient suicide method, England

456

515487

456473

538

453

564 575

636 654

345379

339

273 281 283 306 313

380 354 351

210182 192 206 200 195 203 179 173 188

226

0

100

200

300

400

500

600

700

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Nu

mb

er o

f p

atie

nts

Year

Hanging/strangulation Self-poisoning Jumping/multiple injuries• Around 50% of

suicides are by

hanging

• Commonest

method in men &

women

• Seen as quick

and painless

Helium poisoning, England

Source: ONS

UK_SUICIDE

© National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. All rights reserved. Not to be reproduced in whole or part without the permission of the copyright

holder.

Sensationalising and romanticising suicide

Support for bereaved families

• Support and practical

advice

• Where to find help

• Services that men will access

• Plan to reduce heavy drinking

• Prevent suicide clusters, eliminate “hotspots”

• “Zero Suicide”

National support for local action

“It is time to change the widespread view that

individual deaths are inevitable – such a view is

bound to discourage staff from taking steps to

improve safety.”

National Confidential Inquiry 2006

“….. if mental health staff are to give up the

culture of inevitability, it is up to commentators

outside clinical practice to give up the culture of

blame.”

From Avoidable Deaths, 2006

Website:

http://www.manchester.ac.uk/nci

Like us on Facebook

https://www.facebook.com/pages/Centre-for-Mental-Health-and-Risk

Follow us on Twitter

https://twitter.com/NCISH_UK


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Dr Rita Robertson Chair of Partnership Board

Champs Mental Wellbeing Programme • Mental Wellbeing is a priority for the Directors

of Public Health, underpinning work to improve health and wellbeing across their communities

• Champs Public Health Collaborative has been leading collective action on mental wellbeing since 2010

• Five Ways to Wellbeing- making the messages real

• Children & Young People’s Mental Health & Wellbeing; 2015-16 priority for the collaborative, building on to value activity

• Suicide Prevention – NO MORE Zero Suicide Strategy

Zero Suicide

The vision Cheshire and Merseyside is a region where suicides are eliminated, where people do not consider suicide as a solution to the difficulties they face. A region that supports people at a time of personal crisis and builds individual and community resilience for improved lives.

Key drivers for action

Locally, men account for eight out of every ten suicides, therefore our actions must particularly engage with and positively influence men.

Increase in pressures and negative circumstances on local populations including deprivation, vulnerability, debt, unemployment.

Local audit data suggests a) over a third of people who complete suicide in our region had been in contact with their GP in the month before their death and b) half had been in contact with mental health services.

We also know many suicides occur out of the blue – with the individual not having a diagnosed mental health problem and many close to them with no idea that they were considering suicide.

Data on Cheshire Merseyside Suicides Number of deaths by suicide and undetermined injury, Cheshire

and Merseyside

How can we reach zero? Suicides are not inevitable. There are many effective ways in which

services, communities, individuals and society as a whole can help to

improve mental health and prevent suicides. The aims of the NO MORE

Zero Suicide strategy are underpinned by key objectives:

A Cheshire and Merseyside becomes a Suicide Safe Community

B The Health Care System transforms care to eliminate suicide for patients

C Support is accessible for those who are exposed to suicide

D A strong, integrated Suicide Reduction Network provides oversight and governance

Suicide Reduction Network

http://www.no-more.co.uk

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David Fearnley

Striving for zero suicide

No medication-

led or physical restraint

No suicides for those in

our care 100% compliance

with the Lester Tool

1 2 3

Culture of low aspirations and low confidence in mental health sector– people often lack belief that they can really improve things

Through our Centre for Perfect Care and Wellbeing we have spent a long time challenging lower aspirations in mental health than in physical health services.

Why can’t suicidal thinking be seen in the same terms as central chest pain, breathlessness, loss of consciousness, paralysis, urinary retention?

Pursuing ‘zero’ or 100% in mental health has been contentious, but if not zero what is acceptable to us?

Why aim for zero?

Why Perfect Care?

If not Perfect Care, are we really proposing that we should aspire to imperfect care and the acceptance of inbuilt error? Why would we view amenable, avoidable deaths by suicide differently from avoidable death in other healthcare settings?

If zero is not the right number, what is it?

We feel it is time for a much more ambitious approach

• Our aim is to eliminate suicide, in the first instance, of patients in our care;

• We believe that this can be done because suicide in our care is avoidable

amenable to interventions that we can optimize using specific approaches and strategies, and is therefore avoidable;

• It is therefore both a concept and a set of practices;

• It is the ultimate expression of Mersey Care Trust’s commitment to patient safety;

• Its essence is an integrated approach in that it requires multi-agency involvement;

• However, it is about an organisational commitment to being the fulcrum point for change to demonstrate that ‘where there is a will, there is a way’;

• For Mersey Care Trust, if this approach had been successfully adopted over the last decade, 200 people would be alive today.

Aiming for zero suicides in our care

Driver Diagram: Zero Suicide

Secondary Aim: To identify and measure four priority areas that when consistently implemented across Mersey Care Trust will reduce suicide

Engagement with all

stakeholders / partners

Competent workforce

Continuous analysis of data,

research and innovation

Service user and carer engagement 1

Co-production with MCT service user s and carers 2

Staff engagement in all stages of design and implementation3

Collaborative / integrated care pathways across services 4

Stakeholder training and guidance to support early identification and post-discharge support 5

Wider stakeholder engagement and partnerships6

Leadership and governance 7

Integrated community services - Standardised care pathways for specific conditions / services / transitions 8

Intensive care: post discharge and in times of crisis9

Evidenced based interventions stringently applied across the pathways 10

psychologically informed safety planning intervention 11

environmental risks and reduction of access to means 12

medication safety 13

Timely Post incident reviews , learning and sharing 20

Actions based upon emerging evidence from internal, national and international analysis and recommendations 21

Mersey Care led research and innovation priorities 22

Safe and effective care and treatment

Development of a learning strategy 14

Connect with OE strategy 15

Competency based suicide prevention training for all staff 16

Skilled workforce in evidence based interventions 17

Confidence in use of appropriate assessment tools 18

Ensure appropriate staffing skill-mix 19

Projects / PDSA cycles

Secondary drivers Primary drivers

Primary Aim Zero suicide: to eliminate deaths from suicide by service users under the care of Mersey Care Trust by 2020

Psychosocial Interventions - Safety planning - Formulation based care - Self management - Recovery

Standardised care pathways - Stepped up care - Safer discharge planning - Medication

- Environment / removal of means

Innovate Depression

Measures a. Number of suicides (completed) b. Number of near-fatal self harm c. Number of repeated self-harm d. Adherence to standardised care

pathways e. Number of staff undertaking

training f. Number of safety plans

implemented g. 4 week post incident reviews h. Patient experience

i.

Research and Innovation

RM: Rebecca Martinez CK: Cecil Kullu LW: Lisa Woods SB: Steve Bradbury CI: Claire Iveson PR: Paul Roberts JB: Jane Boland SG: Simon Graham LK: Lee Knowles PL: Peter Lynes LE: Louise Edwards AS: Andrew Sedgwick

No. of suicides

Competency based training - Learning Strategy implementation

- External stakeholder training

Post Incidence reviews

- Predictive analysis

Self Harm clinics in A&E Frequent attenders in A&E

CI, PL LE,LW

JB,

JB, LW

RM

SB, JB

RM, AS LK

CK, PR

LW, LE

CK RM RMLW

Personality Disorder Hub SG

Primary Drivers

Engagement with Stakeholders and Partners

Safe and Effective Care and Treatment

Competent and Skilled Workforce

Analysis of Data, Research and Innovation

Our change journey

Create Urgency

Create a Coalition

Develop a Vision

Communicate the Vision

Empower Action

Quick Wins

Drive Change

Embed in Culture

Our change journey

Create Urgency

Create a Coalition

Develop a Vision


Empower Action

Quick Wins

Drive Change

Embed in Culture

Today !

OUR change journey

Create Urgency

Create a Coalition

Develop a Vision


Empower Action

Quick Wins

Drive Change

Embed in Culture

Today ! Moving Forward

Why do we think that this is possible?

• There is evidence, albeit in a limited number of systems, that a focus both on the leadership of prevention as well as on the means of suicide can have a dramatic effect;

o The effective elimination of in inpatient setting suicides is a practical example of success

• Systematic approaches to quality improvement have been shown to be effective in impacting on other problems with these features;

• No Force First is a practical example of success

• Suicidal people often fall through the cracks in the existing, fragmented and busy system healthcare system;

• There is some predictability associated with what happens.

Staff sickness and absence: Gladstone Ward – Acute

Male Admissions Unit:

In the 23 months ( 1/11/2012 – 30/9/2014) since the issue of restraint

reduction was first explored on Gladstone Ward there have been a

total of 25 days lost in work related absence. In the same 23

month period prior to this (1/12/2010 – 31/10/2012) the figure was

888 days lost.

Early signs from some of our quality improvement work suggest that people become more engaged in work if we unleash their intrinsic motivation to improve patient care

This has been achieved by doing the right things first time, which systematizes evidence based practice.

“To improve is to change: to be perfect is to change often” Winston Churchill

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Richard Brown, CEO

0151 488 1614

07850 476 360

[email protected]

Headstart – cognitive behavioural coaching

mailto:[email protected]



About Listening Ear

• Operational since 1992

• Established open age counselling and support agency

• 1st BACP accredited adult counselling agency on Merseyside

• Specialist in bereavement support across all ages

• Based in Halewood, operational in Merseyside and Cheshire


SLS procurement process

• Tender opportunity advertised 1st December 2014

• Submission deadline 17th December 2014

• Appointed as delivery agent 5th January 2015

• First planning meeting 26th January 2015

• Service operational 1st April 2015


Significant milestones to become operational

• Recruit staff

• Develop referral pathway and process map

• Cultivate 3rd party relationships

• Create the brand and marketing material

• Apply for Ministry of Justice secure email address


Developmental lessons

• 3rd party relationships

• Regular meetings with commissioners

• Remote working and service footprint

• Internal communication

• Signposting


Service Impact quarter 1

• 22 suicides leading to 37 beneficiaries

• 90% initial contact commenced within 24 hours of referral

• 92% offered first appointment within 7 days of initial contact

• 100% completed full needs assessment

• 100% have a safety plan in place following risk assessment


Stakeholder feedback

• ‘You don’t know how much this has helped’ - client A

• ‘I feel much better knowing someone who gets it’ – client B

• ‘AMPARO have been there to support individuals and communities at a time of great tragedy and they have done so in a sensitive and professional way.’ Dr. Rita Robertson - Director of Public Health Warrington MBC

• ‘AMPARO provide timely and empathetic support and I’m confident in recommending this service’ Pat Nicholl - CHAMPS


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A Zero Suicide Strategy for Cheshire & Merseyside 2015-2020

Paul White – Mental Health Lead, Liverpool Community Health

Suicide Safer Community

What is a Suicide Safer Community

• A “Suicide Safer Community” is one that will demonstrate a commitment to suicide prevention, providing compassionate care and support to those bereaved by suicide and promoting the mental health and wellness of its citizens.

• Suicide Safer Communities are passionate in their belief that suicides are preventable and that prevention is a shared responsibility where every person has the potential to make a difference and save a life.

• It is a community that believes that everyone has a fundamental right to have a future filled with hope and possibility.

http://suicideprevention.ca/engagement/building-suicide-safer-communities/








Objective A Canadian Suicide Safer Community Model:

1. Establish a Suicide-Safer Community committee

2. Establish the population size of your community

3. Identify organisations representing your committee

4. Create and agree an action plan or strategy with identified priorities

5. Support and commission accessible suicide intervention services

6. Support and commission accessible suicide bereavement support

7. Support and commission promotion of mental health and wellness activities

8. Support and commission proactive suicide prevention activities

9. Establish a pool of formally trained gatekeepers

10. Participate in World Suicide Prevention Day

What are we doing locally?

7) Support and commission promotion of mental health and wellness activities Champs Public Health Collaborative and local teams implement a full range of programmes that build resilience in communities and individuals Connect 5 – a successful shared programme For people in non-mental health roles who have contact with clients, service users and patients on a daily basis. Helping to support everyone’s emotional health and wellbeing.

Three levels of training

Session 1 Brief Mental Wellbeing Advice

Session 2 Brief Mental Wellbeing Intervention

Session 3 Extended Mental Wellbeing Intervention

Numbers trained in one of the nine local areas

2014-15: 368 individuals attended all three sessions

8) Support and commission proactive suicide prevention activities

CALM – Man Dictionary & Man Down (local) State of Mind (Rugby) Opening up Cricket

MIND/Sport England - Get Set Go

Time to Change Hub Liverpool

• Time to Talk

• Everton in the Community Football Club Foundation (LFCF)

• Brew Monday – Mersey Care NHS Trust

National Campaigns

Local Campaigns

9) Establish a pool of formally trained gatekeepers

Gatekeepers - individuals who have attended commissioned

training, which is ongoing, for example Suicide Potential

Training for communities:

• Suicide recognised as a hidden problem

• If suicide rates were applied to different health scenarios then there would

probably be national outrage

• Mental health GP leads in Liverpool identified suicide awareness as a training

need

• Brief Suicide Awareness for Primary Care,

by Dr Reeves (Chair BACP) approved by Liverpool CCG

• Designed to be 30 minutes long so they can be incorporated into practice

meetings

9) Establish a pool of formally trained gatekeepers

• Review commissioned of Suicide Awareness Training by Champs in 2014

• Recommendations were to roll-out the Brief Suicide Primary Care Training and the wider community suicide prevention training

Local suicide awareness

Papyrus Assist/ SafeTalk Suicide Potential Training

STORM

10) Participate in World Suicide Prevention Day

What does the future hold?

• Links with national & local MIND (Get, Set, to Go)

• Sport England

• Liverpool Time to Change Hub

• Development with Homotopia and National MIND of a play touring schools across the area

• Roll out Brief Primary Care and Community Suicide Prevention Training

• Call to Action for each Local Authority to become a Suicide Safer Community

Contact Details

Paul White – Mental Health/Suicide Awareness Lead

Public Health Promotion Team

Liverpool Community Health

Mob: 07887657128

Twitter:@MentalHealthPW

E-mail: [email protected]

THANK YOU


Group work

Thank you for attending


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Presentations will be available via the Champs website

www.champspublichealth.com

Full zero suicide strategy available via www.no-more.co.uk

http://www.champspublichealth.com/

http://www.no-more.co.uk/



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