Doncaster Multi-Agency Guidance for Preventing and Responding to Behaviours Which May Indicate Potential Suicide or Self Harm Clusters

1. Background

Safeguarding Children Partnership investigate the death of every child in their area in line with their statutory duty of care (Working Together to Safeguard Children). Doncaster Safeguarding Children Partnership undertakes this duty via its Child Death Overview Panel; in addition to the investigation of every death including those by suicide, agencies in Doncaster will consider the impact suicides and/or potential suicidal acts have on young people and families. Exposure to suicide may be a strong predictor of suicide ideation and attempts (Swanson and Colman 2013) therefore if concerns of a suicide cluster are identified, agencies in Doncaster will consider review the cases concerned with a view to preventing further suicides or suicide attempts.

This resource has been developed to assist agencies in Doncaster to manage or contain an actual or potential suicide cluster. A community plan will be developed and implemented by members of the community and the services that support them in order to manage and contain the associated risk of 'copycat suicidal acts'. The plan might focus on a ward, a particular facility e.g. a school, hospital or youth club, a rural or virtual community.

A suicide cluster is defined as a collection of suicides or behaviours which indicates a significant intent to die by suicide or self-harm; in addition the number of incidents exceeds that expected of the cohort under consideration. The term 'suicidal acts' includes both completed and attempted suicides and will be further defined by the community under focus.

Research estimates that's between 1 and 5% of all suicides by young people occur in the context of a cluster, and that 6% of suicides in prisons and 10% of suicide by people with mental illness are due to imitation or clustering effects. Therefore early identification and action are required to contain the impact.

Suicide 'Contagion'

It has been proposed that suicide clusters are due to 'contagion' or the process where one person's suicide influences another person to engage in suicidal acts. Contagion may be particularly likely to occur in circumstances where the second person is already contemplating a suicidal act, or is particularly vulnerable or impressionable. The mechanisms by which contagion operates are not fully understood, and may vary considerably from person to person. Possible links proposed by research includes:

An expression of grief or a means of escaping from pain after experiencing the suicide of another, particularly a friend or relative;
Imitation of another's suicidal behaviour as a way to deal with a range of emotions or events;
A desire to be recognised, for identity, or to be part of a group, which may occur if previous suicides are perceived to have achieved recognition for those who have died; and
Exposure to a particular method, providing a 'suggestion' for that method to be used again.

Although it is important to talk about suicide and raise awareness of risks, encouraging help-seeking, there is a substantial body of evidence demonstrating that media reporting of suicide can promote contagion, particularly if it glorifies or sensationalises suicide or provides explicit detail about suicide methods. Careful consideration must be given to the publication of all information to ensure that messages are clear but do not glorify aspects of suicidal acts.

Conversely identification of a particular community (such as a school) as the focal point of a cluster can lead to a perception that everyone in that location is at an elevated risk of attempting suicide, when in fact the location/community is just one factor that members of the cluster share. Sometimes the location/community and time period are coincidental and there is no clear link between those who have engaged in suicidal acts.

Self-Harm

This plan uses the definition used by NICE (2012) for self-harm which is: 'any act of self-poisoning or self-injury carried out by an individual irrespective of motivation. This commonly involves self-poisoning with medication or self-injury by cutting.'

2. Community Plan

This community plan should be activated when the community or the co-ordinating agencies for the plan perceives that a cluster is occurring or is at risk of occurring. An initial suicide may be the precipitating factor, but other external events may also act as triggers. These might include one or more deaths from other causes (e.g. trauma) which influence others to engage in suicidal acts out of grief, or pervasive environmental circumstances (e.g. economic downturn or extreme weather incidents) which cause stress for a whole community.

In Doncaster this community plan sits within the Child Death Overview Processes (CDOP) and Doncaster Safeguarding Children Partnership Policies and Procedures and Doncaster Suicide Prevention and Self-Harm Action Plan. It has the twin aims of providing support to the bereaved, and reducing the risk of further suicides. It is a stepped approach which will vary from one incident to another.

The steps will be developed and implemented following the involvement of multiple agencies. A lead agency or a steering committee should be identified to lead and host the plan, but not to fulfil all responsibilities within the plan. This decision should be made on the basis of:

Organisational mandates and existing responsibilities, including consideration of which agencies already have a co-ordination role in mental health, community crises or responding to suicide;
Existing networks and relationships;
Cultural considerations and community access; and
Availability of resources, particularly skilled and knowledgeable staff, and time.

Communities should plan their stepped approach utilising three overlapping phases of action to prevent and respond to suicidal clusters in an appropriate and timely manner. These are:-

Phase 1 - Preparedness: Actions in this phase should ideally be undertaken prior to the onset of a cluster, but if this is not possible, then they should begin as soon as the risk is perceived.

Phase 2 - Intervention: Actions in this phase should commence as soon as the community/ agencies perceive it to be experiencing a cluster or a potential cluster, or when more formal mechanisms indicate that a cluster is forming.

Phase 3 - Follow-Up: Actions in this phase relate to the longer term healing and risk reduction needs of a community.

STEP 1: Identify a lead agency or steering committee to develop and host the plan.

Table 1 describes the interlinked phases and stepped approach to be considered in each specific case by agencies and services in Doncaster if there is a number of suicidal acts exceeding an expected cohort. This may be based on perception or actual suicidal acts and the plan will be written to manage and contain the emerging incidents. Agencies and individuals will be expected to co-operate under the statutory expectations of Working Together to Safeguard Children and Children Act 2004.

Appendix 1: Checklist of Possible Tasks for the Lead Agency or Strategic Group provides a checklist of possible tasks for the lead agency or steering committee to consider.

Click here to view Table 1: Community Plan for the Prevention and Containment of a Suicide Cluster.

STEP 2: Identify relevant, available contacts and resources

A community plan should include the names and contact details of individuals and organisations that can come together as a cluster response team. Roles to be covered by this team might include:

Coordinating the response;
Collecting and monitoring suicide data and information;
Providing information;
Identifying and supporting those at risk; and
Follow-up, including longer term risk reduction programs.

The cluster response team will need to be activated as soon as a cluster, or the risk of a cluster, is identified. Not everyone will need to be involved in all stages of the response. Appendix 2: Likely Roles Required in a Cluster Response Team, and Possible Sources of Expertise provides a demonstration of the likely roles required in a cluster response team, and possible sources of expertise that should or could be consulted upon.

STEP 3: Establish the facts

The possible emergence of a suicide cluster may be accompanied by significant rumour and suspicion. It is important for details to be confirmed as soon as possible to enable tailoring of the response, and to ensure responsible, accurate public statements (if any) are made.

There are a number of possible sources of information on suicide clusters that may need to be explored if the cluster occurs beyond a single facility. Police generally will have the most complete data of both completed suicides and public acts of deliberate self-harm. Hospital emergency departments may also be a source of information on emerging trends in suicidal behaviour, assuming they see the individuals involved.

STEP 4: Provide ongoing and accurate information

The way in which a suicide death is announced or is reported in the media can have significant implications for the risk of suicide clusters. Community plans need to consider how and by what routes information and misinformation is likely to spread and institute measures to counter this. People's social networks, including their virtual networks, are important in this regard. For example, public statements may need to be made to confirm facts and disconfirm rumours that may be circulating via text messaging, email, Facebook or other social network sites. Appendix 3 provides some lessons about information dissemination from a school-based cluster; this can be altered to meet the needs of specific cohorts as required.

Caption: table about STEP 4: Provide ongoing and accurate information

Announcing suicide deaths: good practice suggestions to reduce the likelihood of contagion Provide factual information immediately to reduce the risk of misinformation; Don't provide unnecessary detail regarding the means of suicide; Announcements should be made to smaller audiences such as families, class groups, friendship groups, and other peer groups; Notify individuals who had a close relationship with the deceased person in private before any announcements are made in a group setting; A central spokesperson should release information about the suicide and responses to the community to ensure a single and consistent account is presented; Present information in a way which is age and culture appropriate, in terms of language used and the level and type of detail provided; Provide information with the aim of maximising support and minimising panic; Emphasise understanding without condemning or glorifying the suicidal event or the person who died by suicide; Make support and counselling services available to all following the announcement, and encourage help-seeking. Source: Department of Communities. Principles for Providing Postvention Responses to Individuals, Families and Communities Following a Suicide Death. Brisbane: Queensland Government, 2008.

STEP 5: Identify individuals, groups and areas of greater risk

To identify whether it is at risk of a cluster, a community might consider whether there are individuals who are already at higher risk. Possible risk factors and warning signs are summarised in Figure 1, but, communities are cautioned not to rely completely on lists of observed risk factors. The community might also consider whether the initial suicide was linked to a particular event that might also affect others. When suicides in a cluster appear to be co-incident, rather than directly linked, wider risk factors may need to be examined.

Click here to view Figure 1: Examples of Possible Triggers and Precipitating Events to Suicide.

Source: Department of Health and Ageing. Living Is For Everyone (LIFE): A Framework for Prevention of Suicide in Australia. Canberra: Australian Government, 2007.

To identify those who may have an elevated risk of suicide, the community may consider a mapping and/or a screening process. Mapping would identify individuals and groups linked in some way to those who have died, including witnesses, family, partners, friends (including 'virtual' friends), and others in the community who may have been in regular contact with them (e.g. members of common associations, such as sports teams).

In the case of a school-based cluster, risk assessment should also consider those who are outside the school system, particularly as disconnectedness and lack of social support networks can be risk factors. Absences from schools in the aftermath of a suicide should be directly followed up.

A succession of stories about suicide can normalise suicidal behaviour as an acceptable option. Research shows that reporting the method of suicide can promote copycat suicides, and so if possible, reporting the method should be avoided. If it is important to the story, it should be discussed in general terms only. Particular care should be taken not to promote particular locations as 'suicide spots'.

STEP 6: Respond to risks and immediate support needs

The community plan needs to identify what services and support can be made available to support the bereaved and those at elevated risk. Based on experience from previous clusters, five general areas of input might be considered:

Immediate support to the bereaved;

Coroners and Coroners' officers and other organisations are a source of immediate support. Communities are advised to think laterally about the resources they have and how they may be deployed.
Provision of information;

In the early stages of a cluster, there may be an increased demand for information on suicide risk, on how to talk about suicide, and on available services; for example training for frontline workers.
Access to debriefing and counselling;

The community plan should identify how to scale up access to counselling services. Training may be required for agencies to increase capacity to provide grief and crisis counselling or Mental Health First Aid. Counselling should also be available to those responding to the crisis.
Establishing support networks;

The community plan should provide guidance about developing support networks. Support networks might include professionals (e.g. General Practitioners, Teachers, School Nurses, Children's Services Staff) and general community members who can listen to people's concerns and monitor their level of risk. Support networks might also take the form of group events designed to encourage a sense of identity and hope and to reduce individuals' isolation. They might also involve structures to ensure that people at risk are not left alone at critical times.
Reducing access to means of suicide;

The plan might also consider whether it is possible to reduce access to means of suicide. There is significant evidence that restricting access to means can interrupt the suicidal process, and reduce suicide rates. Examples of means restriction used in previous suicide clusters have included removing or placing barriers on sites used for jumping, electrocution and hanging.

STEP 7: Link to longer term suicide prevention work

There is considerable value in linking the crisis response to a longer term program of suicide risk reduction and community recovery. The anniversaries of suicide deaths can bring to the surface a range of difficult emotions for family and friends, and promoting help seeking should be considered at this time.

STEP 8: Revise and update the community plan

The experience of responding to a cluster will provide an opportunity to update and expand the contents of the community plan. Updating the plan may also allow the cluster response team to reflect on and debrief about the experience.

In updating the plan, communities should consider establishing a surveillance system for suicide attempts and completed suicides. Such a system would facilitate the early identification of suicide clusters, as well as of individuals who are at higher risk or in need of support.

3. Resource and References

Department of Health (2008): Help is at Hand: A resource for people bereaved by suicide and other sudden, traumatic death

Department of Health and Ageing. Living Is For Everyone (LIFE): A Framework for Prevention of Suicide in Australia. Canberra: Australian Government, 2007.

HM Government (2012) Preventing suicide in England: A cross-government outcomes strategy to save lives

National Collaborating Centre for Mental Health (2012); NICE Clinical Guideline 133 Self-Harm: Longer Term Management; The British Psychological Society: Leicester

Samaritans; Developing Emotional Awareness Learning (DEAL)

Samaritans (2013): Help when we needed it the most: How to prepare and respond to suicide in schools

Samaritans (1st Edition 1994) Media Guidelines for reporting suicide and self-harm

Swanson S.A and Colman I (2013). Association Between Exposure to Suicide and Suicidality Outcomes in Youth. Canadian Medical association Journal, CMAJ 20133,DOI:10.1503/cmja.121377

Working Together 2015, Working Together to Safeguard Children, A Guide to Inter-Agency Working to Safeguard and Promote the Welfare of Children, March 2015. HM Government

Appendix 1: Checklist of Possible Tasks for the Lead Agency or Strategic Group

Phase	Phase
During Phase 1: Preparedness (or at crisis onset)	Act as a focal point for information on completed and attempted suicides, to enable monitoring and identification of possible clusters; Establish reporting mechanisms and communication trees, including 24/7 emergency contact details; Lead development of the community plan (ideally before a cluster emerges); Link this plan to other relevant policies (such as Samaritans; Developing Emotional Awareness Learning (DEAL); Facilitate identification of possible agencies or individuals to cover each role within the cluster response team. Ensure up-to-date contact details are available for each; Ensure cluster response team members have access to training and briefing/debriefing relevant to their role, and have relevant resources on hand.
During Phase 2: Intervention	Contact and activate cluster response team; Arrange initial face-to-face meeting or teleconference to ensure all roles are covered, and identify steps to be taken, by whom, and when.
During Phase 3: Follow-up	Document the experience as a more detailed community plan; Periodically review and update contact details and supporting resources for each role.

Appendix 2: Likely Roles Required in a Cluster Response Team, and Possible Sources of Expertise

Key roles	Examples of potential organisations and individuals who might take on these roles
Coordinating the response and convening the cluster response team meetings	Mental health Trusts, Local Authority Learning and Opportunities or Public Health Teams, School Governors, Community Health Services, Doncaster Children's Services or specific individual community cohorts (e.g. Traveller, EU Migrant communities).
Collecting and monitoring suicide-related data	Coroner, police, hospitals, General Practitioners, health clinics or health workers, youth advisers, schools.
Providing information: To students and parents (in the case of a school based cluster or cluster occurring among young people); To the media; To the wider community.	Head teachers, teachers, school counsellors and other trained counsellors, chaplains, youth advisers, MIND, RDaSH, Specialist mental health professionals, facility managers, media professionals, community elders Local Authority / Children's Services, Public Health England, agency Communication and Media teams.
Identifying and supporting those at risk	Trained counsellors, suicide or mental health professionals, General Practitioners, suicide hotlines, drop-in centres, Well-Being Centres, community groups and individuals.
Follow-up, including longer term risk reduction programs	Community programs, sporting clubs, youth clubs or groups, business associations, local interest groups, schools, health facilities.

Appendix 3: Lessons about Information Dissemination from a School-based Cluster

Parents want information about how to best support their children;
Clear, immediate, factual and consistent communication to parents, students, and staff is very important;
Forums for parents can be useful, and should extend to parents of children who go to a different school but may still be affected;
Outside experts are useful for providing information, but they need to be embedded within local support services to ensure that there is an ongoing contact point;
Providing a comfortable room for students to use as their own space can be helpful. Information and support staff should be readily available here, to enable students to talk through recent events in a supervised environment;
Media professionals are an important partner in the cluster response. Establishing a direct relationship with the media can help to ensure that the text of stories does not glorify or sensationalise suicide, and images are used cautiously.