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Self harm in primary and specialist care services policy

Contents

  1. Policy summary
  2. Introduction
  3. Purpose
  4. Scope
  5. Procedure and implementation
  6. Training implication
  7. Equality impact assessment screening
  8. Associated documents
  9. References
  10. Additional reading
  11. Appendices

1 Policy summary

This policy highlights that all services can contribute to the care of such individuals by providing a comprehensive and research based approach to care.

This policy aims to cover the assessment, management, and prevention of recurrence for children, young people, adults, and older adults who have self harmed and provide context to the complex and subjective nature as to why people self harm. It includes those with a working mental health diagnosis or diagnosed mental disorder, neurodevelopmental disorder or learning disability and applies to all colleagues within RDaSH that work with people who have self harmed.

2 Introduction

Although the act of self-harm is not an illness, but dangerous behaviour, it should alert clinicians to potential links to underlying problems, or disorders.

All the clinical services that RDaSH provide may potentially encounter patients who have self harmed, not only mental health services. Self harm is an issue that has broad spectrum co-morbid diagnostic associations, and all clinicians must be aware of the assessment and management guidelines in regard to their contact with this patient group.

3 Purpose

The purpose of this policy is to provide a proactive as opposed to a reactive approach to the assessment and management of patients who present with previous or current self harming behaviour within primary and specialist care services.

4 Scope

This policy relates to all colleagues within the trust:

  • all patients in receipt of care and treatment from the trust. It is relevant to all patients who self-harm, and it addresses all health and social care professionals who encounter them. Where it refers to children and young people, this applies to all people who are under the age of 18

For further information about responsibilities, accountabilities and duties of all employees, please see appendix A.

5 Procedure and implementation

5.1 Quick guide

5.1.1 Psychosocial assessments

  • Highlighting the fundamental factors which should be explored when conducting comprehensive biopsychosocial assessments (biological psychological and social factors).
  • Highlighting triage, consent and capacity to engage in the assessment process understanding the implications of doing so.

5.1.2 Risk assessment tools and scales

There has been a move towards a more descriptive assessment of risk, therefore it is advised that you:

  • do not use risk categorisation such as low, medium, or high to predict future suicide or self harm or to determine whether a person does or does not require further care and treatment

5.1.3 Cohorts of patients

  • children and young people
  • adults
  • older Adults
  • complexities associated with co-morbidities

5.1.4 Care planning

  • The assessment and management of self-harm is an ongoing part of care planning and should be reviewed regularly in accordance with the care programme approach (or alternative).
  • Care plans should highlight the aim for interventions and consist of exploration between the practitioner and patient emphasising patient choice, collaborative working and shared decision-making.

5.1.5 Crisis and safety planning

  • Crisis and safety plans should also be devised in partnership with the patient to explore means of self-harm, triggers and coping strategies for when self-harm can and cannot be managed.
  • Crisis and safety plans should be made available to the patients and their families or carer, if appropriate and in an accessible format.

5.2 Definitions

5.2.1 Self harm

“Self harm is when someone damages or injures their body on purpose, including taking an overdose of medication or other substances. People of all ages may self-harm, but recently, more young people have been self harming than before. Some people may only harm themselves once, but around a fifth (20%) of people self harm again within a year. Most people do not go to hospital after they have self harmed, but those who do may be at even higher risk of repeat self harm and suicide” as classified by NICE guideline (NG225).

5.2.2 Para suicide

An act with non-fatal outcome, in which the individual deliberately initiates a non-habitual behaviour that, without intervention from others, will cause self-harm, or intentionally ingests a substance in excess of the prescribed or generally recognised therapeutic dosage, and which is aimed at realising changes which the individual desired via the actual or expected physical consequences.

It has been generally accepted that the words “deliberate” or “intentional” to pre-fix self-harm and “commit” to pre-fix suicide have a negative effect and are not acceptable to patients, and in view of this these words should be avoided by colleagues.

5.3 NICE guideline principles

NICE Guidelines should be adhered to as per up-to-date guidance and standards, on the website (opens in new window). Select ‘download’ from this page.

Self harm toolkit (opens in new window). Select ‘download services for self harm toolkit (PDF version)’ from this page

Everyone who has self harmed should have a comprehensive assessment of needs and risk. The assessment outcome should form a collaboratively agreed plan of care with the patient that should include a crisis and contingency plan.

Colleagues should give full information and make all efforts necessary to allow someone who has self-harmed the opportunity to give meaningful and informed consent to participate in a comprehensive assessment of needs and risk. Please see consent to care and treatment policy.

Colleagues working with those who have self-harmed should understand when and how the Mental Health Act can be used to treat the physical consequences of self harm.

Colleagues who have emergency contact with children and young people who have self-harmed must understand how issues of Gillick competency, capacity and consent apply to this group.

The clinical colleagues must also be aware of other guidance, including:

5.4 Psychosocial assessment guidance

NICE Guideline (NG225) stipulates that “after an episode of self harm, discuss and agree with the person, and their family members and carers (as appropriate), the purpose, format and frequency of initial aftercare and which services will be involved in their care. Record this in the person’s care plan and ensure that the person and their family members and carers have a copy of the plan and contact details for the team providing the aftercare”.

At the earliest opportunity after an episode of self-harm, a mental health professional should carry out a psychosocial assessment (opens in new window) to:

  • develop a collaborative therapeutic relationship with the patient
  • begin to develop a shared understanding of why the patient, has self-harmed
  • ensure that the patient receives the care they need
  • give the patient and their family members or carers (as appropriate where consent has been given) information about their condition and diagnosis
  • do not delay the psychosocial assessment until after medical treatment is completed
  • if the patient who has self-harmed is intoxicated by drugs or alcohol, agree with the patient and colleagues what immediate assistance is needed, for example, support and advice about medical assessment and treatment
  • do not use breath or blood alcohol levels to delay the psychosocial assessment
  • if the patient is not able to participate in the psychosocial assessment, ensure that they have regular reviews, and complete a psychosocial assessment as soon as possible
  • if the patient who has self-harmed has agreed a care plan, check this with them and follow it as much as possible
  • carry out the psychosocial assessment in a private, designated area where it is possible to speak in confidence without being overheard:
    • initial after-care should be provided within 48 hours of presentation for people who have ongoing safety concerns, to ensure people who need rapid aftercare are prioritised

Take into account the needs and preferences of the patient who has self-harmed as much as possible when carrying out the psychosocial assessment, for example, by:

  • making appropriate adaptations for any learning disability or physical, mental health or neurodevelopmental condition the patient may have
  • providing the option to have a healthcare professional of the same sex carry out the psychosocial assessment when the patient has requested this

During the psychosocial assessment, explore the functions of self-harm for the patient. Take into account:

  • the patients’ values, wishes and what matters to them
  • the need for psychological interventions, social care support, or occupational or vocational rehabilitation
  • any learning disability, neurodevelopmental conditions, or mental health problems
  • the patients’ treatment preferences
  • that each patient who self-harms does so for their own reasons
  • that each episode of self-harm should be treated in its own right, and a patients reasons for self-harm may vary from episode to episode.
  • whether it is appropriate to involve their family and carers

During the psychosocial assessment, explore the following to identify the patients strengths, vulnerabilities and needs:

  • historic factors
  • changeable and current factors
  • future factors, including specific upcoming events or circumstances
  • protective or mitigating factors

5.4.1 Best practice approaches towards self-harm as being

NG225 identifies that a structured, person-centred, cognitive behavioural therapy (CBT), informed psychological intervention (for example, CBT or problem-solving therapy) that is specifically tailored for adults who self-harm.

A comprehensive psychosocial assessment for those individuals following self-harm should guide the assessing practitioner to make a person-centred, collaborative decision with the patient based on need and risk. This formulation or outcome may then warrant a patient to be referred into specialist mental health services in order to engage with interventions such as structured CBT Therapy if applicable and in accordance with the local area’s service provision and in line with the local working instruction and standard operating procedure.

Additionally, for children and young people with significant emotional dysregulation difficulties who have frequent episodes of self-harm, consider dialectical behaviour therapy adapted for adolescents (DBT-A). The practitioner receiving the assessment referral and, or the assessing practitioner must take into account the age of the child or young person and any planned transition between services and liaise with the relevant service dependent on age and patient need.

5.4.2 Supporting people to be safe after self-harm

Ensure continuity of care, wherever possible, in the colleagues caring for people who have self-harmed by minimising the number of different colleagues they see.

For guidance on ensuring continuity of care, see the section on continuity of care and relationships in the NICE guideline on patient experience in adult NHS services (opens in new window) and the section on continuity and coordination of care in the NICE guideline on babies, children and young people’s experience of healthcare (opens in new window).

Do not use colleagues who are untrained in clinical observation (for example, security colleagues or trainee health and social care colleagues) to undertake supportive and therapeutic observations in a patient who has self-harmed.

Ensure that the care plans of people who have self-harmed can be accessed by primary and secondary care plus other professionals and practitioners involved in their care.

Ensure that colleagues working with people who have self-harmed are visible and accessible to the people they are caring for, to encourage interaction, particularly during handovers and busy periods.

Assess the safety of the environment, balancing respect for the patients’ autonomy against the need for restrictions. Use the least restrictive measures. Consider removing items that may be used to self-harm and involve the patient who has self-harmed in this decision.

At the earliest opportunity, healthcare colleagues should help people who have self-harmed to become familiar with the clinical setting in which they are being cared for and tell them how to get support.

Colleagues should know how to raise concerns without delay about a patient who has self-harmed.

5.4.3 Risk assessment tools and scales

  • Do not use risk assessment tools and scales to predict future suicide or repetition of self-harm.
  • Do not use risk assessment tools and scales to determine who should and should not be offered treatment or who should be discharged.
  • Do not use global risk stratification into low, medium, or high risk to predict future suicide or repetition of self harm.
  • Do not use global risk stratification into low, medium, or high risk to determine who should be offered treatment or who should be discharged.
  • Focus the assessment on the patients needs and how to support their immediate and long-term psychological and physical safety.
  • Mental health professionals should undertake a risk formulation as part of every psychosocial assessment.

5.5 Associated mental health conditions

NICE recommend that psychological, pharmacological, and psychosocial interventions for any associated conditions, must consider the most appropriate NICE guideline (see Self-harm: assessment, management and preventing recurrence NICE guideline (NG225) (opens in new window): Recommendations: 1.11).

5.6 Patient experience

People who have self harmed should be treated with the same care, respect, and privacy as any patient. In addition, healthcare professionals should take full account of the likely distress associated with self-harm. Involvement and practice should be in line with the professional code of conduct.

Providing treatment and care for people who have self harmed is emotionally demanding and requires a high level of communication skills. Therefore, it is imperative that all colleagues working in this field have regular clinical and managerial supervision to allow them the opportunity to reflect on their practice, as defined in the RDASH supervision policy for clinical colleagues.

Wherever possible, people who have self-harmed should be offered the choice of male or female worker. When this is not possible, the reasons should be explained and recorded in the patient records.

When caring for people who repeatedly self-harm, colleagues should be aware that the individual’s reason for self-harming may be different on each occasion and therefore each episode needs to be treated in its own right.

Colleagues should involve people who self-harm in all discussions and decision-making about their treatment and subsequent care, if applicable. Colleagues should ensure that the patient has full information about the different treatment options available. Colleagues must be mindful of whether Safeguarding procedures need to be followed if patients are being discharged back to an environment in which they have self-harmed in where they live with families, carers or friends taking into special consideration the welfare of any children.

5.7 Relatives or carers

People who self-harm should be allowed, to be accompanied by a member of their family, friend or advocate during assessment and treatment. The initial biopsychosocial assessment should be completed in an area to uphold and promote privacy, confidentiality and dignity but this ultimately should be led by the patient accessing services. For example, in general hospital settings due to a variety of factors including age and mobility, a patient’s physical health state, lack of appropriate assessment space or because of patient preference then an assessment may take place by a bed space.

When thinking about involving family members or carers in supporting a patient who has self-harmed, take into account issues such as:

  • whether the patient has consented for information to be shared and, if so, if the consent is limited to certain aspects of their care
  • any safeguarding concerns
  • the patients mental capacity, age, and competence to make decisions
  • the patients right to confidentiality and autonomy in decision-making
  • the balance between autonomy (in children and young people, their developing independence and maturity) and the need to involve family members or carers
  • the balance between the possible benefits and risks of involving family members of carers and the rights of the patient

Also see the NICE guidelines on decision-making and mental capacity, service user experience in adult mental health (opens in new window), and babies, children and young people’s experience of healthcare (opens in new window).

When involving family members or carers in supporting a patient who has self harmed:

  • encourage a collaborative approach to:
    • empower and support the patient who has self-harmed
    • minimise the patients self-harm behaviours
    • support the patients’ recovery to prevent recurrence
  • give them opportunities to be involved in decision-making, care planning and developing safety plans to support the patient beyond the initial self harm episode, and through their care pathway
  • ensure that there is ongoing and timely communication with the family or carers
  • regularly review whether the patient who has self-harmed still wants their family or carers to be involved in their care, and ensure that they know they can withdraw consent to share at any time

5.8 Triage

It is of paramount importance not to use aversive treatment, punitive approaches, or criminal justice approaches such as community protection notices, criminal behaviour orders or prosecution for high service use as an intervention for frequent self harm episodes. In regard to triage decision-making processes, it’s important to apply the same criteria to every scenario.

This needs to include:

  • the reason for referral and subsequent biopsychosocial assessment
  • the patient’s fitness to engage in the process paying attention to whether they are medically and psychiatrically fit to do so
  • detail any contributing factors such as alcohol and, or illicit substances
  • if the patient wishes for their family or carer(s) to be involved in the process as their support network
  • if the patient is willing to engage in the process and if they have the capacity to make such decision and understand the implications of doing so
  • the patient’s immediate risk to self should also be explored prior to intervention following an episode of self harm

5.8.1 Waiting areas

If a patient must wait for treatment or assessment, they should be offered an environment that is safe and, supportive to help minimises their distress respecting their privacy and dignity. For many patients, this may be a separate quiet room with supervision and contact to ensure safety.

5.8.2 Consent

Colleagues often face difficult decisions about whether they should intervene to provide treatment and care to a patient who has self-harmed and then refuses help. Not only are these decisions difficult but they can provoke disagreements between colleagues who may interpret differently the legal framework that underpins them.

Consent may pertain to emergency treatment of self-harm or may pertain to longer terms care options provided by services. Assessment of capacity and consent should be assessed at each point of contact with a patient who self harms. Please see consent to care and treatment policy.

5.8.3 Mental capacity

The concept of mental capacity is central to determining whether treatment and care can be given to a patient who refuses it. The Mental Capacity Act (2005) gives clear definition of capacity and “best interests”, how to measure and record decisions and will not be dealt with explicitly within this policy. Colleagues should refer to the Mental Capacity Act (2005) Code of Practice for guidance.

For any concerns about the patients’ capacity to consent where requires Colleagues should refer to the Mental Capacity Act (2005) Code of practice for guidance.

Please see MCA policy o our website and on the UK government website (opens in new window)

If the patient is under 16, health and social care professionals should follow the guidelines in ‘Seeking consent: working with children’ (opens in new window).

5.9 Psychosocial assessment following self harm

Those who present to services following an episode of self harm should receive a psychosocial assessment. This should include an assessment of needs and risk.

However, delaying an assessment can result in the patient receiving more appropriate care and treatment. If a patient is not able to meaningfully engage in the assessment process (for example, if the patient is unconscious following intentional overdose or has very high levels of intoxication due to alcohol or illicit substances), they should be regularly reviewed by the responsible Medical team and assessing mental health practitioner so that an assessment can take place as soon as practically safe and appropriate to do so.

If a patient has self-harmed and presents to services but wants to leave before a full psychosocial assessment has taken place, assess the patients safety and any acute or enduring mental health problems before they leave. This should involve a patient’s capacity (time and decision specific) to make this choice and an exploration of their rationale for making such decision considering immediate risk, future planning and support networks.

When undertaking a full psychosocial assessment following an act of self-harm the following is to be included:

  • social situation (including living arrangements, work, and debt)
  • personal relationships (including recent breakdown of significant relationships)
  • recent life events and current difficulties
  • psychiatric history and mental state examination, including any history of previous self-harm and alcohol or drug use
  • spiritual and religious needs
  • assessment of mood, intent, and levels of hopelessness

Enduring psychological characteristics that are known to be associated with self-harm:

  • motivation for the act
  • long term vulnerability factors
  • short term vulnerability factors
  • precipitating factors

The assessment needs to be clearly recorded in the patient’s clinical records and conveyed to others involved in the care and treatment of the individual.

In respect of patients who are not previously known to the service it is recognised that there may only be limited information available. However, it is the responsibility of the colleague completing the assessment to gain as much information as possible from the available sources to aid in the recognition and management of any risk of self harm.

Whenever possible, any assessments made should be shared with the patient to encourage joint clinical decision-making.

All people who have self harmed should be assessed for risk, including the identification of the main clinical and demographic features known to be associated with risk of further self-harm or suicide, in particular, depression, hopelessness, helplessness, and suicidal intent.

If standardised risk assessment scales are used to assess risk, they should only be used to identify those at high risk of repetition of self-harm or completed suicide. They should not be used as a means of excluding those viewed as low risk.

Patients who repeatedly self-harm should not be treated in any way that could infer punishment for their actions.

It is the responsibility of the colleague completing the assessment to gain as much information as possible from available sources to aid in the recognition and management of any risk of self-harm.

5.9.1 Psychological, pharmacological and psychosocial interventions for the management of self harm

Following psychosocial assessment for patients who have self harmed. A clear plan of care should then be developed (or amended).

Clinicians working with those who have self harmed should be aware of the treatment options that are available and encourage patients to make active decisions in their care.

Within primary care services: If a patient presents in primary care with a history of self harm and a risk of repetition, consider referring them to specialist mental health services (following local referral policy) for assessment. If they are under 18 years, consider referring them to CAMHS for assessment.

Within specialist care service: assessment of needs should include:

  • skills, strengths, and assets
  • coping strategies
  • mental health problems or disorders
  • physical health problems or disorders
  • social circumstances and problems
  • psychosocial and occupational functioning, and vulnerabilities
  • recent and current life difficulties, including personal and financial problems
  • the need for psychological intervention, social care and support, occupational rehabilitation, and also drug treatment for any associated conditions
  • the needs of any dependent children or adults they may have caring responsibilities for

NICE recommend that pharmacological interventions should not be offered specifically to reduce self harm. When prescribing medicines to someone who has previously self harmed or who may self harm in the future, healthcare professionals should consider:

  • the toxicity of the prescribed medicines for people at risk of overdose (for example, opiate-containing painkillers and tricyclic antidepressants)
  • their recreational drug and alcohol consumption, the risk of misuse, and possible interaction with prescribed medicines
  • the patients wider access to medicines prescribed for themselves or others
  • the need for effective communication where multiple prescribers are involved. Also see the section on reducing access to methods of suicide in the NICE guideline on preventing suicide in community and custodial settings (opens in new window)

Use shared decision-making to discuss limiting the quantity of medicines supplied to people with a history of self-harm (for example, weekly prescriptions), and ask them to return unwanted medicines for safe disposal. Also see the NICE guideline on shared decision-making (opens in new window).

A medicines review should be completed 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. Also see the NICE guideline on medicines optimisation (opens in new window).

5.9.1.1 Physical health interventions following an episode of self harm

Practitioners working with individuals who self-harm must take into the account the nature of the self-harm and the potential need for intervention and treatment and where this may need to be delivered. Whilst completing parallel assessments is deemed best practice it is important to prioritise physical health interventions first and foremost in severe cases. Practitioners deemed competent and safe to intervene and treat acts of self-harm should do so at the earliest opportunity. For example, cuts of a manageable nature can and should be cleaned and dressed appropriately for individuals admitted to an acute inpatient unit with the appropriate aftercare explained and followed through. Alternatively, if a patient has taken an intentional overdose of any substance(s) requiring baselines observations with the potential need for treatment, then they should be directed to the accident and emergency department as soon as practically possible. The nature of any act of self harm and the immediate effect that this has had on a patient dictates the potential need for a 999 response.

5.10 Specialist groups and service transitions

Take into account the needs and preferences of the patient who has self-harmed as much as possible when carrying out the psychosocial assessment, for example, by:

  • making appropriate adaptations for any learning disability or physical, mental health or neurodevelopmental condition the patient may have
  • providing the option to have a healthcare professional of the same sex carry out the psychosocial assessment when the patient has requested this

5.10.1 Older adults

Clinicians should be aware of the heightened risk of self-harm in this age group and all people over 65 years who self-harm should be assessed by mental health professionals experienced in the assessment of older people who self-harm.

Studies show that older adults with health conditions (both physical and mental illness) have been found to be at increased risk of self-harm.
Rates of mental health conditions in later life are high (approximately 15% for adults aged 60 and over), and suicide rates are among the highest in older adults.

Research also suggests self-harm is often concealed in older adults given a sense of shame and stigma experienced within this population, which may lead older adults not reporting their self harm or seeking support.

  • Pay particular attention to the potential presence of co-morbidities of a physical health nature such as increased risk of infection and subsequent Delirium and chronic pain.
  • Pay particular attention to the potential presence of co-morbidities of a mental health nature such as anxiety, depression, and cognitive impairment.
  • Include a full assessment of the patients social and home situation, including any role they have as a carer.
  • Recognise the increased potential for loneliness and isolation.
  • Recognise that loss of control and ‘perceived’ burden to others or  ‘burdensome ageing’ has been reported by older people as self-harm motivations.
  • Consider the higher risks of suicide following self harm in older people.

5.10.2 Children and young people’s mental health services

For children and young people who have self-harmed, ensure that a mental health professional experienced in assessing children and young people who self harm carries out the psychosocial assessment. They should ask about:

  • their social, peer group, education, and home situations
  • any caring responsibilities
  • the use of social media and the internet to connect with others and the effects of these on mental health and wellbeing
  • any child protection or safeguarding issues (please see the safeguarding adults policy and the safeguarding children policy)

Children and young people who have been admitted to a paediatric ward following an episode of self harm should have:

  • access to a specialist child and adolescent mental health service (CAMHS or children and young people’s mental health services [CYPMHS]) or age-appropriate liaison psychiatry 24 hours a day
  • a joint daily review by both the Paediatric team and Children and Young People’s Mental Health team
  • daily access to their family members or carers
  • regular multidisciplinary team meetings between the general Paediatric team and mental health services

Colleagues working in this field should be fully aware of treatment approaches in dealing with self-harm and be trained in appropriate interventions. This may include such treatments as dialectical behaviour therapy and cognitive behaviour therapy.

5.10.3 Transitions

Self-harm research and NICE guidance emphasises the risks posed when patients who self-harm undertake transitions within healthcare services. Core transition points within the services that RDASH provide include:

  • primary care to specialist care services
  • CAMHS or other children’s services to adult care services
  • adult to older adult services
  • inpatient to community health services
  • community to inpatient services
  • discharge from any services

Risk assessment, risk management, therapeutic support planning and crisis and contingency planning must be considered in preparation for any transition for a patient with a history of or current self-harm. This is specifically essential to minimise risk and proactively intervene with patients who may resort to self harm at periods of high stress.

5.10.4 Substance misuse

If the patient who has self-harmed is intoxicated by drugs and alcohol, agree with the patient and colleagues what immediate assistance is of paramount importance, for example, support and advice about medical assessment and treatment.

Furthermore, if a patient is experiencing the acute withdrawal effects from alcohol and requires a detox regime then this should be instigated in the first instance with the patient then regularly reviewed by the medical team providing treatment and the assessing mental health service. A psychosocial assessment should then be completed when the patient is medically and psychiatrically fit to engage meaningfully in the process.

Do not use breath or blood alcohol levels to delay the psychosocial assessment. The decision to delay psychosocial assessments should be based on a patients’ presenting clinical picture.

Mental health services should consider referral to substance misuse services or seeking advice from substance misuse services where they identify significant substance misuse in self harming patients within regards to the completion of psychosocial assessment and especially future care and treatment.

If the patient is not able to participate in the psychosocial assessment, ensure that they have regular reviews, and complete a psychosocial assessment as soon as possible.

5.11 Colleagues support

Dealing with those that self-harm is often stressful and distressing. Consequently, colleagues need appropriate supervision and support arrangements, (see supervision policy for clinical colleagues).

Colleagues also need to recognise:

  • addictive or compulsive nature of self-harm and be prepared to discuss this with the patient
  • understand that patients who self-harm may very quickly become distressed or volatile during consultations and be able to support and manage these types of encounters
  • colleagues and services involved with people who self-harm need to adopt a consistent approach across all disciplines involved in care, with clear, unambiguous care plans that are explored with the patient to ensure maximum involvement and ownership. Complex case discussions and multidisciplinary across agency working is therefore essential to support patients and ensure consistency
  • in the inpatient setting, supportive and therapeutic levels of observation of the patient in the acute phase may be required. It is important for colleagues to recognise that this is a therapeutic intervention that should involve the patient. It should not be carried out in a way that could be considered punitive (see the trust for supportive therapeutic observation policy). Once instigated supportive and therapeutic levels of observation of the patient should be constantly reviewed so that they are carried out only for as long as is absolutely necessary

5.12 Care planning

The assessment and management of self harm is an ongoing part of the care planning process. Review the patients care plan with them regularly, including the aims of treatment. Care plans should be reviewed at a minimum every 12 months.

For all patients who have been assessed as at risk of self harming behaviour there will be an agreed plan in place as to how this behaviour is to be managed in both the short and long term.

When developing this management plan consideration will be given to any advance directives which the patient may have in place.

Prior to discharge from inpatient services there should be a pre-discharge MDT involving where appropriate community support services, a discharge care plan must be developed and agreed and should include contingency and crisis plans.

Crisis planning must be considered for all patients who self harm. These must consider self-management strategies and how to access services if self-management fails. Crisis plans should be in place for all patients receiving specialist services and should be considered within Wellness recovery action planning on discharge from primary and specialist services.

5.12.1 Crisis and safety planning

Consider developing a crisis or safety plan in partnership with people who have self-harmed. Safety plans should be used to:

  • establish the means of self harm
  • recognise the triggers and warning signs of increased distress, further self-harm, or a suicidal crisis
  • identify individualised coping strategies, including problem-solving any factors that may act as a barrier
  • identify social contacts and social settings as a means of distraction from suicidal thoughts or escalating crisis
  • identify family members or friends to provide support or help resolve the crisis
  • include contact details for the mental health service, including out-of-hours services and emergency contact details
  • keep the environment safe by working collaboratively to remove or restrict lethal means of suicide

The plan should be in an accessible format and:

  • be developed collaboratively and compassionately between the patient who has self harmed, and the professional involved in their care using shared decision-making
  • be developed in collaboration with family and carers, as appropriate use a problem-solving approach
  • be held by the patient
  • be shared with the family, carers and relevant professionals and practitioners as decided by the patient
  • be accessible to the patient and the professionals and practitioners involved in their care at times of crisis

5.12.2 Complex cases

If a patient presents with frequent episodes of self-harm or if treatment has not been effective, carry out a multidisciplinary review with the patient and those involved in their care and support, and others who may need to be involved, to agree a joint plan and approach.

This should involve:

  • identifying an appropriately trained professional or practitioner to coordinate the patients care and act as a point of contact
  • reviewing the patients existing care and support and arranging referral to any necessary services
  • the patient should be considered for referral to forums that the trust has active representation in such as the complex and serious referrals meeting which incorporates a senior level MDT approach and can be referred into by any practitioner within the trust
  • the trust also has representation at the high intensity user group (HIUG) meeting which pulls together a range of community based services including Yorkshire ambulance service (YAS), South Yorkshire police (SYP), social care, drug and alcohol services and social prescribing services thus enabling a wider MDT approach
  • developing a care plan
  • developing a safety plan for future episodes of self-harm, which should be written with and agreed by the patient who self harms

5.13 Therapeutic risk taking

NG225 refers to positive risk taking as therapeutic risk taking which focuses more on collaboration with the patient emphasising patient strengths and coping strategies.

Therapeutic risk taking should only be used after a psychosocial assessment and risk assessment (see the section on psychosocial assessment and care by mental health professionals), and should:

  • use shared decision-making, to ensure that the patient is able to make an informed choice at all stages, and include family and carers, as appropriate

Include other relevant professionals involved in the care of the patient who has self harmed.

  • draw on the patients strengths and coping strategies and what matters to them
  • focus on positive outcomes
  • be part of an ongoing assessment to revisit the decision
  • be concurrent with psychiatric care if necessary
  • harm minimisation should be applied on a case by case basis and not introduced to every patient who has difficulty in managing and reducing their self harming behaviours

5.13.1 Harm minimisation

If a patient is engaged in ongoing care and treatment but is not yet in a position to resist the urge to self harm, only consider harm minimisation strategies:

  • in the spirit of hope and optimism, and to reduce the severity or recurrence of injury
  • as part of an overall approach to the patients ongoing recovery-focused care and support, and not as a standalone intervention
  • after being discussed and agreed in a collaborative way with the patient and their family members or carers (as appropriate), and the wider Multidisciplinary team

Mental health professionals should discuss with the patient harm minimisation strategies that could help to avoid, delay, or reduce further episodes of self-harm and reduce complications, for example:

  • distraction techniques or coping strategies
  • approaches to self care
  • wound hygiene and aftercare
  • providing factual information on the potential complications of self harm
  • the impact of alcohol and recreational drugs on the urge to self harm

5.14 Discharge from inpatient services

When a patient who self-harms is discharged from the inpatient services, colleagues are to follow the local discharge procedures (see admission, transfer and discharge manual)

Follow up from discharge is to be within a minimum of 48 hours for patients identified having a risk of suicide on preparation for discharge, or following an episode of self harm where there are ongoing safety concerns for the patient. It is therefore vital that if the patient is involved in specialist services, the mental health team, GP or team responsible for their care are notified that the discharge has gone ahead as planned, if referred to another service; they are also informed of the discharge.

5.15 Environmental considerations

Whilst it is difficult to eliminate all risks from inpatient areas, the trust endeavours to minimise the potential risk of patients harming themselves whilst receiving inpatient care by having in place the following measures within high-risk areas:

  • the Bolton anti ligature risk assessment
  • anti ligature considerations in environmental assessments
  • collapsible curtain tracking
  • none barricade doors
  • observation panels in doors
  • controlled access or egress systems
  • modern matron ligature audit

These measures are also supported by the following trust policies and procedures:

5.16 Reporting incidents of self harm within inpatient services

Within the inpatient services all incidents of self-harm are to be reported using the trust’s electronic reporting system. The information provided on these reports will assist the clinical team in:

  • reviewing the risk management plan
  • identifying any triggers to the self harming behaviour
  • identifying any trends in relation to self harming behaviour

6 Training implications

There are no specific colleague training needs identified in relation to the use of this policy. Colleagues will be made aware of the policy contents in the following ways:

The reissue of the policy will be included in the trust weekly news bulletin, discussion at team or ward meetings.

Use of the policy during clinical supervision if colleagues have any issues or concerns re a patient which falls under this policy.

7 Equality impact assessment screening

To access the equality impact assessment for this policy, please email rdash.equalityanddiversity@nhs.net to request the document.

7.1 Privacy, dignity and respect

The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi’s review of the NHS, identifies the need to organise care around the individual, ‘not just clinically but in terms of dignity and respect’.

Consequently, the trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity, and respect, (when appropriate this should also include how same sex accommodation is provided).

7.1.1 Indicate how this will be met

Privacy, dignity and respect underpin the implementation of this and the associated policies, which set out a person centred approach to care, working in partnership with the patient and carers as appropriate.

7.2 Mental capacity act

Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individual’s capacity to participate in the decision-making process. Consequently, no intervention should be carried out without either the individual’s informed consent, or the powers included in a legal framework, or by order of the court.

Therefore, the trust is required to make sure that all colleagues working with individuals who use our service are familiar with the provisions within the Mental Capacity Act (2005). For this reason, all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act (2005)to ensure that the rights of individual are protected, and they are supported to make their own decisions where possible and that any decisions made on their behalf when they lack capacity are made in their best interests and least restrictive of their rights and freedoms.

7.2.1 Indicate how this will be achieved

All individuals involved in the implementation of this policy should do so in accordance with the guiding principles of the Mental Capacity Act (2005).

8.1 Mental Capacity Act policies

8.2 NICE guidance

This list is not exhaustive. Refer to trust intranet.

9 References

10 Additional reading

  • Annual report 2023: UK patient and general population data 2010 to 2020: 2023 National confidential enquiry into suicide and safety in mental health.
  • Department of Health (2007b) The Mental Health Act (1983) revised: 2007. HMSO, London.
  • Department of Health (2005) The Mental Capacity Act. HMSO, London.
  • Department of Health (2019) Preventing suicide in England: Fourth progress report of the cross government outcomes strategy to save lives. Self-harm: assessment, management and preventing recurrence.
  • Great Britain (1998) The Data Protection Act 1998: Elizabeth II c30. London, H.M.S.O.
  • Great Britain (1998), The Human Rights Act 1998: Elizabeth II London, H.M.S.O.
  • NHS community mental health framework for adults and older adults: 2019 NHS England and NHS Improvement and the National Collaborating Central for Mental Health.
  • NHS Mental health implementation Plan 2019/20 to 2023/24. 2019 NHS England and NHS improvement.

11 Appendices

11.1 Appendix A Responsibilities, accountabilities and duties

11.1.1 The board of directors

The board of directors is responsible for ensuring that the organisation consistently follows the principles of good governance applicable to NHS organisations. This includes the development of systems and processes for clinical risk assessment and management.

11.1.2 The chief executive

The board of directors delegates to the chief executive the overall responsibility for ensuring the trust employs a comprehensive strategy to support the management of risk, including clinical risks associated with patient care.

11.1.3 The Care Group Senior Leadership team

The Care Group Senior Leadership team are responsible for disseminating the policy in its entirety to their service managers and matrons.

11.1.4 Service managers and matrons

The service managers and matrons are responsible for:

  • the dissemination of this policy to their colleagues
  • identifying the training needs of their colleagues in relation to this policy
  • releasing colleagues to attend for training
  • supporting colleagues who care for patients that self harm

11.1.5 All clinical colleagues

All clinical colleagues that have contact with people who have self harmed should be adequately trained to assess mental capacity and to make decisions about when treatment and care can be given without consent.

11.2 Appendix B Monitoring arrangement

11.2.1 Area for monitoring, compliance with the standards set out in this policy

  • How: Investigation of any complaints, SUIs and structured reviews which arise as a result of the use of this policy.
  • who by: Service managers or matrons.
  • Reported to: The Care Group Senior Leadership teams
  • Frequency: As and when complaints or SUIs occur

11.2.2 Area for monitoring, ligature audit

  • How: Tendable.
  • who by: Matrons.
  • Reported to: The Care Group Senior Leadership teams.

Document control

  • Version: 7.
  • Unique reference number: 407.
  • Approved by: Clinical policies review and approvals group.
  • Date approved: 6 February 2024.
  • Name of originator or author: Mental health hospital liaison team manager.
  • Name of responsible individual: Executive director of nursing and allied health professionals.
  • Date issued: 19 February 2024.
  • Review date: 28 February 2027.
  • Target audience: All RDASH clinical staff.

Page last reviewed: November 14, 2024
Next review due: November 14, 2025

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