Dr Beverley Ward
It's vital that lessons are learned from cases where a patient has taken their own life in order to improve suicide prevention, as Dr Beverley Ward explains.
The House of Commons Health Committee recently launched an inquiry into the action needed to be taken to improve suicide prevention in England. The report, published in March 2017, found that 4,820 people were recorded as having died by suicide in England in 2015, with the true figure likely to be higher.
Suicide remains the biggest killer of men under 49 and the leading cause of death in people aged 15-24. Those at highest risk include people in the lowest socioeconomic groups in the most deprived areas and prisoners, with both groups being 10 times more at risk of suicide than people in the community.
The report called for training for healthcare professionals to be more aware of the benefit of sharing information with the patient's family or friends, with consent, to help in their recovery.
A recent review of MDU files over a 10-year period reflected the increasing numbers of people taking their own life, with the number of doctors asking for support after a patient commits suicide more than doubling over this period.
When a suicide occurs, relatives will often want to know whether it could have been prevented and what steps healthcare professionals took to assess and reduce the risk. There will also be an inquest, at which the deceased's doctor may be asked to give evidence.
In 2016, 265 cases involving suicide were notified to us by members, an increase of 128% since 2007 when there were 116 cases. Most of these related to inquests. National figures show the rate of suicide peaked in 2014, and reduced very slightly in 2015.
Managing mental health conditions poses significant difficulties in both primary and secondary care. Signs and symptoms can be subtle, and patients may be reluctant to disclose suicidal thoughts or symptoms of depression
Access to specialist mental health services may be difficult in areas where resources are short and services stretched. Knowing who to refer, and to which mental health service, can also be complex.
GPs' central role
GPs are on the front line for the identification and management of mental illness. Of the 265 cases notified to the MDU in 2016, over half (62%) were from GPs and practice managers. Around a third (31%) came from psychiatrists, and the remainder from other specialties.
The RCGP has issued guidance and has online learning modules on the management of depression in specific groups, including the elderly1 and those with a chronic illness. There may also be local CPD-accredited training for doctors who wish to update their skills and knowledge in this field.
Not all those who commit suicide are depressed. Other causes may include psychosis, personality disorder or physical illness.
Types of cases
Inquests were by far the most common reason for doctors to seek our help last year (216 of the 265, or 81% of cases). There were also 12 cases arising from complaints and four from a claim. More complaints and claims may follow after the inquest has taken place. Ten cases related to an adverse incident investigation.
Complaints relating to a suicide can be difficult to resolve, especially if the inquest is ongoing. You may need to consider informing the coroner or procurator fiscal of any additional disclosure of information made to the family.
A number of investigations can follow a suicide, including a complaint, claim for clinical negligence, coroner's inquest or procurator fiscal investigation, internal trust investigation, serious incident report and disciplinary action. In rare cases complaints can also be made to the GMC, as happened in four cases seen by the MDU last year.
Other queries related to ethical matters and adverse media coverage.
MDU advice when treating patients at risk of suicide
- Be alert to the possibility of depression in patients with a history of mental illness, chronic health conditions and vulnerable groups. This might include those who are elderly or young, socially or geographically isolated, or in prison.
- If you can't discuss all of a patient's mental health concerns in one short appointment, ask them to come back for a longer appointment. Try to book this before they leave the surgery/clinic.
- Document discussions with patients carefully. If they are seen by a colleague at the next appointment, it should be clear from the notes that the patient has had depressive symptoms or suicidal thoughts and that they may need to ask specifically about them.
- Make sure you document any risk factors for suicide, such as alcohol or substance misuse, previous suicide attempts, or a family history of suicide. Other risk factors include being a victim of sexual or physical abuse and keeping firearms at home.
- If the patient fails to attend a follow-up appointment, try to contact them to find out why. Don't rely on the patient to take action; if they are suffering from depression, they may be less able to ask for help. The MDU is aware of cases where opportunities may have been missed to review a patient.
- Encourage the patient to let you involve close family members or friends, who may be able to offer additional support. Remember your duty of confidentiality and do not discuss the patient with friends or relatives without their permission. The GMC is clear that it is not a breach of confidentiality to listen to the concerns of a relative or friend, as they can often provide important information that might alert you to a risk of imminent suicide. Warning signs that a loved one might be aware of include the patient talking a lot about death, making comments about being helpless or worthless, losing interest in life, putting their affairs in order, contacting people to say goodbye, or passing on their possessions.
- Keep up to date with best practice in mental health treatments, and mental health services available in your area. Knowing what extra help is on offer can make it easier when trying to arrange referral or crisis help for a patient.
- If you're making an urgent referral in a crisis, track the referral to make sure it is actioned as you intended.
- Don't be afraid to ask a patient about depressive symptoms or suicidal thoughts if you have concerns. A sensitive enquiry might encourage the patient to discuss feelings they otherwise felt unable to express.
- It's a good idea to document objective measurements of mood in the records using standardised questionnaires.
- Have a system in place to audit or review all patients on long-term anti-depressants.
- Explain patients' options to them clearly, including talking therapies, the risks or side effects of medications and details of crisis team or out of hours help.
Case study – missed opportunities
A GP contacted the MDU for advice after being asked to attend an inquest. The GP had already provided a statement for the coroner after a male patient in his 40s had been found hanged.
The patient had suffered bouts of depression on and off over the last 15 years and had been prescribed various antidepressants, which he tended to take for a short period before stopping against advice.
He had been under the care of the mental health team 10 years earlier after an overdose of his antidepressant medication and alcohol. Since then he had attended infrequently, until a recent appointment where he described feeling very low after being made redundant. The GP he saw prescribed anti-depressants and arranged to review him four weeks later. Although it was the GP's usual practice to assess risk factors for suicide, he hadn't recorded his assessment in the notes.
The patient did not attend the review appointment, and a few days later his wife, who was also a patient, attended and voiced concerns to a locum doctor that her husband was very withdrawn and drinking heavily, and that she was having difficulty talking to him. The locum advised her to encourage him to attend, recording this conversation in the wife's medical records but not in those of her husband because of concerns about breaching her confidentiality.
The patient died one week later.
The coroner was critical of the practice's care of the patient, explaining that there were missed opportunities to follow-up when he failed to re-attend, and when his wife raised concerns. The family later complained to the GMC and brought a claim against the practice alleging that negligence had contributed to the patient's death.
The MDU supported the GP with the GMC complaint and successfully defended the claim, but the whole process took more than a year and was stressful for all involved.
Dr Beverley Ward
Beverley is a former GP and has been a medico-legal adviser at the MDU since 2008. She provides advice and assistance to members of all specialties on ethical and legal matters arising from their care of patients.
See more by Dr Beverley Ward