ROLES AND TRAINING
This chapter will address two related terms of reference. The first term
of reference (c) is the appropriate role and effectiveness of agencies, such as
police, emergency departments, law enforcement and general health services in
assisting people at risk of suicide. The second term of reference (e) is the
efficacy of suicide prevention training and support for front-line health and
community workers providing services to people at risk. In the view of the
Committee the appropriate roles, effectiveness and training of frontline personnel
assisting people at risk of suicide are clearly linked issues.
Suicide prevention roles
Health professionals and primary care
Primary health care and general practitioners (GPs) were recognised as
important for identifying and supporting people who are at risk of suicide and
for the provision of postvention support to people who have attempted suicide.
The Australian Medical Association (AMA) observed that about 88 per cent
of Australians visit a GP at least once a year, providing significant
opportunities for suicide prevention risk assessment and treatment. They noted
that research indicates that those who complete suicide are likely to have seen
a GP in the weeks and months prior but rarely communicate their intentions. They
are reliant on the GP recognising their risk and providing treatment. While GPs
were well placed to identify patients at risk of suicide, the AMA argued that
this activity relies on the availability of speciality follow up services patients
can be referred to. They stated:
Specialised out-patient and acute care services need to be
immediately available to ensure patient safety. Any delays or problems with
accessing these services may undermine the initial efforts to prevent suicide.
Similarly the Australian General Practice Network (AGPN) highlighted the
importance of GPs having the skills to identify and respond to people at risk
of suicide or self harm as well as patients at risk of suicide having access to
specialised suicide prevention services from psychologists, psychiatrists and social
They emphasised the importance of patients building relationships with a single
doctor or practice over time '...which provides a critical foundation for primary
health care and encourages GPs and patients to take a long-term approach to
However GPs and nurses were perceived as having minimal education and
training regarding suicide and suicide prevention.
RANZCP recommended that ongoing education regarding identification and
appropriate treatment of depressive disorders should be provided to GPs and all
those training as health professionals should be given suicide prevention
education to ensure good literary early in their careers.
Police and ambulance officers
Police officers are generally regarded as having a number of roles in assisting
people at risk of suicide:
- in cases of attempted suicide, seeking the intervention of health
professionals, including by utilising legislative provisions, such as detaining
persons pursuant to mental health legislation where appropriate;
- assisting health workers when there are issues of safety in
dealing with a person who has attempted or is contemplating suicide, to reduce
the risk to a safe level to enable intervention; and
- acting as a referral service to health agencies.
The Committee received mixed evidence regarding the role and
effectiveness of police assisting people at risk of suicide. For example
Lifeline Australia noted that while in its experience the response by police to
people at risk of suicide had been good, 'individual officers may lack the
necessary training, experience and skills to adequately assess and assist
someone at risk of suicide'. They commented that in '...some instances police
response have been described as “heavy handed” by individuals requiring
assistance (particularly those with chronic mental illness) and the treatment
they have received from police has further traumatised them'. Lifeline argued
this demonstrated the need for universal training in suicide awareness and
appropriate responses to people at risk of suicide for police and other
The Salvation Army also suggested that after analysing the feedback they
received '... it could be observed that police in major cities appear to have the
resources and training to respond appropriately and compassionately and more
needs to be done to train and support police operating in rural and regional
There were also indications police and coronial investigations could
impose further trauma on the bereaved families following a suicide. This could
occur in situations where there is initial uncertainty as to whether the cause
of death was suicide or homicide. Standard police procedures such as
questioning family members and treating the location of a suicide as crime
scene 'can often be perceived as insensitive and distressing'.
The NSW Consumer Advisory Group Mental Health told the Committee:
Police are often the first called to respond to a person
experiencing a crisis due to a lack of after-hours crisis services or because
of a perceived danger to community mental health clinicians. Consumers have
talked about their concerns about marked cars and uniformed police involved in
a mental health crisis intervention and how this can be misconstrued as a
criminal matter by other members of the community. This can result in feelings
of humiliation and shame for the person who is actually in crisis, which can
have a very real and long-term effect.
There were other views expressed that police officers should be allowed
to concentrate on law enforcement rather than functioning as 'front line mental
health officers'. The challenges that police officers face in dealing with
people at risk of suicide were also recognised. The Private Mental Health
Consumer Carer Network Australia stated:
We acknowledge the critical role of police and/or emergency
services in de-escalating attempted suicides, risking their own safety and
wellbeing. Mental health is a challenging area when people with florid
psychotic symptoms, who are at risk of harm to themselves, prove very difficult
The SPA submission commented that there is limited information available
about 'first responders' such as police in terms of their training and impact
on those at risk of suicide. 
Committee understands the majority of police receive limited suicide
prevention training as part of their training for dealing with people who may
have mental health issues.
The NSW Government noted the success of the pilot NSW Police Mental
Health Intervention Team (MHIT) which was developed to reduce the risk of
injury to police and people with mental health illnesses. It aims to improve
awareness by frontline police of risks involved in dealing with people with
mental illness and provide strategies to reduce injuries to police and
consumers; improve collaboration with other government and non-government
agencies in the response and management of mental health crisis events; and to
reduce the time taken by police in the handover of people with mental illness
to the health care system. The MHIT has now been established as a fulltime unit
and been given the target of training a minimum of 10 per cent of all frontline
NSW Police Force staff by 2015.
Ambulance officers were also highlighted as a group with an important
role in assisting people at risk of suicide. Where the consequences of a
suicide attempt require medical attention an ambulance is often called to the
scene. Ambulance officers usually have basic mental health training. The SPA
Position Statement on Crisis Response notes:
Ambulance staff need the skills to assess suicide risk and
provide immediate management, but they also need support and training to
safeguard their personal needs and to deal with the trauma associated with
crisis response. Knowledge of local mental health legislation, involuntary
admission laws and mental health or support services, facilitates ambulance
workers’ decision-making about suicidal patients.
A large amount of evidence was received regarding the responses of
hospital emergency departments to persons who had attempted suicide or were at
risk of suicide. The Salvation Army had 'grave concerns about the response of
many emergency departments to people who are in immediate crisis'. They
commented it appeared that many emergency departments are so stretched because
of lack of resources and increasing demand that people in crisis do not receive
the attention and support they need.
They also noted serious concerns with the risk assessments conducted before a
person is discharged from hospital.
Whilst the Mental Health protocols state that suicidal people
should not be discharged from hospital without a Risk Assessment being
conducted, people quickly learn how to respond to the questionnaire. 
The NSW Consumer Advisory Group described hospital triage systems as not
identifying mental health as a priority.
RANZCP noted that acutely suicidal persons can be made to wait for
inappropriately long periods of time. They argued that emergency departments
need to be able to respond both to the psychological and emotional needs of
suicidal persons as well as any physical consequences of a suicide attempt.
RANZCP outlined Australian research which found '...about one third of suicide
attempt survivors described their satisfaction with their hospital treatment as
‘mixed’ and one fifth as ‘poor’ or ‘very poor’'. Similarly, 28 per cent of
suicide attempt survivors described the attitudes of health care professionals
in the hospital environment as ‘mixed’ and 33.5 per cent as ‘poor’ and ‘very
SPA suggested that persons at risk of suicide may benefit from improved
widespread training of all emergency department staff in current suicide risk
assessment protocols. They argued that:
When a person who has attempted suicide comes to the
attention of an emergency department, a prime opportunity opens up for
intervention. However, the majority of those who do come to attention following
a suicide attempt do not receive any subsequent help.
A number of witnesses and submissions emphasised the importance of
taking seriously any situation where someone is talking about suicide. Many
related personal stories when they had difficulty in receiving assistance from
emergency departments, particularly where a person had suicidal ideation but
had not attempted suicide. Ms Carla Pearse from the Community Action for the
Prevention of Suicide commented:
I have got a great deal of respect for our public health
system, our public mental health system, but they are absolutely snowed. They
simply cannot respond to people... My experience with my clients is that they
might go to A&E. If they are accepted into the system they will be sitting
there for hours and hours unless they have made an attempt. But if they are
going to A&E with suicidal thoughts then they are sent home.
The Committee understands that guidelines and protocols exist in most
jurisdictions for healthcare staff to undertake suicide risk assessment of
patients. The NSW Government noted that the Framework for Suicide Risk
Assessment and Management for NSW Health Staff provides detailed information
for health staff on conducting suicide risk assessments, and includes specifics
on the roles and responsibilities of generalist and mental health services. The
People with possible suicidal behaviour must receive preliminary
suicide risk assessment and, where appropriate, a referral for a comprehensive
mental health assessment including a detailed suicide risk assessment. The goal
of a suicide risk assessment is to determine the level of suicide risk at a given
time and to provide the appropriate clinical care and management.
However the Psychotherapy and Counselling Federation of Australia
reported that its practitioners who support staff working in emergency
departments of hospitals report that these personnel feel unsupported in
assessing suicide risk.
Some State and Territory governments appear to be responding to the
difficulties for persons in crisis attending hospital emergency departments.
The NSW Government reported it had established nine psychiatric emergency care
centres (PECC) for patients with acute mental health needs. The ACT Government
also noted an initiative it was undertaking to assist in the referral of
persons at risk of suicide.
Recognising the crucial role that Emergency Departments
(ED’s) play in assisting people at risk of suicide, the ACT is currently
constructing a Mental Health Assessment Unit (MHAU) which will be attached to
the ED of the Canberra Hospital. The MHAU will be a 6 bed mental health
assessment unit that will provide specialised mental health assessment, crisis
stabilisation and treatment for all people presenting to the ED with an acute
mental illness or disorder.
The Committee also received evidence that other government agencies as
well as commercial services often need to display more tact and discretion in
their transactions with people who may be at risk of suicide. For example the Psychotherapy
and Counselling Federation of Australia commented:
Many Centrelink workers do not have skills in adequately
responding to the needs of at risk clients. It was noted that when discussing
depression with their clients staff may not be sensitive to the needs of the individual.
The NSW Government noted Mental Health First Aid training would also be
rolled out to RailCorp station staff in 2010 as part of an initiative 'to
address the risk and incidence of suicide in the NSW rail system'.
The Committee heard many stories from people who felt that they had not
been treated appropriately by frontline personnel after an attempted suicide or
completed suicide. Mr Alan Woodward of Lifeline related an experience of one of
the Lifeline managers where a man was not treated appropriately by hospital
staff after attempting suicide. He noted:
Lifeline believes that whatever else is provided to suicidal
persons, whatever else is done to keep suicidal persons safe, whatever else is
done to prevent the onset of suicidality, there must be genuine, non-judgmental
caring in our response.
The Lifeline submission also noted that some emergency service
personnel, health, and other community support workers who are the first
responders to a suicide incident can suffer from 'compassion fatigue', and at
times can have misinformed attitudes towards suicidal behaviours and risk
Similarly Salvation Army stated there was a perceived lack of empathy or
concern for patients who are suicidal and a perception health professionals
often believe the person who has attempted suicide is attention seeking.
Submitters and witnesses, including those who have worked as health
professionals, gave evidence to the Committee that health care services are not
always free of stigmatised views of suicide, and that people presenting with
suicide attempts have had experiences of punitive and dismissive attitudes from
health care professionals.
The Committee was disturbed to receive evidence of practices in
hospitals and by doctors whereby patients who presented following an attempted
suicide or self-harm were treated badly or even 'punished'. This included
publicly scolding them for their actions and treatment such as stitches for
self inflicted injuries without anaesthetic. Professor Graham Martin linked
these practices to the stigmatisation of people who self-harm by medical
SPA also submitted the following descriptions of personal experiences
which patients had contributed:
The nurse informed me that I was both selfish and stupid to
have done what I did and that her nephew had also done something similar that
week and was equally selfish and stupid. I lied to every medical person who
came to see me in order to get out of the hospital quicker. The experience I
had in hospital meant I didn’t go and see a GP for quite a few years.
I found that ambulance workers, nurses and doctors (both from
ER and ICU) were judgmental of me as if I had brought my sickness on myself and
was wasting the resources available for deserving sick people.
Some hospital staff are still under the impression that
suicide and self harmers are attention seekers. This is far from the case, and
needs to be recognised without prejudice.
Support for frontline personnel
The support available for those frontline staff dealing with suicide and
attempted suicide was frequently raised. Their experiences were seen as
resulting in 'vicarious trauma' causing stress-related anxiety, depression and
post traumatic stress disorders. As an example Professor John Mendoza related
the circumstances of two Queensland Ambulance Service officers who were deeply
traumatised by their experience of assisting a young man to an emergency
department and then being subsequently called to attend the scene of the man's
suicide a few hours later.
The vicarious trauma and impact of suicide (particularly
where the deceased was a patient or client) on first responders, clinicians,
general practitioners and other health professionals (including coronial
staff), and also volunteers, work colleagues and whole communities more
broadly, should not be underestimated.
The SPA Position Statement on Crisis Response recommended:
First responders who are exposed to crisis situations and
suicide attempts as part of their job should have formal structures of support
and debriefing embedded in their work practices....
Strategies for debriefing and support embedded in
organisational practice should safeguard the professional’s own needs to reduce
distress and burnout.
Discharge and follow up support
The time following discharge from hospital or inpatient psychiatric care
was identified as a period of particular risk for people who were at risk of
suicide. DoHA commented that studies have estimated that the rate of suicide in
people with a mental illness following discharge from inpatient psychiatric
treatment could be over 200 times the rate of death by suicide in the general population.
The elevated risk of suicide is highest immediately following
discharge, with 12.8% of deaths by suicide after discharge occurring on the day
of discharge, 28.4% in the week following discharge, 47.7% in the month
following discharge and 80% within one year of the last episode of inpatient
Despite this period being recognised as a time of risk for suicide Lifeline
Australia noted that discharge from hospital 'does not always include a
workable discharge plan, and a person at risk of suicide can return home with
limited or no supports in place'.
Similarly the MHCA noted that it was 'commonplace for a person to be discharged
from a mental health service following an attempted suicide and disappear into
the community, without any arrangements for follow-up care in the community'.
There needs to be a compulsory follow-up plan for people
discharged from hospital or other services after attempting suicide. There is
currently no requirement upon hospital and frontline staff to ensure that
individuals at high-risk of suicide are given the necessary follow up care and
The NSW Consumer Advisory Group Mental Health argued that 'discharge
planning needs to extend beyond the current minimum of making sure the
individual has somewhere to go or that someone has been informed of there
discharge...[t]here needs to be a process in place to ensure a continuity of
RANZCP commented that the majority of those who do come to attention following
a suicide attempt do not receive any subsequent help.
Non-attendance of suicide attempt survivors at follow-up interviews
is alarmingly high with some researchers estimating this non-compliance to be
as high as 50 to 60 per cent.
The Private Mental Health Consumer Carer Network Australia recommended mandatory
introduction and routine use in public and private mental health sectors of a
clinician rated, validated suicide risk assessment tool at admission and
discharge from inpatient settings as well as a 3 monthly review in community
The NSW Government noted that the period following discharge is a period
of increased risk for mental health patients and stated this was recognised in
the Discharge Planning Policy for Adult Mental Health Inpatient Services.
This policy 'provides direction on the principles and practices that mental
health clinicians must follow to promote the safe transition to the community
for patients leaving mental health units'.
Research which indicated that follow up procedures with patients after
their discharge could reduce their rate of suicide was frequently mentioned in
submissions. The MHCA commented that enough evidence exists to demonstrate that
an appropriate discharge follow-up care plan and management by appropriately
trained staff cannot only prevent future attempts, but assist in rebuilding the
lives of people.
SPA outlined a range of interventions after discharge through which contact
with the person at risk of suicide could be maintained. They noted:
Recent studies have shown that maintaining contact with
suicide attempt survivors or other high risk groups (e.g. psychiatric
inpatients refusing follow-up) after discharge significantly reduces their risk
of subsequent attempt and death.
The Suicide is Preventable submission also emphasised that studies have
demonstrated that simple letter or postcard interventions, where postcards are
mailed to persons discharged from acute care mental health units inviting them
to stay in touch at regular intervals, have been effective in reducing repeat
episodes of self-harm and also death by suicide.
DoHA highlighted two programs relevant to this area of support. The
first was the Consumer Activity Network operated Community Connections project
in Sydney which provides peer support and practical assistance to mental health
consumers in the community for the first 28 days following discharge from
psychiatric inpatient units. The service also offers a national telephone peer support
for mental health consumers.
DoHA also highlighted the Access to Allied Psychological Services
(ATAPS) Suicide Prevention Pilot which aims to provide better support for
people at high risk of suicide after presentation to an emergency department or
general practitioner following a suicide attempt or self‐harm. It facilitates priority access to
referral pathways to specialised allied psychological services for people who
attempted suicide or who have suicidal ideation.
Funding is also given to Crisis Support Services to provide 24 hour telephone
The AGPN provided the Committee with further details about the
operations of this pilot project.
A pilot extension of ATAPS called Specialist Services for
Consumers at Risk of Suicide is allowing provision of intensive, prioritised
services for people at risk of suicide delivered in 19 GPNs [general practice
networks]. It includes treatment for people discharged from hospital to GP
care, people who have presented to a GP after an incident of self harm, and
people who have expressed strong suicidal ideation to their GP. The GP is then
able to refer the person to an experienced psychologist for immediate,
intensive counselling (within 24-72 hours, for up to 2 months). The GP
maintains responsibility for ongoing clinical case management, ensuring
continuity of care. The person receives priority access to care, is followed up
actively by the psychologist and receives care through a flexible model of face
to face and telephone consultations.
The Interim Evaluation Report for this program indicates the
services have been positively received, are attracting increasing numbers of
referrals and are providing services to a different group of consumers to those
normally seen by ATAPS services, hence complementing the general ATAPS program.
As part of the pilot, participating allied mental health
professionals were required to complete a suicide prevention training course
developed by the Australian Psychological Society (APS) and delivered through
DoHA told the Committee the ATAPS suicide prevention pilot would not be
expanded but that it would be 'continuing for another two years' incorporating
a comprehensive evaluation. However DoHA indicated it was giving other
Divisions of General Practice the capacity to opt into the program. Ms Colleen
Krestensen of DoHA stated:
We are building into our additional funding for ATAPS some additional
service capacity for the rest of the divisions, which is about 100 divisions,
to enable them to boost their capacity to provide more services to people who
have presented to a GP or have been referred to ATAPS post a suicide or a
self-harm attempt. 
Stepped care and accommodation services
The lack of appropriate accommodation for those at risk of suicide was
frequently highlighted. The Psychotherapy and Counselling Federation of
Australia described the number of ‘secure’ or gazetted beds available in
‘acute’ publicly funded residential facilities for adolescents as 'extremely
inadequate'. They reported acutely suicidal adolescents have sometimes been
admitted to adult psychiatric units. The AMA also noted the while people who
are receiving (acute or inpatient) mental health care for suicidal risk may
improve in supported accommodation there was a lack of available spaces. This
made the appropriate referral of persons at risk of suicide by treating GPs
A common observation during the inquiry was the need for alternative and
graded accommodation for people at risk of suicide or having a mental health
crisis. For example AGPN argued that there was growing evidence that a 'stepped
care' approach to mental health service delivery improves mental health
outcomes, reduce costs and increases access to care.
Stepped care models are those in which there are
interventions of different levels of intensity, and consumers are assigned to
the level of intervention that matches their needs. Care ranges from low to
high intensity interventions... Stepped care can better tailor care to meet
patients’ needs and minimise unnecessarily intensive or invasive treatment.
One of the projects proposed by the AISRP was for a full residential
care facility where clinical specialists and support workers will care for
people who have made an attempt at suicide. They described the 'Life House' as
filling an important gap by '...offering a coordinated service, outside of the
hospital setting, specifically designed to treat people who are suicidal and
assist their families'. They commented:
Research strongly suggests that individualised and
coordinated care for first-time attempters in an appropriate environment is
critical to providing an effective response and recovery. By providing at least
14 days of care at no charge, the Life House will fill the significant gap between
hospital-based care and emergency room or outpatient care for people who are suicidal.
SPA noted that services which provide one-off short-term accommodation
in a supported non-medical environment can allow '...people with a mental illness
who require urgent/emergent need to receive crisis stabilisation services in a staff-secure,
safe, structured setting that is an alternative to hospitalisation'.
Similarly a key recommendation of Mr Jim Snow was for the provision of
flexible graded services for the mentally ill with alternatives based on care
in the community, accommodation in houses, accommodation in larger supervised
hostels with respite care arrangements, and accommodation in psychiatric
hospitals depending on need. In particular supervised hostels could benefit
those people who are able to live in the community but need occasional respite.
Properly done, the cost of a flexible system of care for
mental health patients would be reduced by greater efficiency, the avoidance of
high police, hospital and other costs associated with suicide, suicide
attempts, violence, family breakdown and delayed corrective action.
The need for alternative accommodation options has also been recognised
by community organisations. For example the Launceston-based Youth Suicide
Action Group (YSAG) has created Time Out House which provides secure
accommodation to young people from the age of 14 to 28 years of age at risk of
suicide and self harm.
The Mental Health Coordinating Council noted the Victorian Government
funding for Prevention and Recovery Care services (PARC) which provide access to
step-up/step-down bed based alternatives to hospital inpatient care showed the
'...potential for step-up programs to reduce some of the impact on the acute
Queensland Alliance also highlighted the recent state funding for a Time Out House
That is about funding community organisations to offer safe,
friendly and welcoming spaces. The whole purpose of that is an early
intervention response, and the whole purpose of the place is that it is safe,
friendly and welcoming—a mental health service that people actually want to
access rather than one that you drag people to and that they then get a really
bad experience of.
DoHA noted that $1.6 billion was made available through COAG commencing
next financial year to support the 1300 sub-acute beds. The range of target
groups for these subacute beds included people with mental health needs coming
in and out of hospital.
Coordination of care
The coordination and continuity of care was seen as essential for
persons at risk of suicide to prevent them 'falling between the gaps'.
Repeatedly the Committee received personal stories which highlighted a lack of
coordination of care between services. The Integrated Primary Mental Health
Service of North East Victoria observed that difficulties 'routinely' arise in
cross-jurisdictional activities involving emergency services and mental health
services and assisting people who are at risk of suicide.
Similarly Lifeline Australia noted:
Lifeline has seen examples of where a lack of coordinated
care between services such as drug and alcohol, mental health, and hospitals
can mean that people at risk of suicide do not receive appropriate and holistic
care and intervention. Such a lack of cohesion in the health sector can mean
that people requiring help ‘fall through the gaps’ and the onus of
responsibility and care is left to friends, family, or carers.
The Psychotherapy and Counselling Federation of Australia stated that
where their members were already involved with a patient they 'report not being
included in plans for support following discharge and, for example not being
copied into discharge plans and not receiving advice regarding the follow up
care that is needed'. They noted:
Patients can be discharged quite suddenly without the
hospital notifying families or the counsellor/psychotherapist involved. This is
not effective and discourages clients from seeking further help.
Mr John Dalgleish of Boystown stated that the reasons for lack of
coordination appear varied:
In the community sector and health sector there still seem to
be artificial silos and barriers to coordination. People have different
frameworks for intervention, people have different language and different
culture. People do not know what services exist in their local community. All
those things add up to a lack of coordination.
The Suicide is Preventable submission highlighted the results of the Tracking
Tragedy report which included the examination of suicide deaths of patients
in community mental health settings. Concerns were raised in this report regarding
gaps in assessment documentation, deficient duration and continuity of care,
and poor ongoing risk monitoring.
The implication arising from such findings is that improved integration
at critical transitions of inpatient and community-based care may well reduce
the risk of suicide among mentally ill individuals.
The SPA Position Statement on Crisis Response noted that GPs generally
refer suicidal patients needing acute or community care to emergency departments
rather than directly to rather than directly to inpatient or community
SPA suggested one way of ensuring greater continuity of care may be to develop
working partnerships between emergency mental health services and crisis
Such care extends beyond the boundaries of the traditional
health and mental health care systems. Crisis hotlines also provide relatively
low-cost, effective services to individuals seriously contemplating suicide and
are available to all regardless of geographical barriers, appointment
availability, or ability to pay.
The AGPN argued there should be better greater efforts to link people
who have attempted suicide to community based primary mental health care
following discharge from tertiary services to avoid patients at risk of suicide
'falling into the gaps' between services. They highlighted two key programs:
the Better Outcomes in Mental Health Care initiative and the Better
Access to Psychiatrists and General Practitioners through the Medicare Benefits
Schedule program. The AGPN stated:
These programs have increased the capacity of primary health
care professionals to more effectively respond to and treat mental health
problems by driving uptake of mental health education and training, providing additional
referral channels from general practice to mental health specialists, and
access to psychiatrist advice.
It was noted that the transport of suicidal patients by police to
psychiatric services or emergency departments can be difficult due to a lack of
clarity regarding responsibility for patient safety and supervision. 'Handovers'
were seen as a time of particular risk for patients at risk of suicide. The SPA
position statement on crisis response highlighted the memorandum of
understanding between the NSW Health, the NSW Ambulance Service and the NSW
Police as an example of an effective measure to promote safe and coordinated
systems of care.
The Committee also heard of good examples of cooperation and
coordination between public agencies and community organisations. For example
Ms Dulcie Bird of the Dr Edward Koch Foundation told the Committee:
The life bereavement service has a memorandum of
understanding signed with the Queensland Police Service. It incorporates a
faxback referral system, which requires that a Queensland police officer who is
attending any unexpected death offers the support of our life bereavement
support service to the person bereaved. A person agreeing to this signs the
faxback referral assistance request, the police officer faxes it to us and we
are able to go out and see these people.
Patient information and privacy
An issue frequently raised in submissions related to the level of access
family members should have to the patient information of a person at risk of
Often bereaved family members were frustrated they had not been informed of
significant events, for example when a patient had been discharged from a
healthcare facility or if the medication of a person had been altered. Lifeline
Australia noted that when privacy policies prevent contact with other members
of a patient’s family '...important information which could be vital to the
treatment of the patient is lost'.
Similarly Ms Fatima Clark of the White Wreath Association argued:
Confidentiality and privacy must not be allowed to cause loss
of life. Commonsense, natural justice and good professional practice dictate
that the preservation of life is of paramount consideration. Doctors and
psychiatrists must involve families and use their knowledge and opinion to help
fight this epidemic as they would with any other life-threatening condition.
The balance between patient privacy, family access and risk is reflected
in a number of areas. The AMA Code of Ethics states that doctors have an
obligation to maintain a patient's confidentiality and exceptions to this must
be taken seriously. These include where '...there is serious risk to the patient
or another person... or where there are overwhelming societal interests'.
The National Privacy Principles also provides that organisations which provide
health services must not disclose the health information of an individual.
Exceptions include where the organisation reasonably believes that the use or
disclosure is necessary to lessen or prevent a serious and imminent threat to
an individual's life, health or safety.
The Committee was also referred to the NSW Mental Health Act 2007 which
includes recognition that carers and family members need greater access to
information about the consumer and also giving some control to the patient
regarding who can be provided with information.
Mr Michael Barnes, the Queensland Coroner, also highlighted the refusal
of mental health practitioners to involve families in treatment decisions for
patient as an area of concern. He suggested greater use be made of advanced
health directives and other standing powers of attorney to authorise the
disclosure of patient information to family members.
Poor information sharing practices between healthcare services and
practitioners was also often highlighted during the inquiry. The Suicide is
Preventable submission recommended that the Commonwealth, through the National
e-Health Strategy, lead efforts to improve collaboration and information
sharing and surveillance between and among systems of care for all patients but
particularly for those with severe or persistent mental illness (SPMI). They
Poor communication and lack of information sharing between
social service agencies, law enforcement, justice, education, health care and
mental health care providers and others precludes key opportunities to advance
suicide prevention efforts for persons with SPMI.
Different forms of medication were seen as an important method of
reducing suicides during the inquiry, particularly antidepressants. In 2005,
Professor Robert Goldney's review of recent studies into suicide prevention
included positive assessments of effectiveness of psychotropic drugs in
decreasing rates of suicide and suicidal behaviour for patients with a range of
mental health conditions. These included anti-depressants, mood stabilisers and
The importance of closely supervising patients with a mental illness
commencing or changing medications was highlighted during the inquiry.
This was seen as a particular period of high risk. The Suicide is Preventable
submission noted that ' available research confirms that individuals may
experience an increased risk of suicidal behaviour in the early stages of
starting antidepressant medication, given that this treatment may not be
The Committee also received conflicting evidence regarding the dangers
and efficacy of patients being prescribed two forms of antidepressants
simultaneously. Professor David Horgan argued that despite overseas practices
in relation to combination antidepressants the practice in Australia '...is to
take the patient off that antidepressant, which, unfortunately, means the
illness is going to come back again, and to start them on the next one in the
hope that the next one will lock on'.
However Dr Watson from RANZCP commented the all medications have side effects
and 'combinations of drugs have combinations of side effects'. He stated '...the
research around combination antidepressants and its relative safety is markedly
Suicide awareness and assistance training
The Committee received many recommendations during the inquiry for
suicide prevention training to be more wide spread amongst healthcare
professionals, government agencies and the general community. Recommendations
were also received which suggested mental health first aid and suicide
prevention training should be subsidised to encourage broader participation and
The Suicide is Preventable submission stated that suicide prevention and intervention
training and education for frontline workers or 'gatekeepers' (for example. emergency
workers, health care workers, GPs.) has been shown to reduce suicide rates.
It recommended the development of 'accredited and fully evaluated training
programs for front line staff in a range of settings... to better enable staff to
identify and support those who are vulnerable or at risk'.
RANZCP and others also identified 'gatekeepers' in the communities '...whose
contact with potentially vulnerable populations provides an opportunity to
identify at-risk individuals and direct them to appropriate assessment and
treatment'. These included include clergy, first responders, pharmacists,
geriatric caregivers, personnel staff, and those employed in institutional
settings, such as schools, prisons, and the military. Large scale evaluations
of gatekeeper training in institutional settings such as the US Air Force
suggest this approach can be an effective in lowering suicide rates.
Ms Jacinta Hawgood of AISRP noted the education and training of GPs was
one of the demonstrated ways of preventing suicide. She stated:
Training usually takes the form of targeting, at a gatekeeper
level, allied health professionals, community workers, including emergency
workers, and/or targeting GPs. Since there is evidence about the effectiveness
of this particular initiative, we often ask the question: why do we not invest
more in this initiative?
Lifeline Australia argued that competence in role appropriate suicide
intervention knowledge and skills should be a foundational requirement for
front-line health and community workers providing services to persons at risk
of suicide. However it noted that 'systematic suicide intervention training to
agreed standards across sectors, among emergency services personnel, and within
professions has yet to be realised'.
The Salvation Army stated 'there is no doubt' that suicide prevention
training raises the confidence of frontline and community workers in
intervening to support people who are at risk of suicide. They considered it
was imperative that all workers in community services are able to understand
and recognise warning signs and know how to take action to get people the
assistance they need.
Suicide prevention training
A range of different models of suicide prevention training were outlined
during the inquiry. Some focused on health care professionals or community
workers while others were aimed at members of public.
The Lifeline Australia LivingWorks program delivers both safeTALK and
the ASIST (Applied Suicide Intervention Skills Training). They commented:
Whereas ASIST prepares people to engage more fully with
suicidal persons to review their risk and develop and mobilise a safety plan,
safeTALK enables a briefer engagement – recognising risk, reaching out and
enabling referral. These two programs can potentially work together within an
organisational or community setting.
The AGPN recommended the SQUARE education and support package as a
useful resource for GPs and other frontline workers providing services to
people at risk.
....important work has been done to increase the capacity of
primary care clinicians to work with patients who are experiencing suicidality,
most notably through the development and dissemination of the SQUARE (Suicide
QUestions, Answers and REsources) resources developed by the South Australian
Division of General Practice and Relationships Australia SA with joint funding
from the NSPP and the South Australian Government.
The Kentish Regional Clinic also outlined their CORES (Community
Response to Eliminating Suicide) training program which has provided services
to 25 communities around Australia. The CORES model is based around a community
package which delivers one-day suicide intervention training to members of
different communities with local volunteer team leaders trained to deliver the
program and ‘champion’ the training locally. Communities are then responsible
for shaping the way the program is delivered in the future.
The Salvation Army referred to the online suicide prevention training
course which they deliver called QPR (Question, Persuade, Refer). The one hour
QPR training includes myths and facts about suicide, warning signs of suicide,
applying QPR and how to offer hope and support.
It was also recommended that suicide awareness training should be as
accessible and promoted as First Aid courses for the public.
A Lifeline telephone counselling trainee told the Committee about her
significantly increased ability to provide appropriate support to a friend who
was considering ending their life after completing an ASIST suicide
This leads me to two points: one, is that having recently
been made aware of a practical model for responding to this distressing and
confronting situation gave me infinitely better resources for coping, and
hopefully helping, than I would have had a month previously.... Secondly, I wondered
at the time if my friend sought me out to talk to about their situation because
they knew I was doing the suicide intervention course...Perhaps they thought that
I would be not afraid to talk about this confronting topic. Most people would
have few or no people in their life that they would feel comfortable openly
sharing pain this dark with, as it changes the nature of a relationship, and
talk about mental illness and death by suicide is highly stigmatised...Any
strategies that lead to people having a greater number of safe avenues for
dialogue with someone else about how they are feeling can only be positive.
Suicide prevention roles
The role of staff in primary care, law enforcement and emergency
services and care was seen as vital to the detection and treatment of persons
at risk of suicide and care for bereaved families. The Committee considers it
is necessary for staff in these areas to receive broad suicide prevention
training which is assessed, updated and maintained.
Any person who seeks assistance because of suicidal ideation or
following a suicide attempt should be taken seriously and treated
appropriately. In the view of the Committee is important that there is at least
one person in each emergency department with the mental health training and
capacity to conduct suicide risk assessments and referral for persons who may
Front line staff often encounter confronting and stressful situations
which involve suicide and attempted suicide. Adequate support, debriefing and
counselling services should be made available to these key personnel to access.
4.78 The Committee recommends that Commonwealth, State and Territory
governments ensure that staff in primary care, law enforcement and emergency services
receive mandatory and customised suicide risk assessment, prevention and
awareness training as part of their initial training and ongoing professional
The Committee recommends that Commonwealth, State and Territory
governments mandate that hospital emergency departments maintain at least one
person with mental health training and capacity to conduct suicide risk
assessments at all times.
4.80 The Committee recommends that Commonwealth, State and Territory
governments review debriefing procedures and counselling support available to
frontline workers regularly exposed to suicide and attempted suicide related
Discharge and follow up
The period following discharge from mental health services or hospital
following psychiatric care or an attempted suicide was recognised as critical
during the inquiry. Discharging persons who have attempted suicide or are at
risk of suicide without providing follow up support or referral to appropriate services
appears to the Committee a breach of duty of care. The Committee considers
everyone should have a well resourced and supported care plan when being
discharged from hospital or psychiatric care if they are assessed as having been
at risk of suicide.
4.82 The Committee recommends that Commonwealth, State and Territory
governments establish mandatory procedures to provide follow up support to
persons who have been in psychiatric care, have been treated following an
attempted suicide or who are assessed as being at risk of suicide.
Coordination of care
The Committee heard many personal stories of people at risk of suicide
'falling through the gaps' between services because of lack of coordination
between agencies and service providers. The coordination and collaboration of
agencies and services such as law enforcement, emergency care, mental health
services, primary care, telephone crisis support services and community
organisation is essential in providing continuity of care for people at risk of
4.84 The Committee recommends that Commonwealth, State and Territory
governments provide funding for programs to identify and link agencies and
services involved in the care of persons at risk of suicide. These programs
should aim to implement agreements and protocols between police, hospitals,
mental health services, telephone crisis support services and community
organisations and to improve:
- awareness by different personnel of suicide prevention roles and
- handover procedures and continuity of care for persons at risk of
The need for graded or stepped accommodation and alternatives to acute
inpatient care for people at risk of suicide and people with severe mental
illness was emphasised during the inquiry. The Committee notes some governments
are providing some funding for subacute accommodation and other alternatives.
However the Committee considers further investment in this area is necessary and
has the potential to significantly assist people who have attempted or who are
assessed as being at risk of suicide. The Committee also received evidence that
closely supervised accommodation may be necessary where patients change their
medication as this was a period of increased risk for suicide.
4.86 The Committee recommends that Commonwealth, State and Territory
governments provide additional funding for graded accommodation options for
people at risk of suicide and people with severe mental illness.
The Committee recognises the difficult balance that must be maintained
between persons at risk of suicide (who can often suffer from a mental illness)
and rules regarding the privacy of patient information. There does not appear
to be an easy solution to this problem. Any significant changes to patient
privacy could potentially lead to patients not feeling comfortable or able to
entrust medical information to their doctors. The Committee considers that
medical practitioners should recognise the benefits of family involvement in the
treatment and care of patients as well as the possible use of waivers of
privacy where the patient is willing to give consent.
4.88 The Committee recommends that the Australian governments oblige health
care staff to offer prior consent agreements, such as advance health directives
and standing medical powers of attorney, to patients at risk of suicide.
Training issues have been recognised in the Fourth National Mental
Health Plan. One of the Prevention and Early Intervention National Actions
is to 'provide education about mental health and suicide prevention to front
line workers in emergency, welfare and associated sectors'. It states:
Supporting these groups to better understand and recognise
mental illness and to know how to react to individuals during an acute episode
of illness or suicidal behaviour will improve earlier intervention and bring
better outcomes for individuals and their families. Workers that are
particularly important include police, ambulance, child protection workers,
correctional services staff, employment support officers, pharmacists,
residential aged care workers and teachers.
The Committee considers it is appropriate for Australian governments to
provide leadership in this area through providing suicide prevention training
to their frontline staff. This would also function to improve understanding and
awareness of suicide in community.
4.91 The Committee recommends that Commonwealth, State and Territory
governments provide accredited suicide prevention training to all 'front line'
staff, including those in heath care, law enforcement, corrections, social
security, employment services, family and child services, education and aged
Increasing the number of persons with suicide prevention training was
seen as having a number of benefits during the inquiry. These benefits included
the improving the opportunities for someone at risk of suicide to be detected
and assisted and building community awareness and understanding about suicide. Better
training is a suicide prevention strategy with a supportive evidence base.
The NSPP already grants funding to a number of projects which provide
suicide prevention training such as the CORES program. The Committee considers
there is scope for this access to suicide prevention and awareness training to
be extended. Several community organisations noted the cost of suicide
prevention training and mental health first aid training was a disincentive to
4.94 The Committee recommends that the National Suicide Prevention Strategy
promote and provide increased access for community organisation and the general
community to appropriate suicide prevention training programs.
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