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Policy
1811
Administration
and Clinical
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Suicidal or deliberate self-harm thoughts or behaviour,
01 August 2015
management of patients
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Wayne de Beer
Tom Watson
Mo Neville
Document expiry date:
Specialist, Mental Health
Chief Medical Advisor
Director of Quality & Patient
01 August 2018
and Addictions
Safety
Waikato DHB, July 2020
1. Preamble:
This policy sets Waikato District Health Boards (DHB) standard for the
appropriate management of patients who have suicidal or deliberate self-harm
thoughts or behaviours.
Suicidal or deliberate self-harm (DSH) may result from a wide range of causes,
not necessarily mental illness. It is acknowledged that, in general, people who
have attempted suicide or deliberate self-harm have done so as a result of
psychological distress.
This policy assumes that staff members involved in the assessment of the people
who have attempted suicide or engaged in DSH have the required knowledge and
competencies to deal with this condition.
This policy relates to any Waikato DHB clinical and administrative settings
(excluding the Mental Health & Addictions Service (MHAS) which have other
supporting policies and procedures in place)
2.
Policy
The Waikato DHB policy for management of patients who have suicidal or deliberate self harm
thoughts or behaviour is that:
All patients who have suicidal or self-harm thoughts or behaviour must have a physical
and mental health assessment completed at the earliest opportunity.
All patients who have suicidal or self-harm thoughts or behaviour must be cared for in a
way that minimises the risk to the patient / client.
3. Authorisation
As signed above on behalf of the Chief Executive.
Disclaimer: This document has been developed by Waikato District Health Board specifically for its own
use. Use of this document and any reliance on the information contained therein by any third party is at
their own risk and Waikato District Health Board assumes no responsibility whatsoever.
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Flowchart for referrals to mental health services for people presenting to Waikato DHB
secondary and tertiary services general health services with self-harm behaviour and/ or
thoughts of suicide
Person presents with self-harm behaviour and/ or thoughts of suicide to:
Community health services, Waikato Hospital (including ED) services,
Tokoroa, Te Kuiti, Taumarunui Hospitals, Matariki and Rhoda Read
Continuing Care Facilities.
Triage assessment by suitably knowledgeable
non-specialist clinician: Risk; mental state;
context of behaviour and capacity to consent &
consents to MHAS service assessment
Refer for urgent
specialist MH
service
Yes
No
assessment?
Y/N
Hamilton Community Health
Services Refer to:
Adult - Contact Crisis Assessment Home
Refer to GP/ primary
Treatment on 0800 50 50 50.
care for follow up
Under 18 Years
Mon to Fri, 08:30 -16:30 – contact Nga
Ringa Awhina on 0800 999903.
Waikato Hospital Refer to
Mon to Fri, 08:30 -16:30: consult liaison,
222 Pembroke Street or via switchboard
or on ext. 94924
After hours contact Crisis Assessment
Home Treatment via switchboard, ext.
22405 or 0800 50 50 50
Rural Hospital and Community
Based Services Refer to:
Thames -
Mon to Fri, 08:30 -16:30 contact 0800
080339
Te Awamutu, Tokoroa, Te Kuiti and
Taumarunui, Matariki and Rhoda
Read Continuing Care Facilities –
Mon to Fri, 08:30 -16:30 contact 0800
154973
After hours - contact Crisis Assessment
Home Treatment via switchboard or ext.
22405, 0800 50 50 50
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Appendix A
1. Standards
It is expected all staff will respond in a timely and professional manner to
any people presenting with an attempted suicide attempt or engaged in
DSH.
Staff members are required to conduct a comprehensive assessment and
must include a physical examination and other physical investigations
deemed necessary.
Staff members who conduct a culturally appropriate assessment of
people with suicidal or DSH behaviours must be familiar with, and be
guided by New Zealand Ministry of Health’s Best Practice Evidence-
Based Guideline: The Assessment and Management of People at Risk of
Suicide.
(http://www.health.govt.nz/system/files/documents/publications/suicide_g
uideline.pdf )
Consult Liaison/ CAHT and ED staffundertaking assessments have
access to Te Puna Oranga (Māori Health Service) Kaitiaki (General
Hospital) and Kaitakawaenga (Mental Health) to assist with culturally
appropriate interviews and assessments.
The assessment must include an analysis of immediate risk and
treatment plans tailored according to estimated future risk.
When staff are uncertain about the safety risk of the patient while waiting
further psychiatric assessment (e.g. admitted to a medical or surgical
ward for medical observations), constant observation of the patient may
be necessary.
Where expert opinion is required staff members must refer to Mental
Health & Addiction Services (MH&AS) for assistance and further
management. MH&AS must be involved with the assessment when staff
members request a Mental Health Act (MHA) assessment, admission to
the Henry Rongomau Bennett Centre (HRBC) or support and observation
in the medical / surgical setting.
Staff may use either the referral form [R1050HWF (W19)] or the
electronic referral for Consultation-Liaison Psychiatry
1.1. Role of Mental
-
The role of Mental Health and Addictions Service is to provide the
Health and
professional assessment of any patient who presents to Health Waikato
Addictions
facilities requiring treatment for suicidal or deliberate self-harm thoughts or
Service
behaviour.
-
Mental Health and Addictions Service can provide advisory information in
relation to:
-
Specialist assessment of the risk for further suicidal and deliberate self-
harm thoughts or behaviour
-
Where and how to admit (if necessary)
-
Implementation of the Mental Health (Compulsory Assessment and
Treatment) Act 1992.
-
Strategies to assist staff in the clinical management of the patient,
including observation levels / patient watching.
-
Treatment options during admission or post discharge.
-
All services within the Waikato DHB can access mental health and
addiction expertise, 24 hours a day, seven days of the week.
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Waikato Hospital: ED, In-patient services (0800-1600 hours)
-
Consult-Liaison (CL) Psychiatric Service
-
Monday to Friday 0800-1600 hours.
-
Phone: 94924
-
Fax: 94926
After Hours (1600-2330 hours)
-
Crisis Assessment and Home Treatment (CAHT) Team
-
Phone 0800 50 50 50 or contact via switchboard
After Hours (2330-0800hours)
-
contact the Duty Co-ordinator
-
Henry Rongomau Bennett Centre
Pager 20097
Waikato Hospital: Outpatient clinics and peripheral satellite services
(0800-1600 hours)
-
Crisis Assessment and Home Treatment (CAHT) Team
-
Phone 0800 50 50 50 or contact via switchboard
After Hours (1600-2330 hours)
-
Crisis Assessment and Home Treatment (CAHT) Team
-
Phone 0800 50 50 50 or contact via switchboard
Community Hospitals, Matariki & Rhoda Read
-
Work hours - Monday to Friday 0830-1700 hours.
-
Contact the local Rural Mental Health and Addictions Service
After hours (1700-0830 hours)
-
Crisis Assessment and Home Treatment (CAHT) Team after hours
-
Contact details as above
Te Puna Oranga (Māori Health Service)
Kaitiaki and Kaitakawaenga Frontline contact numbers:
-
23508 (Waikato DHB ) , 25101 (Taumarunui), 25229 (Thames)
2. Responsibilities of staff when a patient with suicidal or self-harm thoughts or
behaviour wants to be discharged or decline treatment
Staff at point of clinical contact should seek advice regarding any situations
falling outside the ones listed below in Appendix A, 2.1 – 2.4, from the
operations / duty manager / site coordinator or legal advisor.
Decisions and clinical rationale must be documented in the clinical record
including the application for assessment and treatment under the Mental
Health (Compulsory Assessment and Treatment) Act 1992 if required.
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2.1. Patients who
This is considered an emergency situation and treatment that will preserve
have not been
the life of the patient can be provided without consent as per the Waikato
assessed by
DHB Informed Consent policy.
Mental Health
The responsibility for the decision to treat in this circumstance rests with the
and Addictions
multi-disciplinary team who has recourse to common law and consultation
Service but are
with the legal advisor if necessary.
declining life
saving
treatment
2.2. Patients under
A patient being treated in the general hospital setting, and who is being
the Mental
compulsorily detained for assessment and treatment under the Mental
Health
Health (Compulsory Assessment and Treatment) Act 1992, is not free to
(Compulsory
leave or decline treatment for their mental health condition.
Treatment and
Note: Patients can not be treated compulsorily for a physical condition
Assessment
under the Mental Health (Compulsory Assessment and Treatment) Act
Act) 1992
1992; informed consent must be obtained or in the case of a medical
emergency common law may be invoked.
If the patient attempts to discharge themselves, it is appropriate to take all
reasonable measures that do not place staff or other patients / visitors at
risk, to prevent them from leaving.
If the patient is noted to be missing or is unable to be prevented from
leaving, staff should notify security, the police and the Mental Health and
Addictions Service.
If the patient has left the hospital grounds the matter must be referred to
the police to locate the patient.
The above scenarios should be documented using the incident reporting
process.
2.3. Voluntary
These patients may fall into two categories:
patients who
a. Patient who has not yet been assessed by Mental Health and
may be
Addiction Services or
considered to
b. Patient who has been assessed by Mental Health and Addictions
be at further
Service and is deemed not appropriate for compulsory assessment
risk to
and treatment under the Mental Health (Compulsory Assessment and
themselves
Treatment) Act 1992.
A registered nurse may detain the patient to be reviewed by any medical
practitioner for up to six hours by invoking Section 111 of the Mental Health
(Compulsory Assessment and Treatment) Act 1992. They should advise
the patient they are invoking this section and that the patient has the right to
seek legal counsel.
NB: The registered nurse should then immediately contact Mental Health
and Addictions Service for assistance and complete the Section 111 form
available from Mental Health and Addictions Service.
Any medical practitioner can invoke Section 110 of the Mental Health
(Compulsory Assessment and Treatment) Act 1992 to detain a patient in
this circumstance.
Compulsory assessment occurs by completing Sections 8(a) and 8(b) of
the Mental Health (Compulsory Assessment and Treatment) Act 1992.
Mental Health and Addictions Service must be contacted immediately for
assistance.
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2.4. Voluntary
If no evidence of further risk to self is identified then the patient has all
patient
reasonable rights to decline treatment and/or discharge themselves against
identified as not
medical advice.
being a further
Waikato DHB’s Admission Discharge and Transfer policy in relation to
risk to
patient self-discharge must be followed.
themselves
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Appendix B
1. Definitions
Deliberate self-
The act of attempting to deliberately harm oneself with or without the intent to die
harm
as a result of that action e.g. sub-lethal overdose, superficial lacerations.
Patient
Refers to patient / client / consumer / tangata whaiora / service user.
Suicidal
The act of attempting to deliberately harm oneself with the intent to die as a result
behaviour
of that action e.g. potentially lethal overdose, attempted hanging.
2. Legislative / External Requirements
New Zealand Bill of Rights Act 1990
Code of Health and Disability Services Consumers’ Rights 1996
Crimes Act 1961
Mental Health (Compulsory Assessment & Treatment) Act 1992 and
Amendment Act 1999
Criminal Procedures (Mentally Impaired Persons) Act 2003
Intellectual Disability (Compulsory Care and Rehabilitation) Act 2003
Privacy Act 1993
Health Act 1956
Health and Disability Services (Safety) Act 2001
3. Associated Documents
Waikato DHB Admission, Discharge, and Transfer policy, 1848
Waikato DHB Advance Directives procedure, 2181
Waikato DHB Client Pathways for Self-Harm/Suicide
Waikato DHB Clinical Records Management policy, 0182
Waikato DHB Critical Incident Management for staff policy, 0175
Waikato DHB Employee Assistance Programme policy, 0286
Waikato DHB Incident Management policy, 0104
Waikato DHB Informed Consent policy, 1969
Waikato DHB Initial Risk Assessment in Deliberate Self Harm form,
A1360HWF
Waikato DHB Interpreters policy, 0137
Waikato DHB Patient Watch form, A1138WHF
Waikato DHB Watching of patients at risk of being harmed or harming others
policy, 2188
Waikato DHB Reference form, R1050HWF (W.19)
Waikato DHB Restraint policy, 2162 and use of restraint procedures 1860,
1865, 2153, 2154, 2155, 2156, 2157, 2158, 2160
Waikato DHB Risk Management policy, 0118
Waikato DHB Security policy, 0120
Waikato DHB Tikanga Best Practice guidelines, 2118
Waikato DHB Visitors to Patients policy, 0125
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4. References
The Assessment and Management of People at Risk of Suicide Best
Practice Evidence-based Guideline Ministry of Health May 2003
Health and Disability Commissions information pamphlet on Advanced
Directives
