Self-harm and suicidality in vulnerable prisoners: Evaluating a new service intervention involving a structured approach to risk assessment and management

The focus of the study is an evaluation of the implementation of new documentation guidelines based on the structured professional judgment approach to suicide risk assessment and management, in a prison mental health unit. Suicide risk assessments on the unit are currently completed routinely as part of mental health assessments/reviews conducted by custodial mental health staff (mental health nurses and psychiatrists) however assessments vary between clinicians according to clinical skill and experience, and are often primarily focussed on current thoughts of suicide or self-harm. The ‘SLIPS’ documentation guidelines allow for both clinical judgement and the identification of empirically-derived risk factors specific to an offending population or within a custodial environment. It is intended as an additional resource to aid clinical decision making around prisoners at risk of suicide or self-harm. SLIPS is an acronym of Suicide, Legal, Individual, Psychiatric, Safety plan and represents evidence-based risk factors that should be considered during a prison suicide risk assessment and a guide to safety planning with at-risk prisoners. - SUICIDE factors include: History of suicide attempts/self harm behaviours, seriousness, frequency, recency of attempts; experience of suicide (eg suicide of loved one); current suicidal cognitions (ideation & intent) - LEGAL factors include: Legal status (remand/sentenced), stress around court, long sentence or likelihood of long sentence; nature of offence; victim factors – family/domestic violence/child related; and shame/guilt around offence; experience of custody – first time in custody, bullying/victimisation, poor coping with custodial environment, placement: protection/segregation - INDIVIDUAL factors include: Case specific factors (idiosyncratic factors that may be related to this person’s risk); cultural considerations; stressors causing concern outside of prison eg family/relationship/financial/health; history of trauma and/or adverse childhood experiences; social supports/visits/family contact - PSYCHIATRIC factors include: Mental Health History, diagnoses and treatment; current mental state: active symptoms, feelings of hopelessness, poor self esteem; future focus; coping; intoxication or withdrawal; compliance/response to biopsychosocial treatments - SAFETY PLAN component is a structured safety and support plan to be completed or updated with the prisoner at each assessment and includes consideration of warning signs, internal coping strategies, supports, creating a safe environment, reasons for living. The Safety Plan component of the guidelines involves a safety plan document being completed collaboratively between the staff member and patient at the first assessment to occur post-implementation. In subsequent sessions, a new safety plan will not be required but rather the clinician and patient will review and update it as necessary. The guidelines will be used during all staff/patient interactions where a suicide risk assessment would usually occur and will be documented in the clinical notes as per the SLIPS acronym. In this unit, a suicide risk assessment would occur during all mental health reviews. The frequency of review varies from patient to patient but an initial assessment of approximately 60 minutes occurs upon admission to the unit which would include a suicide risk assessment (up to 30 mins), and subsequent mental health reviews including suicide risk assessments will occur as per the formal management plan for prisoners who are in camera cells (ie, daily, weekly reviews, etc as determined by treating team); and “as clinically required” for those in less restrictive placements on the unit. The guidelines will be used as an adjunct to the existing process of risk assessment rather than an additional intervention, it is therefore difficult to determine how often a patient will be subject to this intervention as patients' requirements, clinical presentation and length of stay in the unit vary. The SLIPS guidelines are intended to guide the clinician around the types of risk factors to consider or questions to ask during a risk assessment. Some of the information recorded in the clinical notes as per the SLIPS acronym will be gleaned from the patient interview (as part of the mental health review) and other information will be available to the clinician through other means (eg prior knowledge of this patient, available documentation, electronic patient information). As SLIPS is a guideline and not an assessment tool, strict fidelity is not required. It is anticipated that any use of the guidelines will improve on the existing process of clinical judgment alone. The researchers will monitor the clinical notes in the mental health unit on a monthly basis to determine whether the SLIPS acronym is being utilised. A training package for suicide and self harm and SLIPS has been developed by the project lead for the Justice Health Towards Zero Suicides in Custody initiative, assisted by the research team (forensic psychiatrists and psychologists with experience in suicide risk management with offending populations). Health staff (nursing and medical) are in the process of being trained in the use of the guidelines with implementation to occur shortly. Training is conducted in small groups of staff, in person, with use of power-point presentation, practice scenarios and group discussion, facilitated by the project lead, Zero Suicides in Custody and the Mental Health Screening Unit Clinical Nurse Educator. Sessions take around one hour. The facilitators are responsible for ensuring that all health staff are trained prior to implementation and that any new staff to the unit post implementation receive training. Copies of the guidelines & manual will be accessible on the unit. A (psychiatrist) member of the project team and the clinical nurse educator, who work clinically on the mental health unit where the trial is taking place will provide assistance to staff on the use of the guidelines throughout implementation as required. The researchers will monitor the clinical notes in the mental health unit on a monthly basis to determine whether the SLIPS acronym is being utilised.