Suicide Investigations

What you will find in suicide investigations - if you read carefully - but not in their recommendations

•  Undertreated depression (especially “positive” symptoms: e.g. agitation, anxiety and sleeplessness)
•  Drift (and bias) towards diagnosis of personality disorder and away from engagement, management and problem-solving
•  Concrete, bureaucratised or facile solutions to life events, especially loss (e.g. advice to claim benefits following loss of a job; bereavement counselling following a death etc)
•  Failing to understand the subjective (i.e. the patient’s, not ours) significance of loss – of identity, role, employment etc
•  Assuming protective factors – e.g. living with parents, finding employment, moving into more supportive accommodation – which to the patient may not be protective at all
•  Failing to note changes in the reasons for not committing suicide: e.g. “I won’t do it because of the children” to “I won’t do it because I haven’t found a painless/certain way”
•  False reassurance: i.e. staff being too easily reassured because of not hearing what they don’t want to hear
•  The positive gloss: e.g. “appears to be improving”, “engaged well in conversation”, “benefitted from being able to ventilate…..”
•  Insider blindness: i.e. not being able to see what outsiders (e.g. relatives) could see
•  Dilution of risk events over time
•  Being led by stereotypes: i.e of the sort of person who goes on to commit suicide
•  Dangerous assumptions: e.g. “the more failed past attempts, the less serious the patient is about committing suicide”
•  More dangerous assumptions: e.g “GPs always overstate urgency” 
• Parking risk elsewhere: e.g. on the waiting-list for another service, or simply with another service with the expectation that “they will do the monitoring and alert us if they are concerned”
•  Deflecting key informants and potential co-therapists (i.e. relatives or carers) elsewhere; e.g. to carers’ centres etc
•  Staff feeling de-skilled or lacking confidence: “this person needs to see a specialist, a psychologist etc and I have little to offer”
•  Difficulty in understanding the importance of the “use of self”
•  Uncertainty about what potential for effective clinical work lies in the gaps between medication, admission, psychological treatment and referring on
•  Lack of continuity hampering engagement
•  Lack of inquisitiveness or interest in social and relationship history
•  An understanding of risk not travelling from hospital to the community (the baton of risk being dropped)
•  Stereotypical or negative views of colleagues or other services interfering with an accurate assessment of risk: e.g. ward staff believing that community staff are avoidant or slow to take on patients, and community staff feeling that ward staff tend to overstate risk and to have unrealistic expectations of what community staff can do
• The embargo on understanding because of the primacy given to processing
• Lack of attention given to significance and meaning of behaviour and events (e.g. a parent or sibling coming with the patient to an assessment or routine appointment, which may underline their grave concern but be interpreted as over-involvement etc)
•  Expecting secondary or subsidiary services (e.g. Mind, services providing social or employment support etc) to take on  the primary task of managing risk
•  The narrow perspective: i.e. looking for reasons (“he or she does not exactly fit the criteria for a service”; “the service is currently under too much pressure”) for not taking on a patient or intervening, instead of asking the question “what should the Trust be doing in this case?” 
•  An objective understanding of risk made difficult by an engrained tendency to look for or create reasons for not taking a case on