Review of current risk assessment process
for preventing suicide in the army: Medical management of vulnerable
patients
References:
A. Army Learning Account (Serial 2h) dated
6 October 2003.
B. DGPL 62/03. Army Suicide Prevention Policy—Guidelines
for Medical Officers—Confidentiality and Consent.
C. DGPL 65/03. Army Suicide Prevention Strategy—Clinical
Governance.
1. Reference A tasked AMD to carry out a
review of the current risk assessment process for identifying
and dealing with potential suicide risk. This followed on from
an action point raised by the meeting with Min (AF) to discuss
Deepcut on 24 September 2003. It is understood that the Surrey
police had suggested that the Army might make use of risk assessment
processes used by the Prison Service.
2. This brief review has been done by a
singleton staff officer, as part of routine work. If a fully comprehensive
review is deemed to be necessary it will require the compilation
of an SOR and the allocation of resources to a suitable body to
undertake the task. However, it is the view of AMD that a fuller
review is not necessary by virtue of the various protective measures
that are already in place and which are outlined below.
COMPARISON OF
THE TWO
POPULATIONS
3. The Army and the prison population are
not directly comparable. The Prison population is comprised mainly
of personnel who would be barred from joining the Army. Their
criminal record would preclude. Most prisoners suffer from medical
conditions that would constitute a medical grade of P8, ie unfit
for military service. The majority of the prison population has
known psychiatric disease. Drug use is rife and an underlying
factor in many convictions. Such drug use is again not compatible
with military service.
4. The prison population is held in a captive
location 24 hours a day. It is not possible to apply such constraints
to military personnel, who join a volunteer Army as their paid
employment.
5. Suicide risk is not comparable in the
two populations. The Army rate of suicide is 13 per 100,00 per
year.[17]
The HM prison rate in 2002 was 106 per 100,000 per year, more
than eight times the Army rate.
6. Given the vast differences in the patient
population it is not considered appropriate to employ the same
risk assessment procedures.
RISK ASSESSMENT
IN PRIMARY
CARE AND
COMMUNITY MENTAL
HEALTH
7. Suicide risk may come to the attention
of AMS primary care either through self-referral to the primary
care MO or command referral to the MO because of command concerns.
The primary care doctor will use his clinical skills to evaluate
risk and discuss with medical colleagues where appropriate, eg
GP Registrar may discuss with GP Trainer. The MO will be guided
by the two DGPLs that AMD have issued (References B and C). The
command will be offered employment advice on the individual, for
example no weapon handling and will be informed if the individual's
medical grade has been changed.
8. Deliberate Self-harm (DSH) is the biggest
predictor of future suicide. DSH cases may be referred to the
local Community Mental Health Team (CMHT) for further assessment.
Any patients who the GP considers to be a significant suicide
risk (whether or not they have self-harmed) would also be referred.
CMHTs will advise commanders on employment restrictions and recommendations
on appropriate medical grading will be made to the unit medical
officer.
9. CMHTs are staffed by Specialists in psychiatry
and trained Community Psychiatric Nurses (CPN). There are many
validated tools available for suicide risk assessment. The Army's
Consultant Adviser in Psychiatry (CA Psych) does not commend the
use of any particular validated tool. A properly taken medical/mental
health history is the core tool and all clinical therapists in
CMHTs are well trained in this. They may use a validated tool
if they wish to do so and if it is clinically appropriate.
10. CMHTs are already collecting data on
DSH cases. CA Psych is writing to all Army CMHTs to direct them
to be proactive in ensuring that all military units in their area
refer DSH cases to them. They will also be instructed to offer
military units additional training for commanders in suicide and
DSH risk awareness. This will supplement training that is already
available to military personnel.
11. Significant Event Analysis (SEA). Reference
C requires primary care staff to conduct a SEA if there is a case
of suicide or DSH in their practice. The aim of this SEA is to
evaluate the medical events and inform future practice.
12. GP Continuing Professional Development.
This month the annual Director of Army General Practice Study
Day will cover mental health issues, including an update, with
PS4 involvement, on the command actions being taken to increase
suicide awareness.
SUMMARY
13. The Army population is very different
from the prison population and needs different approaches to risk
assessment.
14. The AMS is very active in improving awareness
of DSH issues, intercepting those at risk, advising commanders
about them and managing them. This is carried out through the
synergistic work of primary care and CMHTs.
17 Fear et al, DASA Report dated 9 June 2003. Back
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