Suicidal patients go unnoticed in A&E

31 July, 2010

A&E departments are failing to spot patients who are at risk of committing suicide in future, many of whom seek emergency care in the year before their death, according to UK researchers.

They found more than 40 per cent of people who committed suicide over a two-year period in the north west had visited an A&E department at least once in the 12 months prior to their death.

Of these, 28 per cent had received emergency care on at least three occasions. These “frequent attenders” were more likely to have a history of self-harm.

“Clinicians should be alert to the risk associated with such presentations and to the possible association between frequent attendance and suicide,” the authors said online in the journal Emergency Care Medicine.

Readers' comments (25)

mike | 31-Jul-2010 2:58 pm
Oh for gods sake, are we expected to be psychic as well now?

In my experience sometimes the signs of depression are obvious yes, but not everyone who is depressed is suicidal. Also, a lot of those who are truly suicidal often show absolutely no clinical signs of depression or behavioural changes beforehand!

Furthermore at the end of the day A&E staff are emergency personell, they are not mental health Nurses, or psychologists, or social workers or anything else. What exactly are we expected to do here?

These people really should think before they come out with ridiculous statements such as this!
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Marjorie Lloyd | 1-Aug-2010 11:10 pm
I find the above comment offensive to nurses - all nurses are supposed to provide holistic care that means assessing for risk of suicide too which is an emergency btw. We do not have a seperate emergency department in psychiatry ?????
Everyone knows that if you self harm you are more at risk of going too far but then perhaps nobody cares or can be bothered to ask?

Mental health professionals are not psychic either;-)
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Paul Carney | 2-Aug-2010 1:18 pm
I agree with Marjorie, Mike's intolerance is perhaps much of the reason that depressed patients might go on to commit suicide. No, you are not expected to be a 'mental health nurse' or a 'psychologist', but it would be nice if you had some compassion.
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Anonymous | 2-Aug-2010 2:06 pm
I admit 1 attendance in 12mths prior to suicide does seem to require some psychic skills. However:

"You must recognise and work within the limits of your competence"
"You must make a referral to another practitioner when it is in the best interests of someone in your care"

Mike - yes, A&E personnel are not (generally) MH trained, but we have a Code of Conduct which answers the 'what are we expected to do' question. I've had some excellent A&E care where staff recognised this & were sensitive, but was put at life-threatening risk when my inability to speak was interpreted as non-cooperation and was sent home without MH assessment.
The same applies to MH nurses re: areas outside their expertise. This week I heard from a patient who had is on a basal/bolus regime that he varies depending on his blood sugar. This was unfamiliar to the ward staff so, rather than check it out with diabetes staff, they withheld his insulin & threatened him with detention under MH Act when he protested this was dangerous.
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Anonymous | 2-Aug-2010 3:09 pm
Some patients present themselves purely with Psychiatric problems such as depression, suicidal and so forth. Since there is no medical problem/ emergency involved we should therefore send the patient for Psychiatric evaluation. There is no need for them to be seen in the ER. This is the system here where I work, therefore no delay on the evaluation and pts receive appropriate treatment quicker. However, Psych pts who also present with minor medical emergencies should be treated first then send them for Psych Eval. This system works well for us not just for the pt but also in the ER in general. We use to see Psych pts in the ER and it was an average of 5 hours wait before they see a doctor for medical clearance. Then it was realized that Psychiatrists are also doctors who can do the same. Since then, any Psych pts without medical emergencies can go straigth for Psych Eval without being seen in the ER.
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Anonymous | 2-Aug-2010 5:45 pm
The frequent attendance at A&E, presenting with minor physical complaints / DSH / parasuicidal behaviour, leading to an esculation and increase risk of suicide occuring, is not something new! This has been known (especially for those who have a diagnosis of PD) for a long time now.

I would still like to know where the plan for an MH nursing and Childrens nurse 24/7 in all A&E departments are?!? Surely this interprofessional working and supporting each branch, can only lead to better quality of care?
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Aaron Bate | 2-Aug-2010 5:57 pm
As a mental health nurse i just dont know what the f**k people who work in A+E are expected to do?
The amount of patients that come into pysch units form A + E is a massive represntation of people on the ward....how unfair is this on A+E to be expected to spot those who are at risk?
Before some smart arse pops up...yes there is psych liason in most A +E, nut its not like the telly on casualty where that fit RMN works shifts and does the same job as evryone else but somehow manages to sort out every person with a mental health problem in each episode.
But most psych liason i know of runs 9-5 mon-fri, which im geussing isnt the time that A+E is at its busiest?
Yeah they can make a refferal to crisis teams...but you'd think with word crisis that it would be a quick service...not a six-seven hour wait, where A +E staff are trying to keep an eye them so they dont go off the ward as well as deal with every other patient that walks in?
if 1 in 3 people have mental illness...would it not be sensible to have a rmn on every shift in a + e , do they do these pead nurses? im not sure...but whats the point of publishing research like that to make peope feel shit about themselves about an area they aren't trained in...but expected to be experts in!!!
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Anonymous | 2-Aug-2010 6:22 pm
I admit 1 attendance in 12mths prior to suicide does seem to require some psychic skills. However:

"You must recognise and work within the limits of your competence"
"You must make a referral to another practitioner when it is in the best interests of someone in your care"

Mike - yes, A&E personnel are not (generally) MH trained, but we have a Code of Conduct which answers the 'what are we expected to do' question. I've had some excellent A&E care where staff recognised this & were sensitive, but was put at life-threatening risk when my inability to speak was interpreted as non-cooperation and was sent home without MH assessment.
The same applies to MH nurses re: areas outside their expertise. This week I heard from a patient who had is on a basal/bolus regime that he varies depending on his blood sugar. This was unfamiliar to the ward staff so, rather than check it out with diabetes staff, they withheld his insulin & threatened him with detention under MH Act when he protested this was dangerous.
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Marjorie Lloyd | 2-Aug-2010 11:21 pm
err so when did being suicidal not become a medical emergency?
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mike | 3-Aug-2010 10:35 pm
Marjorie, what exactly about my comments is offensive?

If a person presents with a medical problem and is obviously in need of MH input then of course they can be referred. If it is not immediately obvious, then that is far more difficult.

As for your extremely short sighted comment 'err so when did being suicidal not become a medical emergency?' When a suicidal patient presents with something minor, yet shows absolutely no outward signs of MH problems or suicidal tendencies (not all do), and an RTA victim comes in at the same time as a patient with a severe stab wound. Are we supposed to second guess everything and spend time with the minor patient just in case he decides to commit suicide at some point in the future?

Get real.

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mike | 3-Aug-2010 10:42 pm
Paul Carney, you do not know nearly enough about me or my practice to make ill informed comments like that. I treat all my patients with compassion or empathy to a greater or lesser degree. I chat to them as I treat them whenever I get the opportunity, they sometimes chat back. Sometimes it is obvious when a patient needs further referral and MH input. It is not always.

In my opinion a quick assessment and treatment at A&E will not always spot (unless they are overt) and almost never trigger suicidal tendencies, which tend to have been the result of long term problems.

If you MH Nurses came off your cushy tea break shifts once in a while and worked across the entire hospital on a broader/more permanent scale, MH patients presenting with medical problems might be picked up more, ever thought of that?
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Marjorie Lloyd | 4-Aug-2010 12:24 pm
Trying not to court more insults here Mike but all nurses should be able to carry out an holistic assessment of need, no matter how busy they are or which branch / speciality they are from. Slinging insults does not help any of us be professional or ethical about our work.
Suicidal thoughts are an emergency if not addressed and cannot wait for a referral to be made that could take days to arrive. Just because you cannot see a symptom does not mean it is not there.

If all nurses behaved in the way you suggest then they would be ignoring and neglecting the needs of every vulnerable patient they came across who could not tell them exactly where it hurts.

I expect you would call those patients time wasters but in our current system staff in A & E are the only people who can help anyone in an emergency situation
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Marjorie Lloyd | 4-Aug-2010 12:32 pm
BTW we can all have suicidial tendancies Mike but suicidal thoughts are usually transient and urgent and may not be a result of any mental illness at all. Given the current economic climate we are more likely to see people who want to end their lives and the lives of their families due to financial and social pressures. There is plenty of literature /research out there if you care to look. Which may give you a more informed opinion of the research you so quickly want to ignore above.
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Anonymous | 4-Aug-2010 7:13 pm
RMN's and CPN's in A&E for round the clock cover very good idea.
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Anonymous | 4-Aug-2010 7:26 pm
I also think what the politician might be getting at is something around being straightforward in addressing issues. However that also relies on the people being straightforward having interpersonal skills and knowledge to deal with the responses therapeutically or at least cause no damage.
I think we are too ready sometimes to regard our speciality as more important than another's. Having trained as a project 2000 guinea pig our MH placement was 2 weeks and the paeds placement also 2 weeks consisting actually of 1 shift where I sat with a 6month old blind infant with 24hr O2 the whole time. I loved it but learnt nothing of paediatrics. The MH placement I spent on a secure acute unit being terrified for the whole 2 weeks and learnt very little of mental health issues or assessment and absolutely no relational skills.
Goes back to training as well. Junior Dr's have placements of what, 3 or 4 months, why don't we?
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Anonymous | 4-Aug-2010 7:28 pm
oops wrong thread!
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mike | 4-Aug-2010 8:06 pm
Marjorie, you seem to be completely missing my point. I am not saying that emergency (or any for that matter) staff cannot or should not perform a holistic assesment of their patients, we often do. What I am saying is that it is impossible to 'notice' (to use the terms of the article) EVERY suicidal patient. It is just not possible. Specialist staff in specialist wards cannot notice every suicidal patient, so why are emergency staff being criticised for not doing so? It is ridiculous.

And I know about the many and varied reasons for suicidal tendencies Marjorie, please do not presume that I do not. To give you one example from my personal history, I once knew a soldier who committed suicide, without going into details, he was in the NAAFI with the rest of us the night before joking and laughing, we spent almost every living hour with the man, he showed no signs of being depressed or having trouble or anything else. Yet one night he decided to end it. We, those closest to him, did not see anything wrong. How can emergency staff who only have a few hours with a stranger spot suicidal patients in those circumstances? It is impossible.

Where it is spotted, of course care must be given and referrals made, but we cannot save everyone. To criticise us for that is ridiculous. To get all high handed and superior helps noone.

Are you a MH Nurse perhaps? If you are, then why not fight for the expansion of your services instead of criticising everyone else for not doing your job?
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Anonymous | 4-Aug-2010 8:26 pm
What is a holistic assesment? Really. I need guidance, can you point out any books I could read that would educate me in this physical/emotional/pychological/spiritual appraisal system and it's benefit Vs. Asking a couple of questions?
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Anonymous | 4-Aug-2010 9:39 pm
I think people are being overly harsh and analysing what Mike is trying to say abit too deeply and not how i percieve his comments.
I don't appreciate the tea comment very much though to be fair...your an A + E nurse?...im sure sometimes its very quiet in the department and can be a scieve now and again, much like a mental healthunit...but when the shit hits the fan you have to be ready and put skills into practice...its no different in mental health mate.
I am an RMN, I do not see any point in publishing an article like this without any incling of a solution or way forward...why guilt trip people that they are failing to stop people commiting suicide, THAT is not fair and is demorilising, wouldnt make you feel that great about yourself would it?
How many times have us mental health nurses not picked up on someones intentions, and like the example Mike gives have pissed around laughing and joking, playing pool to come to work the next day to find they had taken their own life whilst on leave.....this is devestating when this happens and when everyone tells you not to blame yourselves and its rationilised that when people are determined to do this there is nothing you can do, you still do blame youself, have trouble sleeping and looking yourself in the mirror for a while...personally i feel like this it is as a failure as a human being and being a nurse isn't what i'm thinking about.
But in all seriousness as a mental health nurse i may be better equipped to be able to assess and notice these things slightly better than a general nurse in A +E because I have years of exposure to being around people who are of risk of suicide.
Likewise I fully admit I am not as quick with picking up the early signs of physical illness...but what do you I do? get an on call doctor and if they don't know its A + E.
There isn't an equivelent for mental health, so it just isn't fair to compare...simple answer how little it would cost to employ one nurse a shift in an A + E team with RMN qualification and you save 1000s a year with calling out of hours crisis teams with people who may not be acutley at risk of suicide, and also have a positive influenece on the nursing team with a different perspective...might not completly work or be perfect but would be better than what is in my area.
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Anonymous | 5-Aug-2010 9:12 am
Plenty of A&E units (big inner city) have psych liaison nurses working much of the 24hr period. Psychiatric knowledge of most adult nurses, even those in A&E departments who perhaps see the most people with mental health problems (actually more than the average RMN) is sketchy to non-existent. Another vote for having 3 years of common training and then specialization.
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