Thematic review of adolescent suicides, analysing five reports relating to the suspected suicides of young people between May 2014 and June 2018. Learning includes: the interface between different specialist health services and other organisations is a vital, but vulnerable, line of demarcation and may be decisive in determining effective service response; suicidal ideations and suicidal plans may not be a reliable indicator of intent to commit suicide, therefore a comprehensive assessment is required; consideration should be given to a 'trigger event phase' that may capture deterioration in presentation; consideration should be given to how to support family survivors of suicide. Recommendations include: GPs and school teaching staff should be an integral part of the inter-professional holding network and receive training commensurate with this role; professionals need to have greater awareness of young people's use of online activity and social media; professionals need to respond with a comprehensive and immediate psychosocial assessment of the young person and their engagement in a therapeutic relationship; ensure that there is timely and proportionate access to mental health services with emphasis on direct positive engagement, comprehensive assessment and necessary treatments; listening to and learning from young people and their families must be used in creating preventative suicide strategies.
      
 Title:  Suicide in Children and Young People – thematic analysis 2014 – 2018. LSCB: Kent Safeguarding Children Multi-Agency Partnership Author: Terence Nice Date of publication: 2020  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                                 Dr Terence Nice BSc MSw MSc MA PGCHE               Suicide in Children and Young People -    A Thematic Analysis 2014 - 2018  August 2020  Executive Summary  The purpose of this Executive Summary is to highlight the report’s strategic points, key findings and multi-agency recommendations.   1.  Origins of the Study and Research Question  1.1.1 In Autumn 2018, the Kent Safeguarding Children’s Board made the decision to undertake a thematic review of Teenage Suicides to discuss ideas, thoughts and research strategies following a rise in the number of adolescent suicides in Kent, which reflected a rise in adolescent suicides nationally. A Review Panel was established to coordinate and oversee the thematic review, and it was agreed that Dr Terence Nice (Programme Director and Lecturer in Psychological Studies, University of Kent) be commissioned to undertake the review.  1.1.2 A key area in the Panel’s opening discussions was an influential report from Manchester University entitled: Suicide by Children and Young People: Manchester Report (National Confidential Inquiry into Suicide and Homicide by People with Mental Illness), (NCISH, 2017).   1.1.3 The focus of these initial Panel meetings was to identify a strategic, workable and ethical research pathway that would enhance our understanding and knowledge of youth suicides in Kent. It was deemed important that the outcome of the study should not be a theoretical enterprise, but deliver a set of practice recommendations that could inform a multi-agency learning programme and identify any themes and patterns underwriting the suicide process.    1.2 Aim and Objectives  1.2.1 This review undertook a statistical data analysis of existing reports relating to the suspected suicides of 16 young people in Kent between May 2014 and June 2018. This was complemented by a Thematic Analysis of four cases (anonymised for reasons of confidentiality and data protection). The reports consisted of three Root Cause Analysis (RCA) Reports and two Local Safeguarding Board reports detailing multi-agency involvement with the young people and their families. A total of five reports were subjected to thematic analysis.   1.2.2 Aim To gain a wider understanding of the issues experienced by young people that led to them taking their own lives.  1.2.3 Objectives  The objectives of the review were to: 1. To identify principal themes and patterns pertaining to attempted or completed suicide 2. To assist in the raising of staff awareness of early indicators where young people may be vulnerable to self-harm and/or suicide ideation 3. To assist in the identifying of appropriate services to support young people at the earliest possible opportunity.    1.3  Method  Two methodological approaches were adopted:  1) Comparative Statistical Analysis;  2) A Thematic Analysis.      1.4  Key Findings   1.4.1 The key findings of this report are summarised below. The report also includes specific recommendations for the Multi-agency Partnership.   1.4.2 The General Practitioner (GP) is often the first port of call for young people suffering with mental health issues or disorders, and is in a unique position to assess the young person, delivering specialist advice and onward referral to Child and Adolescent Mental Health Service (CAMHS). This places them in a unique and important position in accessing timely, necessary and requisite services. How we bring them on board and support them to be a part of a multidisciplinary holding environment is the next challenge.   1.4.3  The interface between different specialist health services and other organisations is a vital, but vulnerable line of demarcation, and may be decisive in determining effective service response and blue-light actions. Whether this is seamless, integrated or obstructed will determine timely or delayed service response within the suicide trajectories of young people. How one removes these barriers to service is worthy of discussion and action.  1.4.4  Long waiting lists, poor lines of communication and administrative errors can lead to a delay in urgent assessments of self-harming and suicidal young people.  Suicidal young people cannot wait, they require urgent assessment and preventative interventions and evidenced-based treatments commensurate with the severity of their presentation.     1.4.5  Quality of assessment and early treatment is indicated in the diminishment of risk and meeting the complex needs of young people. Suicidal ideations and suicidal plans may not be a reliable indicator of chronic intent to commit suicide, therefore, a comprehensive assessment is required involving actively listening to parents and young people, cross-checking and cross-referencing at an individual and systems level. What constitutes a gold-standard assessment which keeps young people protected and safe in the heart of their families is a question worthy of further exploration.  1.4.6  In this review, in the context of family systems, the mother is the parental figure who appears to notice small behavioural nuances and changes in child’s behaviours. This may of course also extend to fathers, but this is not demonstrated in this review. She may act as a systems barometer or sensor, picking up feelings and behaviours that otherwise may go unnoticed. Bringing parents’ experiences to the table is vital in creating preventative strategies. For example, parents of young people who have committed suicide have advocated improved mental health training for teaching staff.  1.4.7  The ‘Rising Tide of Risk and Concern’ theme suggests that there is a suicide trajectory, wherein opportunities exist to prevent suicide. This review found that whilst single and ‘Discrete Trigger Events’ (DTEs), may account for a tipping point, consideration should be given to a ‘Trigger Event Phase’ (TEPs), that may capture deterioration in presentation and a sea change in individual presentations and suicidal intent.   1.4.8  A greater understanding of protective factors is warranted, not only as discrete entities, but in how they combine and interact to form a protective membrane around the young person.   1.4.9  Consideration should be given to how to support family survivors of suicide in a respectful, timely and appropriate manner.    1.5  Implications for Practice  1.5.1 The overview data shows that most of the young people were known to services, primarily CAMHS, and that most had communicated concerns about suicide in the form of a previous attempt, an episode of self-harm or suicidal ideation. These cases accord with the strong connection in the research literature between self-harm and suicidal thoughts, ideas and threats, and repeated self-harm and completed suicide. The key implication for practice, and one which might be challenging for services, is that evidence of suicidal concerns needs to be responded to, not with a risk assessment that distinguishes on the basis of method and stated intent, but with a comprehensive and immediate psychosocial assessment and engagement in a therapeutic relationship. This is also the recommendation of the National Institute of Clinical Excellence (NICE) 2011. The challenge is clear to ways of working, common assumptions and, not least, the deployment of resources.   1.5.2 Alongside this, a second practice implication is the importance of addressing the issues faced by identifying the young people, who constitute a minority in this study, and who do not come directly to the attention of mental health services or social care, for mental health and suicidal communications, but who do raise concerns in mainstream services, education, primary care, and amongst family members and peer groups. Inter-professional sharing is crucial, alongside the need for training for the wider professional network. Community focused approaches to suicide prevention are indicated, for which several examples now exist. Additionally, professionals need to have greater awareness of and the capacity to explore young people’s use of online activity and social media.  1.5.3 A third practice implication in this review is the role of GPs, who often represent a first port of call for suicidal young people and their families. This is a vital link in the chain especially in bridging the vulnerable lines of demarcation between other professional services. The importance of bringing GPs on board has implications for practice at a multiplicity of levels, assessing the needs, risks and resilience of young people, onward referral and ensuring that family concerns are given the requisite response in an urgent or timely manner. In this way they are a vital part of a network system that should calibrate and hold ‘concern, risk and need’ in an integrated fashion that is spread across all professional agencies and charitable organisations. Training is required to identify ways in which these demarcation lines can be effectively bridged.    1.5.4 Fourthly, in systems and organisations where there is over-whelming demand, limited resources and poor or broken lines of communication, consideration needs to be given to bridging these lines of vulnerability. There can be no short-cuts or abridged assessments, especially given that absence of suicidal ideation or suicide plans may not indicate genuine suicide intent. These issues have often been a cornerstone to clinical assessment and therefore, revisiting what constitutes an effective gold-standard assessment is important and should be guided by the recommendations of NICE, 2011; 2017). Moreover, assessors have often focused upon single event triggers rather than TEPs that capture the rising tide of risk and need in the context of systems and a cumulative suicide trajectory. Attention in RCA reports centre on ‘risk’, with the odd reference to protective factors. The identification of authentic protective factors is a piece of work that may produce some benefits in informing our understanding of adolescent suicides.    1.6  Summary   1.6.1  The findings of this regional review confirm wider UK national trends surrounding adolescent suicides in terms of age, gender, method and other suicide correlates, such as self-harm, bereavement, depression, social withdrawal and loss (NCISH, 2017). National statistics indicate a significant rise in young male suicides in 2018, and the suicide rate among females aged 10 to 24 years has increased significantly to its highest recorded level since 1981 (ONS 2018). Important areas were identified and highlighted in relation to young people’s contact, access and disengagement with services. Long waiting lists, poor access to services and broken communication pathways were a common feature across the four cases. It was found that assessment of suicide risk and need warranted a comprehensive assessment framework (NICE, 2011), that did not skirt over the issues of ideation, intent, plan and method. There could be no abridged assessments or short-cuts in assessing suicidal young people irrespective of motivation or stated intent. The pivotal role of GPs was recognised as a ‘first port of call’ and the need for inter-professional collaborations in facilitating a holding network which can share vital information is indicated.    1.6.2 In meeting the overall aim and review objectives, an important construct was generated relating to the ‘rising tide of risk and concern’ and how this theme informed understanding of a deterioration in mental health and the suicide process. The shift from suicidal ideations to suicide, could be usefully conceived as a TEP, with a fluidity that rises and falls as opposed to a DTE. The two are not mutually exclusive, but a discrete trigger event may give the finer detail of suicide process. TEPs allows for a bigger picture of the shifts, movements and dynamics underwriting suicide process that may counter the idea that suicides seemingly ‘come out of the blue.’ More research grounded in young people’s experiences and their use of social media is required to map these tides and patterns, accepting the uniqueness of the individual’s own suicide narrative and the patterns and phases that run through young people’s suicides. These themes and patterns are repeated in constructs such as age, gender, ethnicity, bereavement, e-bullying, Lesbian, Gay, Bisexual, and Transgender (LGBT) issues, social media, psychiatric disorders, emotional well-being and self-harm. If, as researchers and clinicians, we narrow our visual range to solely focusing upon ‘risk’, we will construct an edifice built upon weak foundations that ignores the needs, resilience mediators and protective factors that speak of positive survival and a fulfilling life.     1.7 Recommendations  1. For GPs and school teaching staff to be an integral part of the inter-professional holding network and receive training commensurate with this role.  2. Professionals need to have greater awareness of and the capacity to explore young people’s use of online activity and social media. 3. Professionals, where suicidal concerns are identified, need to respond with a comprehensive and immediate psycho-social assessment of the young person and their engagement in a therapeutic relationship. 4. Increase professionals’ understanding of the processes that drive young people to take their own lives.  5. Resources should be promoted to identifying protective factors that combine and foster a protective membrane around the young person and their family.  6. Consideration should be given to timely and proportionate access to mental health services with emphasis on direct positive engagement, comprehensive assessment and necessary treatments with young people and their families.  7. Listening to and learning from Children and Young People and their Families must be used in creating preventative suicide strategies that are credible   1.8  Next Steps   1.8.1  To maximise the impact of this review and to capitalise on the collective energies and collaborations of different parties engaged in this review, further research might conceivably bring clinicians, front-line workers, families and young people together to share their lived experiences of attempted suicide. For some young people, their voices and stories will never be heard; but for the survivors of suicide it is important that as professionals and practitioners, we listen and learn from their experiences. This might be conducted through a series of forums or through a set of focus groups, which identify the interplay of risks, needs and protective factors that characterise suicide. This review represents one step on the road to understanding adolescent suicide and on the onward journey, there are many steps to come and there is much to learn. 