SAFER Briefing SD1 Evaluation Workshop 14th May 2018 The SAFER campaign seeks automatic referral of those bereaved by suicide to the Coroner, who then would seek consent from next of kin to refer to support services. The SAFER Campaign group is made up of people affected by the issue of suicide. In 2016, it launched its report ‘Families Bereaved by Suicide: The Right to Timely and Appropriate Support’i, which recommends changes to the present SD1 process which refers people bereaved by suicide to support. This briefing aims to: Highlight key PHA evaluation findings Propose how the SAFER recommendations can address issues raised in the findings Provide additional international evidence in support of the SAFER recommendations
1. The immediate PHA evaluation findin
response to suicide
1.1 The PHA evaluation described the SD1 process and explained that the PSNI officers first on the scene are required to complete the SD1 form along with two others, for the PSNI and the Coroner’s officeii. It referred to some officers’ view that the filling of these multiple forms was “intensive and burdensome”.iii Importantly, other officers reported that at times the bereaved family members’ state of shock made it difficult for them to remember specific details required by the formiv. 1.2 Some officers described being unaware of the services they were offering: ‘Nine (out of 12) officers did not know what happens after the SD1 form is submitted.’ Some showed limited awareness of support being offered: “I’m completely oblivious if I’m being honest, I know [the SD1 form] serves a purpose but I’m not sure [what happens]”. PSNI officer.’’
“Once that goes we do know that support services will be in contact but as to what services there are I am unaware”. PSNI officer.v 1.3 Another issue raised was the timing of the offer of support: “some support services felt that the shock experienced by the NOK may have impacted their decision to decline consent”vi. Significantly, ‘the majority of bereaved families could not recall providing consent for their details to be passed to support services… ‘ “I had to find out through [the support service] that the police asked me the question on the SD1 because I didn’t know. There’s certain things you remember and you’ll never forget from that day and that wasn’t one of them”. Bereaved family member. “I said I wasn’t asked [for consent]… [The person at the support service]… confirmed I was asked. I never knew I was asked because you’re in such a daze”. Bereaved family member.vii 1.4 The report included a PSNI recommendation to slightly delay the offer: ‘’I don’t think we should be asking them at that time…I think it could be too soon. They are going to have so much going through their mind about what has happened…it could be a few days down the line that support services could be introduced.’’ PSNI officer.viii 1.5 A final issue raised by the report concerned potential gatekeeping: ‘whilst the right to decline support was acknowledged by all support services, there was concern that the NOK acted as a gatekeeper for other family members and/or friends who may need support. If the NOK declined support, other people affected by the death would need to seek support themselves.’ ‘’If the next of kin says ‘no’ there may be a whole raft of other people who may have said ‘yes’.’’ Support Serviceix
SAFER recommendation 1.6 The SAFER campaign argues that a change in the timing and mechanism of the offer of support might well alleviate some of these concerns. If the Coroner were to take the lead in contacting the family with the offer of postvention support, it would likely increase the uptake rate for that support. Coming alongside additional practical information already provided by the Coroner and in a time better suited to the family, the consent to be referred to support would also be more informed. We suggest that this should happen within 48 hours, so that the offer of support does not come immediately upon the discovery of the death of the death of a loved one, but is timely nonetheless. This would mean one less form for the attending PSNI officer to complete and would remove some of the immediate burden of form-filling with newly bereaved family members.
Additional evidence base 1.7 Academic research indicates that this model is already being successfully implemented in different jurisdictions. One is the Department of Forensic Medicine (DFM) in Newcastle, Australia, described as a very clear and ‘held’ response to the traumatic experience of a suicide for families of those who have died… There is a clear pathway which manages both the forensic needs to investigate following a suspected suicide, and the needs of the family to be supported and given information... [in this system] the police report is seen by grief counsellors who then decide what action to take… The grief counsellors advocate for the families in terms of information, legal rights, requests etc. They seek to empower families and have, little by little, tried to influence how the medical team respond and interact with families, by trying to change attitudes and ways of working to help medical staff consider the human element and needs of what is a difficult and distressing process for familiesx.
2. Gaps in service provision PHA evaluation findings 2.1 The evaluation found that “there is an opportunity to address gaps in service provision”xi. For deaths in hospital, the report noted ‘‘there’s this issue where people die in hospitals from their injuries at a later stage. We wouldn’t get the SD1 but the next of kin would still be in need of support…There’s a gap there’’. Support service.xii 2.2 With regard to the particular needs of children, the report quoted bereaved family members: ‘’I would’ve loved somebody to come along and talk me through the stages that we were going to go through and what was going to happen. What to look out for in the children. Bereaved family member. ... There are [some] girls in [my child’s class in school] and their fathers have taken their own lives. Their mothers have asked me if there is counselling…they were asking me ‘where did you go?’ And I was saying there was nowhere for my girls to go…I told them to call [the support service] but there really is a lack for children.’’ Bereaved family memberxiii On this issue the evaluation report also noted that ‘bereaved families perceived a lack of support services specifically for children or information to help guide conversations with children following suicide. Services that were available were reported to limited support for a six month period and this was not felt to be suitable. This issue could be explored regionally to
determine how children and their parents can be better supported following suicidexiv.’
SAFER recommendation 2.3 The SAFER campaign believes that the Coroner’s Office would be best placed to address gaps in services including children and those whose loved one dies in hospital. Moreover, the SAFER campaign urges that this Coroner-led service consider setting up/linking to specialist provision for children, per the New South Wales model.
Additional evidence base 2.4 Academic research has pointed to the fact that “children are often forgotten or not considered in the quest to provide better services for those bereaved by suicide”xv and can suffer long-term ill effects from “disenfranchised grief”xvi. Further, children bereaved by suicide are more vulnerable as they grow up. The largest study to date on the effects of sudden parental death on childhood development, led by Johns Hopkins Children’s Centre, looked at the entire Swedish population over 30 years. It found that losing a parent to suicide makes children more likely to die by suicide themselves and increases their risk of developing a range of major psychiatric disorders (Wilcox et al 2010). But importantly the researchers said there may be a critical window for intervention following a parent’s suicide and that a loving, supportive environment and careful attention to any emerging psychiatric symptoms can offset even such a major stressor as a parent’s suicide. So it makes sense to put in place services for children following a suicide that may prevent mental health issues in adulthood.xvii For this to happen, however, “a system whereby coroners can report deaths to service providers is a crucial starting point for a service... in order for more children to benefit from this expertise there needs to be more connection between large scale national organizations and specialist children’s organizations.xviii
3. Structures and processes PHA evaluation findings 3.1 The evaluation noted that ‘the timing and type of support provided to individuals bereaved by suicide varies depending on their need. Individual circumstances mean there are no standardised packages of care.xix’
The evaluation found that “roles and responsibilities should be clarified when responding to suicide and providing support to individuals and communities” and that “standardisation of the processes for offering support would ensure the same services are offered region-wide”.xx Similarly, the report found that “there should be regionally agreed protocols for contacting individuals who declined support and protocols should ensure individual rights are protected and should not risk any further trauma”xxi. 3.2 In the PHA evaluation, some police officers reported already seeking guidance from the Coroner’s office in specific areas, such as establishing next of kinxxii.
SAFER recommendation 3.3 The SAFER campaign believes that the Coroner’s Office would be best placed to take the lead on the standardisation of processes. SAFER argues that as the Coroner’s Office already plays a role in clarifying issues and providing information, it would be in a good position to take on role of co-ordinating the task team to link agencies together in the standardisation process recommended by the PHA evaluation.
Additional evidence base 3.4 Recent academic research supports SAFER’s recommendation for closer involvement of the Coroner’s Office in supporting bereaved families. International research in Australia, New Zealand and Ireland found that in all three countries the fact that coroners report deaths by suicide to those organizations providing services makes an enormous difference to their ability to offer services, as people are less likely to fall though the netxxiii. Examples included the Department of Forensic Medicine in Newcastle, which works closely with coroners; the Regional Suicide Postvention Coordinator in Wellington, New Zealand, who is informed of every suicide by the coroner and the police; and New Zealand Victim Support, which commented on the enormous advantage of being informed of deaths by the coroner.xxiv The study comments, “this is an area that clearly needs a lot of attention in the UK, where contact with local coroners is patchy and sensitive”xxv.
4. Longer term postvention PHA evaluation findings 4.1 The report pointed to the need for ongoing services to the bereaved:
‘the timing of support can have an impact on effectiveness with earlier support considered most appropriate and effective with a need for ongoing support in the long-term.xxvi’ 4.2 In addition, the report pointed to the importance of having multifaceted, joined-up services for the bereaved: ‘’when someone is a victim of suicide, I feel that there should be a task team put in place that they all link in. Whether it’s a home care team, whether there’s elderly involved there, if there’s a counselling, specialist counselling team and also the GPs linking into that as well to ensure the support network is there for that family.’’ Bereaved family memberxxvii. 4.3 The impact of such postvention support should of course be monitored: ‘although this report provides evidence of the impact support following bereavement by suicide has had on individuals in Northern Ireland, this relates to a small number who participated in this work. There are currently no formal region-wide mechanisms in place to monitor the impact of support for those receiving it and this would benefit from greater exploration.xxviii’ 4.4 The Evaluation report also noted that “consideration could be given to raising awareness of the support services among the general public”xxix.
SAFER recommendation 4.5 The SAFER campaign would support this, as it could potentially enable people to understand its importance and encourage uptake, or empower the public to encourage people they know to take up the offer of support that is tailored to their situation and needs. SAFER would argue as well that postvention support is highly cost-effective.
Additional evidence base 4.6 Research on the Centre for Childhood Grief in Australia found that it ‘works together with the local coroner to run a ‘Support after Suicide Group’ with social workers from the coroner’s office. This group is funded by the coroner, who also provides the venue. StandBy was initiated by the coronial service and the police, which has meant an ongoing positive working relationship between the different agencies.xxx’ On the issue of cost effectiveness, the findings were that ‘most of all funding makes sense. Research undertaken by Health Economists in Australia in 2013 on the costs of prevention and the costs
of doing nothing showed that suicide ‘postvention services are a cost effective strategy and may even be cost saving if all costs to society from suicide are taken into account’ (Comans, T. et al 2013). The British Government itself has estimated that “each suicide costs the economy in England around £1.6 million, although the full costs may be difficult to quantify. It is striking that 60% of the cost of each suicide is attributed to the impact on the lives of those bereaved by suicide… we have a moral and economic imperative to improve the consistency and quality of suicide bereavement services across the country.xxxi ‘ 4.7 The research demonstrates, comparatively, how funding to address road deathsxxxii can save the state money. Similar effort and funding in suicide prevention could not only save more lives, but also a great deal of money.
i
Available at https://issuu.com/ppr-org/docs/safer_report_sept_2016. PHA, Evaluation of the SD1 and CRP processes in Northern Ireland as a response to suspected suicide, March 2018 at http://www.publichealth.hscni.net/sites/default/files/SD1_CRP%20evaluation%20report%202018_2.pdf pp. 10, 16. iii Ibid., PHA Evaluation, p. 16. iv Ibid., PHA Evaluation, p. 20. v Ibid., PHA Evaluation, p. 24. vi Ibid., PHA Evaluation, p. 20. vii Ibid., PHA Evaluation, p. 28. viii Ibid., PHA Evaluation, p. 28. ix Ibid., PHA Evaluation, p. 29. x Winston Churchill Memorial Trust, Improving Services for Children Bereaved by Suicide, 2017 at https://www.wcmt.org.uk/sites/default/files/reportdocuments/Koole%20E%20Report%202015%20Revised.pdf. p. 20. xi Op. cit., PHA Evaluation, p. 8. xii Ibid., PHA Evaluation, p. 25. xiii Ibid., PHA Evaluation, p. 35. xiv Ibid., PHA Evaluation, p. 50. xv Op. cit., Winston Churchill Memorial Trust, p. 5. xvi Ibid., Winston Churchill Memorial Trust, p. 33. xvii Ibid., Winston Churchill Memorial Trust, p. 5. xviii Ibid., Winston Churchill Memorial Trust, p. 7. xix Op. cit., PHA Evaluation, p. 7. xx Ibid., PHA Evaluation, p. 8. xxi Ibid., PHA Evaluation, p. 8. xxii Ibid., PHA Evaluation, p. 23. xxiii Op. cit., Winston Churchill Memorial Trust, p. 14. xxiv Ibid., Winston Churchill Memorial Trust, p. 14. xxv Ibid., Winston Churchill Memorial Trust, p. 14. xxvi Op. cit., PHA Evaluation, p. 9. xxvii Ibid., PHA Evaluation, p. 36. xxviii Ibid., PHA Evaluation, p. 50. xxix Ibid., PHA Evaluation, p. 50. xxx Op. cit., Winston Churchill Memorial Trust, pp. 14, 27. xxxi Ibid., Winston Churchill Memorial Trust, pp. 8-9. xxxii Ibid., Winston Churchill Memorial Trust, p. 9. ii
________________________________________________________________________________________ For further information on the SAFER Campaign: Participation and the Practice of Rights (PPR) Ground Floor, Community House, Citylink Business Park, 6a Albert Street, Belfast, BT12 4HQ Tel: +44(0) 2890 313315 Website www.pprproject.org Facebook pprproject Twitter @PPR_Org Email stephanie@pprproject.org