3. These patients are sometimes considered unwelcome because they are seen as
complex, heavy consumers of staff time and energy, and not infrequently
exhibit aggressive and/or disturbed behaviour.
4. “attention seeking”
You may hear colleagues or parents referring to the child as “attention seeking”, with the unambiguous implication that the
child is being a nuisance and is best ignored. Some stakeholders like to comment on the superficiality of the wound as an
indicator. However please note that the depth of the wound is not necessarily proportional to the depth of the distress and
in some situations the word superficial can be construed by patients as pejorative. Repetitive self harm (regardless of
depth) is strongly associated with suicide as a long term outcome. Your response to those who propagate the “attention
seeking theory” could be “well, what do they need attending to?”.S
13. ● Suicide is one of commonest causes death in young people.
14. If ever you have the opportunity to save a young person’s life – it is now.
15. forms
790% of self-harm involves self-poisoning, and the remainder physical self-injury
(eg cutting)
16. Triage
following an episode of physical self-harm and/or overdose, perform a
rapid initial assessment (triage) to establish the degree of urgency of the
situation, mental capacity, willingness to stay, distress levels, and presence
of mental illness. factors that may render the situation more urgent include:
• need for urgent treatment for physical injury and/or overdose.
• Immediate risk of violence to others.
• Immediate risk of further self-harm.
• need for treatment, but the patient is threatening to leave
19. Ideally
The system in place should ensure self-harm patients are checked upon
at least every hour—a change in triage category may require more urgent
assessment.
22. The young person and their family are likely to be experiencing shame and fear, probably in addition to the trigger behind the
self-harm or overdose.
23.
24. Bloods and other physical investigations and treatments
If there has been an overdose, it is good practice to do paracetamol levels even if this was not the substance allegedly
taken. Heightened distress can mean that inaccuracies may occur.
32. Risk of further self-harm
Recurrence Is most likely if there have been repeated previous episodes (eg
habitual self-cutters or recurrent overdoses)
34. Other factors Include drug or alcohol dependence, a history of criminal behaviour,
previous psychiatric treatment, or the presence of a personality
disorder
41. Suicide notes?
Suicide notes can be important but are sometimes left for dramatic effect
and so are not always reliable indicators.
42. Take all self-harm acts by individuals aged >65y seriously—consider them
to be evidence of suicidal intent until proved otherwise.
43. Assessment of suicide risk
Certain factors are common amongst completed suicides and are significant
if found in a patient who self-harms:
Eldery man living alone, lost his wife, lost his job, lost his health, lost his mind
Turns to alchohol, turns violent to himself&others
44.
45. Modified Sad persons Scale
previously, it was stated that patients with scores of <6 may
be discharged (depending upon circumstances), but latest guidance advises
against the use of scores to assess suicide risk.
However, the scale serves as a guide regarding risk factors and as a useful
prompt for areas to consider
50. Management: physical
Management of poisoning:
sensible to measure paracetamol levels in any patient who presents with a
history of overdose of paracetamol and/or other drugs.
51. superficial skin wounds
Superficial skin wounds <5cm long with tissue adhesive strips.
Employ standard assessment and treatment for deeper skin wounds
or those >5cm in length
52. Offer all patients who present to the ED after self-harm a psychosocial
assessment of the needs and risk by an appropriately trained individual
53. CAMHS
There may be a wealth of other professionals who can assist who may have prior knowledge of the child. These include
school, social services, CAMHS professionals, primary care. As these professionals are typically only available by day, this
may shed light on why the recommendations from NICE and the Royal College of Psychiatrists Guidelines are that children
should be routinely admitted to a paediatric setting overnight following self harm. This provides an opportunity to ‘wrap
the network around the child’ and bring other players in as also described by Kraemer, 2019.
54. Challenges to MGM
Timing of psychosocial assessment
The ideal is to offer psychosocial assessment of patients with self-harm as
soon as possible. There are occasions when this assessment needs to be
delayed, including the following:
• life-saving treatment for physical injuries is needed.
• The patient is unconscious and/or significantly under influence of
alcohol/drugs, and therefore not capable of being properly assessed
55. Sometimes patients state that they wish to leave the department
Very often, it is possible to persuade them to stay.
perform an assessment of the patient’s mental capacity and mental illness to
decide whether it is necessary to detain him/her under the Mental Capacity
Act or Mental Health Act if he/she attempts to leave.
56. Diminished mental capacity and/or significant mental illness
If there is diminished mental capacity and/or significant mental illness, refer
for urgent mental health assessment and prevent the patient from leaving
the department. If the patient does manage to leave the department despite best
efforts, contact the police in order to try to bring him/her back
57. No reduction in mental capacity and no significant mental illness
If there is no reduction in mental capacity and no significant mental illness
and the patient leaves, pass the information on to his/her Gp and to
the relevant mental health services as soon as possible, to enable rapid
follow-up
59. Children
It may be useful to have at the front of your mind that the recalcitrant teenager before you may be struggling with an
unbearable ‘secret’ and that disclosing this will have profound and life changing implications.
60. Concerns about children and other dependants
Always analyse a patient’s presentation following an episode of self-harm in
the context of the family and social setting. In particular, consider whether
the self-harm behaviour places children or other dependants at home at risk
(eg patient self-harms whilst sole carer for a child). Make referrals to social
services to protect children and other vulnerable persons as appropriate—
this can be a tricky area, so if in doubt, discuss with a senior.
