Monday, 6 May 2013

When Do You Intervene When Someone’s Suicidal?

The inquest on Bryan Jobson, who lived in Leeds, was concluded on 1st May 2013. Mr Jobson hanged himself with a noose suspended from his loft hatch in February 2011.
What was particularly remarkable in this case, and which resulted in the inquest being reported not only in the Yorkshire Evening Post, but also in the DailyMirror, was that two mental health nurses from the local Crisis Team had visited him the day before he killed himself, and saw the noose hanging from the open loft hatch, with a chair directly underneath it.
It is reported that Mr Jobson, who was 44, had previously attempted suicide, that his relationship with his wife had broken down, and that he had recently experienced the loss of others close to him. The visit by the two nurses was in response to a call he had made to the Crisis Team.
It was reported that one of the nurses, who saw the noose and chair, told the inquest: “We were thinking about legal aspects. We are not allowed to touch things without their permission. I know it seems ridiculous, but we have rules to abide by.”
The nurses left him after gaining an assurance from Mr Jobson that he would not take his own life and would engage with the Crisis Team.
I do not know all the circumstances of this case other than what I have read in the press, and do not wish to comment further on this specific case, except to say that, from the inquest report, it is clear that these professionals were caring and experienced people who were acting in what they genuinely felt were the best interests of Mr Jobson.
However, the situation those two workers found themselves in does merit further examination.
Community Mental Health Workers often find themselves in the position of having to make an assessment of risk. This can be in a routine assessment, when a patient reveals a history of self harm or suicide attempts, or tells the interviewer that they feel suicidal and have plans to end their life.
It can also be in situations of acute risk, where the worker discovers that a patient has been stockpiling medication with suicidal intent, or has purchased a hose to connect to their car exhaust, or has made a noose or other ligature.
In these situations, a professional has to make a decision as to whether or not further action needs to be taken, such as arranging for a hospital admission, or considering conducting an assessment under the Mental Health Act.
In all cases, the risk of harm to the patient has to be balanced with the need to allow the person self determination and to respect their privacy and personal rights.
Certainly our local Mental Health Trust’s Policy on Self Harm encourages positive risk taking, which is described as “a person centred approach focusing on the service user’s strengths and the support required to enable them to take control over their behaviour.”
I often work with people who deliberately self harm, typically by cutting themselves, although there can be a wide range of self harming behaviours. It is important to distinguish cutting as a means of releasing distress, with cutting designed to cause serious harm or even death.
But what do you do when a patient reports that they not only have the means to take their own life, but also have the stated intent?
It is reported in Bryan Jobson’s inquest that the nurses were prevented from touching the property of a patient because of “rules that had to be abided by”.
I am not actually aware of any National or local guidelines or policies that prevent a mental health professional from taking action designed to reduce the risk of death or serious self harm.
Certainly, on the local psychiatric ward, one of the first things staff do when someone is admitted is to inspect their property and remove anything that could be used to harm themselves, or cause harm to others, such as razor blades, laces, belts, or other things which could readily be used as a ligature. This goes equally for informal as well as detained patients.
To reinforce such basic commonsense steps to safeguard vulnerable people, the Mental Capacity Act is designed at least in part to provide guidelines on what constitutes reasonable action to take to safeguard people who lack capacity.
One of the fundamental principles of the Mental Capacity Act is that anything done should be in the best interests of the person. However, “people have the right to make decisions that others might think are unwise. A person who makes a decision that others think is unwise should not automatically be labelled as lacking the capacity to make a decision.” (MCA Code of Practice Ch2.)
It should not therefore automatically be assumed, just because someone is stating the intent to end their life, that they lack capacity.
But any person, not just a mental health professional, is able to make an assessment of risk and take appropriate action in order to protect another.
A very basic example is that of a small child who is about to step into the path of a lorry. Their carer will make an instant assessment of the risk of harm if the child were to step off the kerb, and would then act to prevent the child from doing so.
The same would apply to an adult with learning difficulties who lacked capacity and was oblivious to the danger.
Not long ago, I was working with a woman with severe depression. She confided to me during one of my visits that she had been systematically going round the local pharmacies and had been stockpiling paracetamol. She made it clear that she was intending to take these tablets.
I asked her to let me have the tablets and give an undertaking that she would not attempt to take her own life. She agreed to this. We were able to involve the Crisis Team, who worked with her until the risk subsided, and we were able to avoid a hospital admission.
But what if she had refused to give me the tablets? While I would not have felt able to physically snatch them from her, I would have taken account of this refusal in terms of the additional risk it posed, made a brief assessment of her capacity to make the decision to refuse, and would have initiated an assessment for her detention under the Mental Health Act.
And if she had been in the act of swallowing the tablets, then indeed, I would have forcibly removed them from her.
After all, what would I rather have to do? Justify my decision to a court, because the person was suing me for interfering with their property, or to a disciplinary panel because I had broken some rule or another?
Or justify my decision to an inquest?


  1. Always hard when you're looking back at a situation but i would of done the same as you suggested ask if i could take the noose and if refused call for a MHA assessment taking recent events into account and the evidence of actual concrete steps to take his own life rather than thoughts but as i said easy to get it right with hindsight

  2. Why do those patients even show their suicidal means such as the noose or the tablets? If they are removed from them, won't they be able to just replace them? For someone who wishes to commit suicide, the most effective way to do it would be to never alert anyone, not let anyone see the means they intend to employ, and if asked anyway, insist that no, they do not wish to kill themselves and would never do something like that. If this is someone who attempted suicide in the past, s/he can say that it was a terrible experience and s/he doesn't want to go through that ever again. The nurses weren't going to search through the man's belongings, so the easiest way for him would have been to just not have the noose out in the open during the visit, that's all. He could have put it right back after they left.

    1. That's a good point Monica. Can we therefore see the noose in plain sight as a "cry for help" and the workers' decision not to remove it as a failure to answer that cry?

      As is always the problem with cases, we lack anywhere near the level of information required to make a clear, precise argument or to judge the actions of the people who were actually there. We do not know the service user, let alone their actual mind and thought process (it's difficult enough for me to know what my girlfriend is thinking at the best of times and she is far from suicidal!) nor do we know the thought process of the workers fully which makes it all very difficult, nigh impossible.

      That said, I think I'd have to go with my gut on this one. Regardless of any protestations, law or directive, if I came across the situation described I would remove the noose. At the very least, since the SU had claimed they wouldn't "do it" I'd try and talk them around to removing it themselves. I think the workers have been punished because they didn't do enough and on the face of it I am inclined to agree.

    2. It is possible to be suicidal and very serious about attempting suicide but also not want to. It's such a mistake to think that if you're in a crisis that you absolutely must 100% want to die to be a serious risk.

      That's one of the most painful things, being desperate to die and also not to die at the same time, and just experiencing this building pressure of confusion where really it could quite likely go either way because feeling suicidal, the loneliness of that, in conjunction with the original set of feelings, is enough to tip contemplation into action.

      Nothing about suicide is black and white.

    3. I really ppreciate your thoughtful and heartfelt comment, Anonymous.

    4. And thank *you* for the acknowledgement

  3. Julia, 26th May 2013,

    I have been a Psychiatric Nurse and also have Bipolar Disorder. However, putting my mental health problems to one side, if I had made that visit then regardless of rules, I could not have left this situation without initiating an assessment/MHA or ensuring the immediate safety of this gentleman with whatever means I had at my disposal. It is both morally and ethically negligant not to take action and to rely on the individual not to take his own life after he stated his intent and visibly displayed how he was going to carry this out. He asked for help for a reason and that reason was that he did not trust himself at that time. A chat with Crisis workers was not enough.

    I have experienced severe depression and have been detained re the MHA and looking back if I had not been detained at that time I would have taken my own live. Self determination is important to me but when depression alters someones perception and they experience such distress, hopelessness and with no other way as to end it all then surely it not right not to intervene. After 1 month I was able to resume my life as an independent person and was thankful for the help I received at that time. It was also a very astute worker who took the decisions.

  4. Anonymous, well said.
    Monica, you idiot, read and learn. It wasn't a 'cry for help' (although that very notion is shit) - HE SUCCEEDED IN ENDING HIS LIFE THE NEXT DAY.
    A 'cry for help' can be a last resort before going through with suicide.

  5. I agree butterflywings, my eldest son took himself to a and e 2 weeks ago saying he was feeling suicidal and wanting to end his life, he told them his gp wouldn't give his prescribed meds because he was suicidal. So he got admitted then sent to a mental health assessment unit, they discharged him telling him he was just attention seeking. 3 DAYS LATER HE TAKES 20 OF HIS PRESCRIBED ANTI SYCOTIC meds, again admission, but docs tell him 20 is not enough, so yet again its just attention seeking, despite having a serious sycotic mental illness.
    Yes he is crying for help desperately, but now hes at the stage where hes going to complete suicide, ive called a million people in health care but no one is experienced enough to have any idea on how serious mental health is.
    Sadly I know I will be writing here and on every mental health site about my sons death, im just his mum, his life long carer but I just cant prevent his death. I cry for help means one day a person succeeds in suicide, wether on purpose or by mistake, ive only ever met London experts in mental health

  6. Sometimes when suicidal thoughts are so intrusive and completely overwhelming what you cling on to are signs that you should stay alive. Even if it's just for the next hour, until daylight, until the terror of life subsides a bit. What 'professionals' call a cry for help I call testing the universe to see if I should stay alive.

    If I have shut down to the extent that MH workers are visiting me then what they say/do in response to my distress- even when non verbalised- takes on a significance that cannot be underestimated. Crisis teams vary but I and many others have been told 'why dont you just do it then' by workers and left with that hanging in the air.I wont see them now as it is such an unsafe service in this area. The Samaritans either on the phone or face to face have the compassion, skills and training that crisis workers need. And that includes supporting people with very complex problems.

    This man was desperate. So desperate for a sign to carry on that he communicated by leaving a noose in place. By walking away it reinforces every feeling of non worth you have when there is serious suicidal intent. Attention seeking? SO WHAT. we are human beings needing attention and he certainly needed someone to pay attention to his mental health on that day.