Standard Operating Procedure Self-Harm and Suicidal Ideation · SOP Self-Harm and Suicidal Ideation...

G4S Health Services (UK) Ltd

SOP Self-Harm and Suicidal Ideation v 1.01 2016 1

Standard Operating Procedure Self-Harm and Suicidal Ideation


Self-Harm and Suicidal Ideation

For Completion by SOP Lead

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G4S is committed to ensuring that, as far as is reasonably practicable, the way we provide services to our patients and the way we treat our staff reflects their individual needs and does not discriminate against individuals or groups on any grounds. This SOP has been assessed accordingly

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Document Author(s) Stephen Dolphin

Document Reviewer(s) Dr Asha Simmons


CONTENTS 1. INTRODUCTION ............................................................................................................................ 4

1.1 Self-Harm and Suicidal Ideation ............................................................................................ 42. PURPOSE ...................................................................................................................................... 43. SCOPE ........................................................................................................................................... 44. DEFINITIONS and DESCRIPTIONS .............................................................................................. 5

4.1 Self-Harm ............................................................................................................................... 54.2 Suicidal Ideation .................................................................................................................... 64.3 Methods of attempted suicide ................................................................................................ 7

5. DUTIES AND RESPONSIBILITIES ................................................................................................ 76. PROCESS ...................................................................................................................................... 8

6.1 General Considerations ......................................................................................................... 86.2 Obtaining information ............................................................................................................. 86.3 Quantifying risk ...................................................................................................................... 96.4 Advice to Custody .................................................................................................................. 9

7. TRAINING REQUIREMENTS ...................................................................................................... 118. VERSION HISTORY LOG ............................................................................................................ 11Version ................................................................................................................................................ 119. Appendix 1 – Previous Suicide Attempt Intent Score ................................................................... 1210. Appendix 2 Training Record ......................................................................................................... 13


1. INTRODUCTION

1.1 Self-Harm and Suicidal Ideation Self-harm and suicidal ideation are related, but are not the same thing.

Large numbers of detainees either shout “I’m going to kill myself” or “I’m going to cut myself” or similar threats, when brought into custody. Quite rightly, HCPs are asked to assess them. These are often empty threats made in the heat of the moment and whilst intoxicated, but nevertheless, the HCP has a responsibility to try to quantify the risk that the threat might be carried through and, if necessary, do something about it.

Similarly, those with a history of self-harm and attempted suicide, and those with a history of depressive or personality disorders, either disclosed on Risk Assessment or by reference to the Police National Computer warning markers are seen, with a view to an assessment of the risk they pose to themselves or anybody else.

In addition to the above, whilst assessing all detainees that pass through the medical room or are seen in the cell or elsewhere, it is also the responsibility of the HCP to determine if there is a risk of self-harm or suicidal ideation, either whilst the detainee remains in custody or on release. This risk needs to be assessed whether there is an explicit or implicit threat or no known threat. All detainees should be assessed for self-harm and suicide ideation, so it isn’t missed. As is noted on the Intent Score sheet, “consider also the quiet, compliant detainee and the inappropriately euphoric detainee”.

Unfortunately, it is impossible to exactly quantify this risk due to the virtually infinite number of variables involved, from the social and psychiatric history of the detainee to the amount of alcohol or drugs they have had that day, and even if they had even a minor personal setback such as missing the bus recently, which may have made them late for work again. Such is human nature that virtually anything could be a trigger to self-destructive behaviour in an individual, particularly a susceptible individual. Most of the time the HCP will have only a vague knowledge of most of these variables.

All the HCP can reasonably do in the setting of Police Custody is to estimate the risk as high, medium or low and recommend reasonable precautions against harm. Unfortunately, these precautions can never be entirely adequate and sometimes a detainee will cause harm to themselves or others. This SOP is designed to minimise the risk.

If the HCP has any doubts about the results of their assessment, the HCP must consult with an FME for advice. If the assessment is made in accordance with this SOP, there should be sufficient information for the FME to give meaningful advice.

2. PURPOSE Given the complexity of the unknowns noted above, the purpose of this SOP is to give guidance on some of the underlying causes and triggers for self-harm and suicide ideation and how to assess them, so that a reasonable quantification of the risk can be made and reasonable recommendations made to the Police.

As was said, sometimes a detainee will cause harm to themselves or others, despite our best efforts. This SOP also gives guidance on recording the assessment, which will aid any subsequent enquiry.

3. SCOPE • This Standard Operating Procedure applies to all Medical Practitioners (FME’s), Nurses and

Paramedics (HCPs), employed by G4S Medical Services (UK) Ltd.

• For the purposes of this SOP, the term HCP includes Nurses, Paramedics and Forensic Medical Examiners (FMEs). Where any part of this SOP is reserved for an FME, the term FME is used.


4. DEFINITIONS and DESCRIPTIONS

4.1 Self-Harm 4.1.1 Definition

Self-harm, also known as self-injury or self-mutilation, is simply defined as an act wherein someone deliberately hurts or injures themselves. Self-injury is most often used as a coping mechanism and is most often not an attempt at suicide. The practice is not limited to teens. Self-harm in adults also takes place and is not unusual.

4.1.2 Types of self-harm The phrase ‘self-harm’ is used to describe a wide range of behaviours. The most common forms of self-harm are cutting the arms, hands and legs, and less commonly the face, abdomen, breasts and genitals. Some people burn or scald themselves, others inflict blows on their bodies, or bang themselves against something.

Other forms of self-harm include scratching, picking, biting, scraping and occasionally inserting sharp objects under the skin or into body orifices, and swallowing sharp objects or harmful substances. There are many ways to hurt yourself, including abusing drugs and alcohol or having an eating disorder. Intoxicants can be seen to remove “the edge” from reality. Smoking is a powerful anxiolytic for some.

4.1.3 Causes of self-harm Self-harm is generally to do with gaining control over anxiety. Physical pain concentrates the mind and can diminish the attention paid by the brain to chronic anxieties. Most of those who engage in self harm will tell you that it helps, at least in the short term, with their anxiety symptoms.

Significantly, self-harm may be a way of a person to “punish” themselves for their past acts, or for abuse by others, which they may have been persuaded was their fault.

There is an association with suicide, in that a percentage of those who complete suicide had a history of self-harm, but it is by no means clear how significant this is, given that we know that over 80% of people who commit suicide have a psychiatric diagnosis.

4.1.4 Adult self-harm Self-harm does not only happen amongst teenagers and young women, but also happens with older, middle-aged females and males.

Adult self-harm is commonly comprised of cutting or burning the skin, or banging one's head repeatedly against a wall. Adult self-harm is often more difficult to treat than that of younger people, as adults may have been self-harming since childhood. The ingrained behaviour, then, may be one of the only ways the adult knows how to deal with stress, one of the major causes of self-harm.

Left untreated, self-harm in adults, and the accompanying psychiatric disorders, can be dangerous. While the majority of people who self-harm are not suicidal, it is easy to accidentally induce a life-threatening wound during acts of self-harm. Adults that self-harm may be at higher risk of this than their younger counterparts due to them having practiced self-harm for some time, often leading to increasing severity to gain significant relief.

As in teens, self-harm in adults may be the result of a severe trauma such as sexual abuse or childhood neglect.

Self-harm in adults may be used to distract from other painful life events. It may also be a release of the emotional pain associated with stressors like marriage problems, work or parenting issues.

Significantly, adult self-harm may also be as a result of ongoing symptoms of psychosis which causes adults to have a break from reality. They may be commanded to hurt themselves. They may hear a voice bargaining with them, telling them that if they don't bang their head 13 times, something bad will happen.

Self-harm could also be a symptom of another mental health problem. Bipolar Disorder, Borderline Personality Disorder and severe Depression and Anxiety can all include the symptom of self-harm.

Traditionally, admonishing people about the consequences of self-injurious behaviour doesn't work very well. The desire for behaviour change needs to come from the patient rather than as a demand from the mental health professional or family members. Group therapy is often helpful, so a referral to a mental health team (either the CJMHT or Community MHT) can be useful.


4.2 Suicidal Ideation 4.2.1 Definition

Suicidal ideation is simply having thoughts about ending one’s life, whether these thoughts are put into some form of action or not.

The aim of suicide is to end life, and therefore it has a clearly different aetiology from self-harm (although it could be viewed as the ultimate control).

4.2.2 Causes of suicidal ideation Naturally, we can know the method, but we cannot fully know the mind-set of the person who commits suicide, even if they leave a note.

It is known that over 80% of people who attempt suicide suffer from mental illness, mostly depression and alcoholism, but also other substance abuse disorders and personality disorders. In most cases, suicide is linked with feelings of hopelessness and worthlessness.

There are many known risk factors for suicidal ideation, but note that 90% of suicides feature the top two factors:

• Depression and other related mental disorders, especially if exhibiting extreme hopelessness, lack of interest in previously pleasurable activities (anhedonia), heightened anxiety and/or panic attacks.

• Alcohol dependency or other substance-abuse disorder (often in combination with other mental health disorders).

• Relationship difficulties (either with an existing partner, or due to divorce, loss of custody of children, being widowed or a relationship break-up). These people are often arrested for breaching non-molestation orders or harassment.

• Prior suicide attempt (one study indicated that anyone who has previously attempted suicide is 100 times more likely to make a successful attempt than the general population).

• Family history of mental disorder or substance abuse.

• Family history of suicide, or exposure to the suicidal behaviour of family members, peers, or media figures. (Social media is increasingly involved).

• Family violence, including sexual or physical abuse (may be current or historical).

• Being in prison (or the imminent likelihood of imprisonment, such as after charge and remand).

• Being arrested or charged with sexual offences, (particularly against children).

• Unemployment (or imminent unemployment, such as following drink-drive charges).

• Issues with education and studies (a major problem for those at university).

• Financial problems.

• Legal problems.

• Social deprivation (especially homelessness).

• Social isolation.

Any one of these factors, or any combination could induce suicidal ideation.


4.3 Methods of attempted suicide Methods vary with age, sex and what is available to the individual. Blades are a common for self-harm, but are rarely used in suicide. Overdoses of medications are a common method of suicide for females, but jumping from heights and hanging are more favoured by males. The difficulties in obtaining firearms makes self-shooting rare, except amongst rural workers, who may have ready access to a shotgun – a highly effective method.

For many people contemplating suicide, there is a real desire to end their lives, but a fear of what their death might feel like often leads to failure. Many attempts are made on the spur of the moment, resulting in failure due to inadequate preparation, such as hanging from light fittings that break or jumping off relatively low bridges or buildings.

The holy grail seems to be a completely painless method of suicide, and people will go to great lengths to find a method that might achieve that. The problem with this is that huge numbers of these attempts fail, as the clean, relatively painless methods are often done in such a way so as to make them less than lethal, such as taking too few tablets or non-lethal tablets. Hence the large numbers of detainees that say they have attempted suicide several times. This does not mean they were not serious attempts and they should not be dismissed out of hand. The point to note is that at some stage in their life, they felt that things were so bad that they attempted suicide, no matter how inept the attempt.

Statistically, for every successful suicide attempt by any method, there are about 33 unsuccessful attempts. Specifically for overdose, the ratio is about 1:40.

Many studies of suicide methods have been carried out. One study asked lay persons and forensic pathologists to rate suicide methods by their lethality, time to achieve the goal and the pain involved. The lay persons tended to drastically overestimate the lethality of the various methods. Jumping from a height and hanging were the most reliable, with over 89% lethality. Overdose and cut wrists were the least lethal, rating only 6% by the forensic pathologists.

Many people end up in hospital requiring treatment for their failed attempt, sometimes with short or long term health implications. Unfortunately, many detainees report that they do not receive a mental health assessment in hospital. A busy and noisy A&E department is not conducive to “opening your soul” to a clinician, so the patient may lie about the causes of their injury.

Many suicide attempts do not result in hospital attendance or any medical care at all, and so may have no chance of mental health assessment. The assessment by an HCP in custody may be the first time they have the chance to receive help and so becomes a turning point in their lives.

5. DUTIES AND RESPONSIBILITIES G4S Health Services (UK) Ltd HCPs have a duty to investigate self-harm and suicidal ideation, with a view to protecting the health and welfare of detainees in Police custody and others.


6. PROCESS

6.1 General Considerations Self-harm and suicidal ideation are part of the Risk Assessment when a detainee is first brought into custody, but this may be too confrontational or emotionally-charged a situation or the detainee may be too intoxicated to elicit a true answer. In addition to this, the risk is not quantified at this stage, just identified, so cannot lead directly to meaningful safeguarding.

Where some risk has been directly identified, or a risk is perceived as possible, either from answers by the detainee, markers on the PNC or the previous knowledge or suspicions of the Police or Detention Officers, detainees should be referred to the HCP for assessment.

Before seeing the detainee the HCP should gather as much background information as possible from previous police records, detention log, crisis team/mental health team/Liaison & Diversion (L & D), arresting officer, family and friends (if knowledgeable to the arrest), CCTV.

The medical room environment should be clear of any objects that can be used as a weapon or to self-harm (hot drinks, stethoscopes, scissors etc. Position yourself between the DP and the exit and be aware of where the panic buttons are.

If possible, carry out a joint consultation with L & D.

It is imperative that HCPs complete a self-harm risk assessment for all detainees that they see, and that this is recorded. If the HCP has any doubt about the assessment of this risk, they should consult with an FME.

6.2 Obtaining information After the HCP has gained consent from the detainee, a normal medical assessment should take place. This assessment may reveal factors that could indicate a risk of self-harm or suicidal ideation, as noted in Section 4 above.

Once any immediate medical needs are satisfied, the HCP should go on to enquire about self-harm and suicidal ideation in a calm and caring manner. HCPs must try to establish a good rapport with the detainee and overcome any negative feelings they might have about self-harm and suicide attempts, and overcome any prejudices about the detainee's motivation. Attempting suicide takes a high level of motivation and should never be dismissed as just attention-seeking behaviour

HCPs need to talk to the detainee, show an interest in them, and ask direct questions, such as:

Self-Harm

• Have you self-harmed recently?

• What have you done?

• How often do you do it?

• What leads you to do it?

• What stops you from doing it?

• Are you thinking of doing it now? Suicidal ideation

• Have you felt as though there is no point in continuing?

• Is tomorrow worth living for?

• Have you ever felt as though life is not worth living?

• Do you feel that way now?

• Have you considered taking your own life?

• CRUCIALLY – What has stopped you?


The HCP needs to consider; • Protective factors that are present, which include children and other dependants, pets,

upcoming life events, continued employment, an expectancy that things will improve (Hopefulness).

• Protective factors that have been removed by recent events, such as the arrest or the events that led to it, divorce, separation, loss of livelihood. (Hopelessness).

Always obtain as much detail of the detainee’s psychiatric history as possible, and ask about alcohol and drug use over the last few days and in general, remembering that depression, personality disorder and substance abuse are common triggers for self-harm and suicidal ideation.

It may be helpful, if possible, to speak to relatives or friends of the detainee, or to Community or Hospital Mental Health Teams (with the consent of the detainee) to learn more of the history.

6.3 Quantifying risk The risk of self-harm and suicide posed by a detainee can only realistically be assessed as “low”, “medium” or “high”.

This classification is based on how the detainee seems to the HCP, any threats or promises made, any past history and an assessment of the factors likely to influence their behaviour, as outlined in Section 4 above.

If the detainee has recently made an attempt at suicide, the Previous Suicide Attempt Intent Score shown in Appendix 1 (adapted from Beck et al) can be completed to give a little more evidence of what to expect. Unfortunately, once again, it can never be completely accurate. It should be used only as additional information to guide the assessment, not solid evidence. If used, it should be recorded.

The Score can also be used to give some guidance to the HCP on assessing the influences at play in any detainee as they contemplate self-harm or suicide.

6.4 Advice to Custody 6.4.1 Referral and Observations

Custody staff will ask to have a recommendation of the precautions to take with any detainee who is seen as posing a self-harm or suicide threat. The level of observation undertaken is a decision for the Custody Sergeant, but they will ask for advice based on the assessment by the HCP.

Whether the detainee is referred elsewhere, such as to the CJMHT or to the FME for additional assessment with a view to a Formal Mental Health Assessment, is a decision for the HCP, guided if necessary by advice from an FME.

As a general guide, in the absence of any other factors, such as intoxication, the recommended precautions to take for a given perceived level of self-ham risk are as follows:

Low risk

• If the detainee has contact with the Community Mental Health Team, they should be advised to make contact with them in the first instance. Alternatively, they should see their GP at the earliest opportunity. Failing these two options, the detainee should be seen by the CJMHT as soon as available.

• General Observation is likely to be sufficient, unless there are other factors in play that give rise to concern.

Medium Risk

• HCPs should discuss the case with the FME. The detainee will probably need to be seen by the CJMHT at the earliest opportunity.

• Constant Observation via CCTV should be considered until seen by a Mental Health Practitioner. The detainee should be provided with safe clothing, such as a “Self-Harm Suit” and safe bedding. The detainee will also need to be visited at irregular intervals.


High Risk

• HCPs must discuss the case with an FME. The detainee may require an additional assessment by an FME with a view to Formal Assessment to determine the need for either voluntary admission or admission under a Section of the Mental Health Act.

• Close Proximity Observation should be discussed with an FME or a Mental Health Practitioner. The detainee should be provided with safe clothing, such as a “Self-Harm Suit” and safe bedding.

6.4.2 Mental Capacity Being at risk of self-harm or suicidal ideation does not necessarily mean that the detainee lacks capacity. Although a way of thinking that is difficult for some to understand, their desire to harm themselves may be well thought out. The normal assessment of the four components of capacity must still apply, as follows:

A person is able to make a decision if they can:

• Understand the information relevant to the decision if it is explained in a way appropriate to their circumstances

• Retain that information in their mind (for long enough to make the decision)

• Use or weigh that information as part of the process of making the decision (can the person appreciate the consequences if they make the decision or if they do not make the decision)

• Communicate the decisions (whether by talking, using sign language or any other means)

The G4S SOP “Mental Capacity and Refusal to Consent” details the assessment process.

An online tool is available from the GMC to assist with this assessment and can be accessed and used at; http://www.gmc-uk.org/Mental_Capacity_flowchart/

There may be a question of the public interest in detaining or charging a detainee who does not have mental capacity, which should be discussed with the FME and then discussed with the Custody Sergeant. If there is a difference of opinion on this, Social Services can also carry out a Capacity Assessment.

6.4.3 Fitness to detain Unless the detainee is in a state of excited delirium, or so intoxicated that they cannot walk and talk unaided, most detainees of this type are Fit to Detain. Self-harm and suicidal ideation are not generally cause for referral to A&E, although it may be required for illness or injury from self-harm or attempted suicide or other medical problems.

If the detainee is being detained under Section 136 of the Mental Health Act, the HCP will asked to make a “welfare check”. This should involve ruling out organic causes and providing any acute medical (not mental health) attention. Custody staff will have contacted the Mental Health Team for a mental health assessment by a doctor and an AMHP.

6.4.4 Fitness to be interviewed / Charged Detainees deemed to be of low risk of self-harm and suicidal ideation will generally be deemed to be fit to interview unless other factors are in play that give cause for concern.

Those of medium and high risk will need to be seen by a Mental Health Practitioner before interview or charge as there may be some doubt about their mental health and capacity. Mental; Health Services do not provide advice on fitness to interview, so the Custody Sergeant may call for a further assessment by the HCP.

6.4.5 Appropriate Adult An Appropriate Adult is required for any detainee that is “mentally disordered” or “mentally vulnerable”, except those detained under S.136 of the Mental Health Act 1983, who are specifically excluded by PACE Code C. 3.16.

Those presenting a low risk of self-harm and suicidal ideation will not generally require an Appropriate Adult, unless they are required for other reasons, such as age or learning disability.

Those of medium and high risk may require an Appropriate Adult as there may be some doubt about their mental state and mental capacity, which will need to be assessed.


6.4.6 Safeguarding Safeguarding procedures still apply, although the threshold for referral may be more easily reached with detainees expressing a desire to self-harm or commit suicide. Particular attention should be paid to children and dependents of the adult detainee. If the detainee is a child themselves, the threshold for referral will be particularly low.

6.4.7 Forensic Sampling Care must be taken with detainees of medium or high risk, as informed consent is required. Being of medium to high risk could affect capacity, which will need to be assessed in any case, as noted above.

Detainees deemed to be of low risk of self-harm and suicidal ideation should normally present no difficulties when required to provide forensic samples of any kind, as capacity will rarely be affected.

6.4.8 Risk on release The HCP may be asked to advise on the risk of self-harm and suicidal ideation after a detainee is released, usually on bail.

If the risk has been assessed as low, bail should present no difficulties, as far as mental health and welfare are concerned. However, in cases of harassment and breaches of court orders, caution should be exercised due to the obsessive or compulsive nature of some of these alleged offences.

Greater caution should be exercised with those of medium to high risk, and the advice of an FME or other Mental Health Practitioner should be sought.

7. TRAINING REQUIREMENTS

• All HCPs should become familiar with this Standard Operating Procedure.

• Training will be provided as part of Induction Training, and updated as identified or required.

8. VERSION HISTORY LOG

Version Date Implemented Details of Significant Changes

1.01 24th November 2016 Second Draft

G4S Health Services (UK) Ltd

SOP Children in Police Custody v 1.0 2016 of 13

9. Appendix 1 – Previous Suicide Attempt Intent Score

Previous Suicide Attempt

Intent Score

Isolation:

0. Somebody present 1. Somebody nearby, or in visual or vocal contact 2. No one nearby or in visual or vocal contact

Timing:

0. Intervention is probable1. Intervention is unlikely2. Intervention is highly unlikely

Precautions against discovery / intervention:

0. No precautions1. Passive precautions (as avoiding other person but doing nothing to prevent their intervention; alone in room with unlocked door2. Active precautions (as locked door)

Acting to get help during / after attempt:

0. Notified potential helper regarding attempt1. Contacted but did not specifically notify helper regarding attempt2. Did not contact or notify potential helper

Final acts in anticipation of death (wills, gifts):

0. None1. Thought about or made some arrangements2. Made definite plans or completed arrangements

Active preparation for attempt:

0. None1. Minimal to moderate2. Extensive

Suicide note:

0. Absence of note1. Note written, but torn up; note thought about2. Presence of note

Overt communication of intent before event:

0. None1. Equivocal communication2. Unequivocal communication

Alleged purpose of intent:

0. To manipulate, get attention, get revenge1. Components of above and below2. To escape, surcease, solve problems

Expectations of fatality:

0. Thought that death was unlikely1. Thought death was possible but not probable2. Thought death was probable or certain

Conception of lethality of method:

0. Did less to self than thought would be lethal1. Wasn’t sure if would be lethal2. Equalled or exceeded of thought to be lethal

Seriousness of attempt:

0. Did not seriously attempt to end life1. Uncertain about seriousness to end life2. Wanted to die

Attitude towards living/dying

0. Did not want to die1. Components of above and below2. Wanted to die

Conception of medical rescue:

0. Thought that death would be rescuable1. Was uncertain if rescuable2. Was certain of death even if received medical attention

Degree of premeditation:

0. None - impulsive1. Contemplated for 3 hours or less2. Contemplated for more than 3 hours

Objective Circumstances Self Report

Detainee d.o.b. HCP NameCustody Reference Date Time

Medical Services (UK) Ltd

Case No.

Score Risk Management

0-10 Low Advise to see GP or Community Mental Health Team.

11-20 Medium Discuss with FME. Probable need to be seen by CJMHT at first opportunity. Discuss need for CCTV Observation.

21-30 High Discuss with FME. Probable need for further assessment by FME with a view to Formal MHA Assessment. Discuss need for Close Proximity Obs.

Objective circumstances

Self Report

Score

Total

Consider also:

. The quiet, compliant detainee

. The inappropriately euphoric detainee

. Specific offences such as sexual offences

. The detainee intent on suicide may offer no warning on risk assessmentSelf harm risk may alter during detention:

. High risk in initial detention period

. After interview

. On being charged

. After refusal of bail

In any case where the HCP is uncertain, they must

consult with an FME before proceeding.Consider refusal to engage as high risk if other factors present


10. Appendix 2 Training Record

Details: To be completed by the SOP Controller

Title of SOP

Reference Number Insert SOP Reference Number. xxxxxxx

Version Insert Version

Issue Date Insert Date Issued

Implementation Date Insert Agreed Date for Implementation.

Personnel Details

Name

Job Title & Research Role

Date of Training

Nature of Training Self Directed/Delivered by etc

Records of any meetings to clarify details in SOP

Signatures

I confirm that I have read and consider myself to be sufficiently trained in the above Standard Operating Procedure with regards to my individual roles and responsibilities Signature of Trainee ………………………………………………………… Date ………………………

I confirm training in the above SOP was delivered as recorded above and that the trainee may be considered sufficiently trained in their roles and responsibilities Signature of Trainer …………………………………………………………… Date ……………………… .

Additional Notes & Signatures

Signature of Trainer (where appropriate) I confirm training in the above SOP was delivered as recorded above and that the trainee may be considered sufficiently trained in their roles and responsibilities Signature of Trainer …………………………………………………………… Date ……………………….

Standard Operating Procedure Self-Harm and Suicidal Ideation · SOP Self-Harm and Suicidal Ideation...

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