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4 th Annual Forum Wednesday 2 nd September 2009 Royal Hospital Kilmainham “Suicide Prevention – Working Together”. Implementation of a Suicide Support and Information System: a pilot study. Dr Ella Arensman, Dr Carmel McAuliffe, Eoin O’Shea, Dr Paul Corcoran, Eileen Williamson

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4th Annual Forum


2nd September 2009

Royal Hospital Kilmainham

“Suicide Prevention – Working Together”

implementation of a suicide support and information system a pilot study

Implementation of a Suicide Supportand Information System:a pilot study

Dr Ella Arensman, Dr Carmel McAuliffe,

Eoin O’Shea, Dr Paul Corcoran,

Eileen Williamson

National Suicide Research Foundation

2nd September 2009

The study has been commissioned by the

National Office for Suicide Prevention


Research priorities NSRF in line with priorities of Reach Out The National Strategy for Action on Suicide Prevention,


- Suicide risk identification

- Standardisation of suicide

bereavement support


ca 500 p.a.

  • - Standardised assessment
  • of DSH
  • Efficacy of treatments
  • for DSH patients
  • -Restricting access to means


self harm

medically treated

ca. 11,000 p.a.

- Evidence based

mental health


“Hidden” cases of

Deliberate self harm

ca. 60,000 p.a.

suicide support and information system a pilot study objectives
Suicide Support and Information System: a pilot-studyObjectives
  • Improve provision of support to the bereaved
  • Better define the incidence and pattern of suicide in Ireland
  • Identify and better understand causes of suicide
  • Identify and improve the response to clusters of suicide, filicide-suicide and familicide

The objectives are in line with Reach Out, the Seventh Report of the Houses of

the Oireachtas Joint Committee on Health and Children, and the Form 104 Report


Scoping exercise 2006

  • Literature review
  • Consultation with relevant agencies and professionals:

- Coroners

- Department of Justice


- Gardai

- National Confidential Inquiry into Suicide and

Homicide, Division of Psychiatry, University of


- National Drug-Related Deaths Index, HRB

recommendations based on scoping exercise
Recommendations based on Scoping Exercise
  • Need for more information on risk and protective factors associated with suicide in general and for specific groups in Ireland, e.g.

- deliberate self harm patients

- psychiatric inpatients

- psychiatric patients recently discharged from in-patient care

- marginalised groups / those from an ethnic minority

  • More information is required on clusters of cases of suicide, filicide-suicide and familicide
  • Coroner service should be linking in more closely with bereavement support services to facilitate support to family members and friends
  • In some cases lack of information to determine verdict of suicide / accident / homicide
  • Currently still many pressures - not to include the verdict of suicide – (from gardai, family members due to stigma around suicide). Suicide cases involving single RTA’s may be underestimated
  • A minority of people who died by suicide (ca. 24%) were known to be in contact with mental health services in the year prior to their death.

In obtaining a complete picture of suicide cases it is therefore important to also involve other health care professionals and agencies, e.g. coroners, GPs, gardai; and also family members or friends.


Obtaining a more complete picture of the suicide case using relevant sources of information



Coroners’ verdict records & Post mortem reports


Close family members/friends

suicide support and information system a pilot study a stepped approach september 2008 may 2010
Suicide Support and Information System: a Pilot-Study – a stepped approach(September 2008- May 2010)

Inquest concluded

involving cases of

suicide /other sudden


Step 1- Support:

SR facilitates

support for families

bereaved by suicide /

other sudden deaths

after conclusion of inquest

Step 2 - Research:

SR will approach

next of kin and health

care professional(s)

after conclusion of


SR: Senior Researcher

screening for possible cases of suicide case finding criteria
Screening for possible cases of suicideCase finding criteria
  • Sudden deaths recorded as open verdicts, drownings and single vehicle road traffic accidents
  • Screening criteria:

- Explicit verbal or nonverbal expression of suicide intent

- Inappropriate or unexpected preparations for death

- Expression of farewell, desire to die, hopelessness, great

emotional or physical pain

- Precautions to avoid rescue

- History of deliberate self harm acts or threat

- Serious depression or mental health problems

- Stressful events or significant losses


et al, 1988

Often insufficient evidence is available to determine a verdict of suicide / accidental death

Information to be obtained from Coroner Service after conclusion of inquest:Verdict records and post-mortem reports - Checklist

Core data items:

  • Socio-demographic information
  • Information on cause of death
  • Presence of suicide note / text message
  • Mental health problems
  • History of non-fatal suicidal behaviour (deliberate self harm)
  • Physical illness
  • Treatment history: in/outpatient care
  • Alcohol and drug abuse
  • Use of medication
  • Toxicology results in relation to alcohol, drugs and poisons
  • Suicide / deliberate self harm by family members / friends
  • Events leading to suicide / probable suicide: Background stressors and precipitating events
After appropriate support has been provided, a family member will be invited to participate in a semi-structured interview*

Core data items:

  • Situation around time of death / events leading to death
  • Presence of suicide note / text message
  • Family and personal history
  • Life events and history
  • History of non-fatal suicidal behaviour (deliberate self harm)
  • Suicide / deliberate self harm by family members / friends
  • Treatment history in the year before death: in/outpatient care, number of psychiatric admissions, compliance with treatment
  • Physical illness
  • Alcohol and drug abuse
  • Social network

*According to guidelines based on

psychological autopsy studies


Information to be obtained from health care professionals who had been in contact with the deceased within 12 months prior to death – Semi-Structured Questionnaire

Core data items:

  • Socio-demographic information
  • Information on cause of death
  • Presence of suicide note / text message
  • Events leading to suicide / probable suicide: Background stressors and precipitating events
  • History of non-fatal suicidal behaviour (deliberate self harm)
  • Family and personal history
  • Mental health problems
  • Physical illness
  • Alcohol and drug abuse
  • Treatment history: in/outpatient care, number of psychiatric admissions, compliance with treatment, recently discharged
  • Use of medication
  • Final contact with services prior to death: estimate of immediate suicide risk, estimate of long term suicide risk, suicide thought to be preventable
  • Additional information
  • Additional information
progress so far
Progress so far
  • 2007/2008: Consultation with Coroners in Co. Cork
  • Dec 2008: Approval Coroners Society Ireland
  • Jan. 2009: - Ethical approval

- Training workshop with Coroners and their


  • Feb 2009: Start pilot study in collaboration with Coroners in Co. Cork
  • Data collection Type 1: Inquests between Sept ’08 – March ’09
  • March 2009: Start data collection Type 2: Inquests between March ’09-April ‘10
  • 6 out of 73 (8.2%) persons indicated that they did not wish to be further approached after having received the first letter.
  • Referral to bereavement support after conclusion of inquest out of N=67:

- Yes: N=17 (25.3%)

- No: N=21 (31.3%)

- Remainder N=35, the majority of those who have only recently been contacted, and those who are not applicable (e.g. misadventure, non-English speaking, inquest not finalised).

  • 17 interviews completed so far (Non-response: 12 refusals i.e. individuals who refused interview or who did not respond to follow-up calls). A further N=36 are in progress (contact ongoing).
  • Interdisciplinary approach: Collaborative structure including Coroners, GPs and mental health care professionals, Gardai
  • Legislation: Submission to New Coroners Bill by the NSRF is currently being considered
  • Following a local pilot study, development of a National Suicide Support and Information System

For further information contact:

Dr Ella Arensman

National Suicide Research Foundation

1 Perrott Avenue

College Road


T: 021 4277499

F: 021 4277545

E-mail: [email protected]


4th Annual Forum


2nd September 2009

Royal Hospital Kilmainham

“Suicide Prevention – Working Together”


4th Annual Forum


2nd September 2009

Royal Hospital Kilmainham

“Suicide Prevention – Working Together”


The NOSP Forum

Royal Hospital,



2nd September, 2009

Organising Nationally:

Living Links

Michael Egan, Living Links


The presentation will look at Living Links -

  • As a Local Community Response Initiative
  • Its Purpose & Objectives
Living Links was first established in May 2002 in Cloughjordan, Co. Tipperary.
  • It was established by a small group of local people in direct response to a suicide in the community.
  • This suicide death was tragic and devastating for people in the community.
  • There was a huge sense of inadequacy on how to respond and to provide appropriate community support and a consequent sense of failure as a community.
Declared Purpose & Objectives:
  • To provide a voluntary listening, support and outreach service to those bereaved by suicide
  • To increase awareness and understanding of suicide and its effects on individuals, families and communities
To liaise and provide families with information on relevant health services available in their own communities and in the region, and the referral pathways to such services should professional advice and support be required.
  • To provide practical help, advice and support to the bereaved and to have this help immediately available to people in their own communities.
To provide and facilitate a group healing programme, on a needs basis, for the suicide bereaved
  • To encourage the suicide bereaved and/or suicide affected to establish and foster an ongoing support group among themselves
To liaise and exchange information with similar support groups nationally and internationally
  • To support and encourage relevant research
  • To produce leaflets and associated literature to be provided to survivors
When invited, the outreach worker can provide information and practical support on the following:

The funeral

The inquest


What to say to children

How to deal with the neighbours

Help the person to clarify their personal grief

Connect the person to other support services in their area

Provide information on suicide and attempted suicide

Be there, as a friend, for the person.


Establishing a Living Links Committee?

  • First Steps
    • Form Local Committee (6 members)
    • Select a Co-ordinator
    • Select volunteers for training (25 – 30 max)
    • Decide Training Venue & Dates (3 days)
    • Volunteers must participate in the Living Links training Programme
    • Form a Panel of Volunteers (Interview)
ASIST Training (Applied Suicide Intervention Skills Training)

Maintain an up to date register of trained volunteers

Insurance – Professional Indemnity/Public Liability

Telephone Line - Access

Recording of Contacts by Co-ordinator

Supervision for Volunteers

Committee & Volunteer Meetings

Living Links active in the following counties -

Kerry & Clare

Tipperary North, Cork East & Limerick

Wicklow & Meath



Midlands – Longford/Westmeath; Laois/Offaly



Committees most recently established –

West Cork, Strabane, Co. Tyrone,

Total of 15 Committees.

Committees planned -

North Cork, Coleraine, Co. Derry, Mayo, Swords, Co Dublin, East Galway.

Training -

Blanchardstown, Dublin. 8th, 9th and 11th September, 2009.

Tipperary North 087 9693021

Cork East 087 1370792

Meath 046 9021407

Clare 086 0565373

Limerick City & County 087 7998427

Kerry 087 9006300

Galway City & County 067 43999 (Provisional)

Wicklow 01 2868413

Donegal 087 9286007

Sligo/Leitrim 086 3999029

Midlands 086 1600641

Roscommon 086 0311888

Cavan 086 0235414

National Committee Office -

5 Lower Sarsfield Street,


Co. Tipperary.

Phone: 067 43999 or 087 4122052

Email: [email protected]


Patron: Daniel O’Donnell


4th Annual Forum


2nd September 2009

Royal Hospital Kilmainham

“Suicide Prevention – Working Together”


Suicidal behaviour among people who resided in industrial schools as children:A ‘forgotten’ risk group

Ms Martina O’Riordan, Dr Carmel McAuliffe

& Dr Ella Arensman

National Suicide Research Foundation

This study was commissioned by the National Office for Suicide Prevention

timeline of events
Timeline of Events
  • 1868-1969: 105,000 children in industrial schools
  • 1934: Cussen report
  • 1970: Kennedy report
  • 1984: Responsibility for these children transferred from Department of Education to Department of Health…and to foster care
  • 1999: An Taoiseach’s apology on behalf of the state
  • 2000: Establishment of Commission to Inquire into Child Abuse
  • 2002: Establishment of Residential Institutions Redress Board
  • 2009: Report of the Commission to Inquire into Child Abuse

(Source: CICA Report, 2009; Raftery & O’Sullivan, 1999; SI 358, 1983)

  • To examine the association between institutional child sexual abuse and suicidal behaviour.
  • To examine suicide risk and protective factors among people who resided in industrial schools.

Phase 1

  • I) literature review of institutional child sexual abuse and suicidal behaviour.
  • II) consultations with survivors of abuse in Irish industrial schools.
  • III) interviews with frontline staff and directors of specialist support services.
part i literature review
Part I: Literature Review
  • Major Outcomes

-There is a lack of studies addressing the relationship between institutional child sexual abuse and suicidal behaviour and related mental health difficulties.

-Studies focusing on the consequences of child sexual abuse in general reveal consistent evidence for an association with adult suicidal behaviour, in particular non-fatal, as well as suicidal thoughts (e.g. Ystgaard et al, 2004;

Roy, 2004; Esposito & Clum, 2002; Brodsky et al, 2001; Molnar et al, 1998).

part ii consultation with survivors
Part II: Consultation with Survivors


6 group meetings + 4 individual meetings = ca. 90 participants


  • Situation at time of deliberate self-harm or suicidal thoughts
  • Factors related to the abuse experience
  • Complaints procedures, inc. Redress Board
  • Mental and physical health issues
  • Available support & contact with health professionals
part iii qualitative study
Part III: Qualitative Study
  • Objectives

-To investigate referral procedures and treatment approaches provided by the National Counselling Service (NCS).

-To obtain information on factors associated with risk of suicidal behaviour as well as protective factors through interviews with health care professionals in the NCS.

risk and protective factors for suicidal behaviour identified by the specialist support services
Risk and Protective Factors for Suicidal Behaviour identified by the Specialist Support Services
phase 2 case control psychological autopsy pilot study
Phase 2: Case-control Psychological Autopsy Pilot Study
  • Objectives

To compare suicides to a control group of people currently living who resided in institutions as children on the prevalence of mental and physical health problems and negative life events.

  • Methodology

Semi-structured interviews with former residents of institutions and with the families of former residents who have died by suicide. Completion of questionnaires by health care professionals of former residents who have died by suicide.

phase 2 pilot study
Phase 2 : Pilot Study

Sample size:

Min. 10 participants in each of the 3 groups (control; family informants; health care professionals)

 Min. 30 participants


Control group interviews completed; informant interviews to be completed

Data items:

Socio-demographic characteristics, traumatic life events, child sexual abuse, psychiatric disorders, self-esteem, use of alcohol and drugs, contact with health care services.

demographic characteristics 11 pilot study control participants
Demographic Characteristics:11 Pilot Study Control Participants

Gender M:7 F:4

Age 56.6 years (47-75)

F:55 (47-58); M:57 (50-75)

Marital Status Divorced/Separated:5


Education Primary/None:4

Age at entry to Industrial

School (mean) 4.5 years (3 months- 12 years)

Have children 9

reported sexual abuse among pilot control participants
Reported sexual abuse among pilot control participants

Age abuse started: 8.9 years (7-11)

Age abuse ended: 14 years (9-22)

No. with more than 1 perpetrator: 8

Total group

Adult perpetrators: 8

Peer perpetrators: 5

Both: 3

deliberate self harm reported by pilot control group participants
Deliberate Self-Harm reported by Pilot Control Group Participants

History of previous DSH 3

No. episodes 5.7 (1-11)

Most recent episode

Medical Treatment 0

DSH by Models 4 (e.g. brother/sister, children,other relatives)

influential life events reported by pilot control group
Influential Life Events Reported by Pilot Control Group

Based on the transcribed information, the negative

impact of life in the industrial school was a recurrent item

conclusion s
  • Although abuse by adults has been highlighted in previous research, the preliminary results from the pilot study reveal the importance of further research into abuse by peers.
  • Despite the high levels of physical, emotional and sexual abuse experienced, the prevalence of DSH amongthe control group is relatively low.
  • Findings from the pilot psychological autopsy study are consistent with the results of the qualitative study in identifying the nature of protective factors for those who resided in industrial schools as children.
Contact details:

Martina O’Riordan

National Suicide Research Foundation

1 Perrott Avenue

College Road


T: 021 4277499

E-mail: [email protected]


4th Annual Forum


2nd September 2009

Royal Hospital Kilmainham

“Suicide Prevention – Working Together”


H.S.E. – SouthRegional Suicide Resource OfficeBereavement Counselling Service for Persons Bereaved by Sudden Traumatic Death

  • Bereaved by Suicide
  • Road Traffic Accident
  • Drowning
  • Industrial Accident
  • Agricultural Accident
  • G.P.
  • Psychiatrist
  • Psychologist
  • Social Workers
  • E.A.P. of HSE
minimum requirement
Minimum requirement
  • Accredited Counsellors
  • Undergo supervision
  • Garda Clearance
  • Professional and public liability insurance cover
general information
General Information
  • Since August 2006, there have been 93 appropriate referrals to the service.
  • Doctors etc who have referred persons who do not come under the remit of the service (persons bereaved through cancer, cot death, brain haemorrhage, under-age etc) have been given information on the relevant support services for those persons in their area.
  • Initially there were 9 Counsellors in 4 areas (not including Carlow), however that is now down to 6 Counsellors in 2 counties (Waterford & Wexford)
average age of clients
Average Age of Clients

Due to differences in the type and amount of data sought from referral sources over the last 3 years, we do not have the DOB for every client. However, we do have ages for 77% of clients (72) that have been referred for counselling and the following figures reflect this.

  • The average age for female clients is 38
  • The average age for male clients is 37
  • In general, clients within the age bracket 30-39 are the most commonly referred to the service
  • The most commonly referred age bracket for males is the 30-39 age group, for females it’s the 20-29 age group
  • The least commonly referred clients are those under 20 and over 70
referral trend by month
Referral Trend by Month*

* August 06 – August 09

counselling hours
Counselling Hours
  • There were 80 referrals received between August 2006 and December 2008.
  • During this period there was a total of 529.5 hours of counselling given to these clients
  • 83.5 hours of counselling were given in 2006 – 17 referrals
  • 280.5 hours of counselling were given in 2007 – 42 referrals
  • 165.5 hours of counselling were given in2008 – 21 referrals
crisis responses south east
Crisis Responses – South East

The Regional Suicide Resource Office provided an immediate response to the following tragedies;

  • Enniscorthy, Co. Wexford, 2002 – Suicide Cluster
  • Monageer Tragedy, 2007 - Familicide
  • Dunmore East, Waterford, 2007 – Trawler Drownings
  • Clonroche, Co. Wexford, 2008 - Familicide
following review eligibility
Following Review eligibility
  • Bereaved by Suicide
  • Road Traffic Accident
  • Industrial Accident
  • Agricultural Accident
  • Drowning
  • Self Referral
  • G.P.
  • Psychiatrist
  • Psychologist
  • E.P.A. of HSE
  • Liaison Mental Health Staff
  • Comhar Adult Counselling

4th Annual Forum


2nd September 2009

Royal Hospital Kilmainham

“Suicide Prevention – Working Together”

role of the suicide resource officer

Role of The Suicide Resource Officer

Garreth Phelan

Mental Health Promotion/Suicide Resource Officer

HSE Dublin North East

purpose of post
Purpose Of Post
  • Co-ordinate and implement national suicide prevention strategy
  • To enhance resilience across all population groups around mental health with a specific focus on vulnerable and at risk sectors.
  • Consultation with statutory and non statutory organisations working in the area of suicide prevention, bereavement support and deliberate self harm.
  • Support and co-ordinate high quality research in relation to suicide and to translate research findings into action
purpose of post1
Purpose Of Post
  • Support stigma reduction
  • Advocate for the development of and access to mental health services within primary care, crisis intervention services and bereavement services
  • Support, co-ordinate, and develop appropriate training in mental health promotion and suicide prevention.
  • To draw strategic guidance from the range of policies/strategic documents.
principal duties and responsibilities
Principal Duties and Responsibilities

To develop a population health approach whereby mental health is improved

over the entire lifecycle encompassing both individuals and communities.

To develop coping mechanisms to address challenging life events e.g.

bereavements, loss, family issues.

This is done within:

  • Health Promotion
  • Community Setting
  • Health Care Setting
  • Research
  • Health Literacy
  • Education &Training
mental health promotion
Mental Health Promotion
  • Develop and progress mental health promotion by developing evidence based programmes and interventions aimed at strengthening individuals, strengthening communities and reducing structural barriers to mental health
  • General Mental Health Promotion Programme
community setting
Community Setting
  • We aim to establish, distribute and maintain a directory of appropriate community & voluntary groups who are providing services in relation to mental health, suicide and parasuicide.
  • We liaise with and establish networks between the HSE, community and voluntary groups which are currently providing services and supports in mental health, suicide and parasuicide, whilst respecting the specific ethos of each group.
  • We aim to enhance the capacity of all groups working in this area through training, support, establishment of best practice procedures/methodologies
health care setting
Health Care Setting
  • Cooperate with all other health and social services on the issue of suicide to promote the prevention of suicide and re-orientate the service to reduce the risk of suicidal behaviour amongst high risk groups and vulnerable people.
  • Act as a resource person and catalyst to enable others to work effectively in reducing suicide and Para suicide in line with standardised evidence based practice.
health literacy
Health Literacy
  • To enhance health literacy across all sup-population groups around positive mental health and suicide prevention and the development of appropriate resources.
  • To promote research and local needs assessment relating to suicidal behaviour in line with the NOSP National research strategy.
  • To develop appropriate evaluation tools by which outcome/impact effectiveness of initiatives can be measured.
  • To create a dynamic whereby intervention’s and programmes are re-aligned with research/needs assessment findings.
education training
Education & Training

SafeTALK is half day training for community groups, to enable participants identify the signs of a person with thoughts of suicide and know how to support them.

ASIST is a two-day skills based course which trains participants to recognise and respond to a suicidal risk. The course provides opportunities to learn what a person at risk needs from others in order to keep safe and get further help.

To oversee the implementation & monitoring of a regional training strategy on suicide prevention and mental health promotion in line with National training strategy

information education training suicide prevention
Information, Education & Training: Suicide Prevention

“Layered Approach” Learning

  • Suicide Prevention Awareness Training
  • safeTALK identify persons with thoughts of suicide and connect them to suicide first aid resources
  • ASIST (Applied Suicide Intervention Skills Training)
  • Gatekeeper Training

The approach taken to suicide prevention is based on recommendations by the WHO and combines

    • a whole population approach
    • a more targeted approach aimed at those individuals who have particular vulnerabilities
    • support to individuals and communities bereaved by suicide
  • Evidence suggests that community based programmes can be effective in reducing suicidal behaviour
national strategy responding to suicide actions
National Strategy: Responding to Suicide (Actions)
  • To provide support following a suicide:
  • Audit and review support services
  • Develop standardised bereavement support services
  • Determine the information needs of those bereaved
  • Support national organisations to work together
  • Develop critical incident response protocols
key messages
Key Messages
  • Develop a help seeking culture, creating an understanding of but taking care not to normalise suicide
  • Not to miss the moment when someone is saying something important
  • Suicide Prevention is everyone’s business
‘Reducing suicide rates requires a collective, concerted effort from all groups in society; health, social services, other professionals, communities and community leaders, voluntary and statutory agencies and organisations, parents, friends, neighbours and individuals. It also requires the careful nurturing of a culture in which people in psychological distress don’t hesitate to seek help’

Remarks by President Mary McAleese

at the World Congress of Suicide Prevention - Killarney in August 2007


4th Annual Forum


2nd September 2009

Royal Hospital Kilmainham

“Suicide Prevention – Working Together”


4th Annual Forum


2nd September 2009

Royal Hospital Kilmainham

“Suicide Prevention – Working Together”

Rural Stress Line

Brenda Crowley

Regional Suicide Resource Officer

HSE South

1800 742 645


4th Annual Forum


2nd September 2009

Royal Hospital Kilmainham

“Suicide Prevention – Working Together”