Self-harming and Suicidal Ideation

The purpose of this advice is to:

• Help all children and young people improve their self-esteem and emotional literacy;
• Education about self-harm for children and young people and adults;
• Prevent self-harm from spreading within the children’s home;
• To have clear guidelines for adults, who needs to be informed, when parents and outside agencies need contacting, helping to reduce the level of uncertainty and stress for practitioners in managing children and young people who self-harm and express suicidal ideation;
• Provide information about reducing the risks of injury or death and ensuring the safety and wellbeing of children and young people;
• Outline the reporting requirements;

Many children and young people who come into the care system have experienced significant trauma in their lives and have often been in highly vulnerable and or unsafe environments. It is likely that these children will sometimes have multiple and complex needs resulting in a range of communication through association with self-harm. These include those who:

• Threaten to self-harm, including threats of suicide;
• Actual self-harm;
• Engage in self-mutilation (self-cutting, blood-letting);
• Express suicidal ideation;
• Attempt suicide;
• Tie, or attempt to tie, ligatures.

In its broadest sense, self-harm describes a wide range of things that people do to themselves in a deliberate and usually hidden way, which are damaging. (Young people and Self-Harm: A national Inquiry First interim Report 2004).

The most important support we can give a child who self-harms is to develop trusting, supportive and engaging relationships with them, alongside

• BEING NON_JUDGEMENTAL Being aware of the stigma associated with self-harm, within the wider society and the health service;
• BEING INCLUSIVE Involving them in decision making about their care and strategies;
• BEING USEFUL Fostering the child’s autonomy wherever possible;
• BEING THERAPEUTIC Maintaining therapeutic relationships;
• BEING KIND Communicate sensitively within and to other team members.

Self-harm, or the threat of, must always be taken seriously. Self-harming should never be dismissed as attention seeking behaviour. It is important to consider the young person holistically. Self-harm is merely one feature of their presentation. Self-harming may not be an immediate response to an incident but may occur later when a young person is alone. Young people may go to great lengths to conceal their self-harm. The reaction a young person receives when they disclose their self-harming can have a critical influence on whether they go on to access support services.

We recognise that adults may have a whole range of feelings about the young person’s self-harming, but they are THEIR feelings, so they need to be careful what is conveyed to the child.  We ask that adults let the child know they are ok with what happened even if they do not feel it.  By avoiding judgement or criticism we know this might make the difference between them opening up and seeking support to shutting down completely.

Given the level of harm that can result from these actions and behaviours, working with and responding to these behaviour requires specific, intensive and strategic planning and prevention. Two major considerations in responding to and managing self-harming behaviours and threats of suicide are harm reduction and duty of care.

Self-harm should be seen as a communication of emotional distress. Whilst it is important that adults tend to any immediate medical need, they must also consider how to respond to this underlying communication. Without doing so, self-injurious behaviour is likely to be repeated. As with many other ways of communicating our children display, for some, self-harm has become a functional strategy of having their needs met. Adults’ responsibility therefore, is to support the child/ young person in finding alternative, more appropriate methods to communicate and have these needs met. Whilst stopping a young person from self-harming may be viewed as desirable, adults must carefully consider the impact this may have on the child/ young person.

Essentially, if we remove their means of communicating this distress (self-harm), without equipping them with an accessible alternative, the child/ young person may find an alternative response, which could be more harmful (more extreme/different methods of self-harm or accidental suicide).

Self-harm is an emotive subject and adults should be aware of the potential impact on those involved and the support available to them (Supervision, Training, Therapy Service).

When dealing with self-harming behaviours the primary concern must be for the child or young person’s immediate safety. However, team members will also need to be proactive in providing the child/ young person with appropriate skills and strategies to understand their underlying needs. They should engage with the child/ young person to consider and educate them in sustainable strategies to reduce or eliminate the self-harming actions.  This can only be achieved through developing positive and trusting relationships between adults and young people which enable them to evaluate and recognise the effectiveness of agreed strategies.

Self-harming behaviours and acts of self-harm by children and young people can have a distressing and traumatic impact on all those involved in ensuring their safety and wellbeing. When working with children and young people who self-harm or are at risk of suicide, adults will be supported to reflect on the impact of such incidents.

To mitigate secondary trauma effects, in situations where any team member is caring for a child who is actively self-harming or suicidal, they should, in consultation with the registered manager, ensure there is a support in place to support them to manage this. This may be possible through systems already in place (supervision, team meetings, Mentalisation sessions) but may also require additional support from other areas of the organisation or external bodies. Consideration needs to be given to the provision of appropriate training and information to adults involved in working with children and young people most at risk of self-harm and suicide.

Where it is known that a young person engages in threats of self-harm/ suicide or actual self-harm, as identified during the matching process and as part of Care Planning, relevant information should be gathered and appropriate analysis of self-harm should be thought about within the child’s safety plan alongside all relevant intervention strategies. This should be completed in consultation with all professionals and services involved and recorded digitally within the child’s safety plan on Clearcare.

This should be regularly reviewed and monitored.

In the case of an emergency move, particular attention should be paid during the initial planning process to any known history of self-harming behaviours.

Involvement of Other Agencies and Professionals

Children and young people who display self-harming or suicidal behaviours may already have involvement with other services that have expertise to offer in addressing or reducing such behaviours, these services should be identified during the initial referral and care planning process. If a child or young person is not involved with such services, practitioners should consider making referrals or seek consultation as part of the placement and behaviour support plans. This may include referrals to therapy service, CYPMHS (CYPMHS) etc.

The involvement of these services on a consultancy basis or as part of the care team in developing intervention strategies and using child therapeutic meetings within the home is essential to attaining the best outcomes for the child or young person involved. It is essential that other agencies and professionals acknowledge that they have a significant role in assisting to formulate intervention strategies and implementing agreed safety plans as part of joint working.

The reasons why children and young people in the care system self-harm are often complex and varied but generally related to a combination of factors which include:

• Past experience of and on-going trauma;
• Significant and continuing stressors in their lives;
• Inadequate or poorly developed emotional or behavioural capabilities;
• Absence of self-care;
• Emerging or diagnosed psychiatric or psychological disorder;
• Lack of appropriate support networks;
• Lack of other coping mechanisms to self-regulate and self-soothe.

The assessment of needs and strengths within the safety plan should include (alongside the safety plan framework)

• Skills, strengths and assets (significant relationships that are either supportive or represent a threat (abusive) and may lead to change;
• Immediate and linger-term worries;
• Coping strategies (the child has used to either successfully limit or avert self-harm or to contain the impact of personal, social or other factors preceding episodes of self-harm);
• Previous threats, attempts or acts of self-harm or suicide/ Preoccupation with or idealisation of self-harm or suicide; (including methods and frequency of current and past self-harm and / or suicidal intent);
• History of self-harm or suicide within the family;
• Psychosocial and occupational functioning, including marked changes in presentation such as depression, mood deterioration (or elevation), high levels of anxiety or unrest, impulsivity / Withdrawal, isolation, separation or alienation from networks such as family, peers, social groups and school;
• Mental health/ physical health problems; depressive symptoms and their relationship to self-harm;
• Social Circumstances and stressors present in a child or young person’s life, including current events and occurrences;
• At discharge from a Psychiatric inpatient unit services;
• Specific risk factors and protective factors (social, psychological, pharmacological and motivational) that may increase or decrease the risk associated with self-harm.

Opportunities should be considered such as:

• Whether there is a plan to self-harm or suicide;
• Where there are means available to carry out self-harm or suicide;
• A significant event or incident occurred with which the child has not coped well with or, in the past has self-harmed as a response to such an event;
• Other factors present which could increase the possibility or desire to follow through with self-harm or suicide, such as access to substances of drugs, involvement with others who self-harm;
• Lack of or reduced contact with important people for the child and monitoring from regular supports;
• Comments indicating an intention to self-harm or suicide.

To formulate the safety plan requires the coordinated and collaborative input of a number of professionals who may be involved or have expertise to offer. In situations where adults are involved with a child who is actively self-harming or suicidal, they should, in consultation with other members of the team, ensure there is consideration to manage the effects such as distress or grief that an incident of self-harm or suicide may cause the other children and young people, other team members, and family members.

Interventions and responses within the plan may be required to:

• Ensure the immediate and on-going safety of the child;
• Prevent escalation of self-harm (if stopping self-harm is unrealistic in the short term consider strategies aimed at harm reduction; reinforce existing coping strategies and develop new strategies as an alternative to self-harm where possible);
• Reduce the harm or stop self-harm; Safety plans cannot be used to predict future suicide or repetition of self-harm (NICE 2019 guidelines);
• Provide the basis for addressing the underlying causes/ focus more on the distress that’s causing the self-harming response than on trying to stop the action of the self-harming
• Improve social or occupational functioning;
• Improve quality of life for the child (as well as any mental health conditions);
• Evidence that the child can be safely maintained and supported in their current home;
• Take appropriate decision making action, such as consult with or report self-harming incidents to the relevant manager or other involved professionals who can provide advice and direction.

Where there are incidents of self-harm that are a worry, the safety plan chronology needs to include:

• A summary of any incidents of actual or threatened self-harm.

AND the safety plan needs to include:

• Identification of any themes and patterns, for example, time of day, location, adults involved etc.;
• Identifying the antecedents and triggers that indicate when an episode of self-harm has been or is more likely, within the domain 'self-harm' within the safety plan;
• The current frequency and duration of incidents;
• Identification of strategies currently employed and an evaluation of their effectiveness;
• If necessary, develop additional strategies to further reduce, prevent, or avoid self-harming behaviours;
• Acknowledgement that it may take a long time for a child to be able to give up self-harming, and understanding that it’s a coping mechanism for them.

AND strategies need to include:

• Formulation of an action plan, (known as Part 2 of the Safety plan) including recommendations and a review date which include wherever possible discussion with the child, their perspective of what they’re experiencing, or their understanding of issues underlying the behaviour. It’s not about specifically the self-harm but whatever’s causing the distress;
• Realistic and optimistic outcomes for their child;
• Steps to achieve these outcomes;
• Roles and responsibilities of the team members around the child (not just the adults within the home);
• Guidance for and with the child helping them to understand how to look after any wounds, when to recognise that they need to be getting themselves to A&E;
• A crisis plan including how to access services during a crisis when self-management strategies fail.

When a child is self-harming the safety plan is to be reviewed monthly, or sooner if an incident occurs which increases the risk of self-harm. This may need to be as frequent as daily or weekly. Where a specific event has led to increased concerns for the child the strategies (Part two of the safety plan) team members should be amended or updated. In such cases it is likely that the care planning process will need to include additional and frequent consultation between relevant professionals.

We offer training provided by external trainers aimed to provide an understanding of assessment, treatment and safe management of self harm. This training is non-judgemental and helps to reduce the stigma associated with suicide and self harm.

Further Information

Useful techniques to use for support:  

The ‘15 Minute’ rule (www.lifesigns.org.uk)

The ‘Everything But’ rule (www.lifesigns.org.uk)

The ‘Surfing the Urge’ rule (www.lifesigns.org.uk)

Using a red felt tip pen to mark where you might usually cut

Hitting a punch bag

Hitting pillows and cushions, or having a good scream into a pillow or cushion

Rubbing ice across your skin where you might usually cut, or holding an ice cube in the crook of your arm or leg

Getting outdoors and having a fast walk

All other forms of exercise

Making lots of noise – musical instruments or pats & pans

Write negative feelings on piece of paper then rip it up

Keep a journal

Putting elastic bands on wrists, arms or legs and flicking them instead of cutting or hitting

Scribbling on large piece of paper with a red crayon or pen

Collage or artwork – doing something creative

Calling and talking to a friend (not necessarily about self-harm)

Statutory Guidance and Government Non-Statutory Guidance

Suicide Prevention Strategy for England

Suicide Prevention: Resources and Guidance

Self-harm: Assessment, Management and Preventing Recurrence NICE Guidance

Good Practice Guidance

Useful Websites

Mind

The Mix - Essential Support for Under 25s

National Self Harm Network

Papyrus

Young Minds

NHS Choices – Self Harm

NHS Choices – Suicide

Self Harm in Young People: For Parents and Carers

“The Language of Injury: Comprehending Self-Mutilation” by Gloria Babiker, Lois Arnold (Copies of this are available in the therapy department and Learning & Development). 

• Self Harm UK;
• Harmless.

Responsibilities

Person first receiving information that a young person may be at risk of self-harm or suicide

• Take immediate action to ensure the safety of the young person, including seeking medical attention as appropriate and with reference to agreed behaviour support plans if applicable;
• Inform shift leader on duty of any concerns as soon as practicable;
• Record incident in line with recording and reporting policies.

Shift Leader

• Manage immediate response to include level of supervision is sufficient and that medical attention has been sought where necessary;
• Inform all adults on duty;
• Notify registered or on call manager of risks presented and regular updates as appropriate, particularly where there is significant increase in risks being displayed or identified;
• Ensure support plan is implemented throughout the shift and sufficient actions have been taken to ensure the safety of the young person;
• Ensure relevant incident reports, Green Form (if appropriate) and daily records are completed appropriately;
• Ensure a comprehensive handover occurs as appropriate including details of support plan and measures in place;
• Work in collaboration with the management team to address any ongoing issues and shortfalls, including the implementation of a self-harm management plan and recommendations for policy and procedure changes to be considered;
• In consultation with registered or on call manager complete any referral to LADO and/ or Ofsted notification.

Registered Manager / On Call Manager

• Oversee shift leaders response to plans for young people at risk of suicide and self-harm to ensure correct actions are taken to safeguard young people and manage process and address any shortfall;
• Contact registered manager / responsible individual / designated safeguarding lead (Kevin Gore) to provide relevant information and updates as agreed;
• Ensure all reactive strategies and protocols have been adhered to and recorded appropriately;
• Oversee and agree updating of relevant documents, (BSP, risk assessments, self-harm management plan, risk reduction plan etc.);
• Ensure that appropriate mechanisms to support adults and other young people potentially affected by the incident are implemented, including any further training required by adults;
• A TAC (team around the child) meeting should be arranged following an incident or if distance an issue a telephone conference at earliest opportunity until social worker can visit.

Key Worker

• Ensure Individual Behaviour Support Plans, self-harm management plan and risk assessments are updated to reflect the incident and any changes to strategies for the young person;
• Identify individual work in consultation with management team to reduce risks of self-harm and suicide;
• Inform other professionals including Social Workers, Therapy service, education provision, CYPMHS and, where appropriate, family members.

Equipment Specification and Maintenance

The ligatures cutters issued by the Caldecott Foundation are purpose specific items that must not be used for any other purpose than dealing with this type of emergency situation.

Ligature cutters offer improved safety and effectiveness for cutting a ligature from a person when compared to some traditional methods e.g. scissors.

Ligature cutters are specially designed items that offer an effective and safe method of cutting a ligature that is tied around a person’s body part, whether the ligature is tied solely to the person or attaches the person to any aspect of the environment e.g. a door handle.

The ligature cutter issued within the Foundation has a “hooked” metal piece that folds into a plastic covered handle. When the metal hook is unfolded it “locks” into the open position for use. The metal part is designed so that the outer edges are smooth and blunt and only the inner edge of the hook is sharp. The design of the metal hook allows for the speedy and relatively safe insertion under the ligature, whilst also minimising the risk of secondary injury to the person or adults e.g. lacerations.

The effectiveness of the ligature cutter is largely dependent upon the sharpness of the blade. Therefore, ligature cutters must only be used to cut ligatures that require quick removal to reduce risk. If a ligature cutter is used for any other purpose, or to cut anything other than a ligature, this will negatively impact upon the sharpness of the blade and ultimately, might render the ligature cutter less effective in an emergency situation. Inappropriate use of ligature cutters may result in disciplinary action against adults.

The sharpness of the ligature cutter is so crucial that they are considered to be single-use items within the foundation, i.e. whenever a ligature cutter has been used to cut a ligature it must be immediately replaced with an unused or re-sharpened one.

Availability and Storage

The Caldecott Foundation acknowledges that incidents involving the tying of ligatures might sometimes occur despite preventative strategies and measures. Consequently, all areas, where risk assessment demonstrates there is a suitably high risk of self-ligature by a young person, will be issued with ligature cutters.

Where ligature cutters are provided the Registered Manager must complete a risk assessment regarding the storage, monitoring and use of the device.

Ligature cutters are supplied in a nylon pouch and must only be removed from this during monitoring checks or when required for use. Locally, ligature cutters must be securely stored in areas that are only accessible to adults. However, it is important that all adults have quick and easy access to the ligature cutters. Therefore, appropriate storage places might include medication rooms (not medication cabinets only accessible to Daily Designated Medication Persons) or offices. A minimum stock of 2 ligature cutters should be maintained at all times. Their storage must form part of routine management monitoring checks. As a minimum this should be weekly. However, where ligature cutters are in active circulation (for example in areas working with young people expressing suicidal ideation or with a recent history of threats or attempts to ligature) these checks should be more frequent/ this may be daily or more often if there is a handover of ligature cutters between adults required to have them on their person.

All “used” ligature cutters must be securely returned to the Senior PRICE instructor for exchange, and also so that arrangements can be made for them to be re-sharpened.

Managers are responsible for ensuring that all adults working in their area(s) are aware of the availability and access to ligature cutters. This will need to be part of the local induction procedure for each area and documented.

Training

In all areas where ligature cutters are available, adults will receive information/training regarding the use of the ligature cutter from a suitably qualified and experienced PRICE instructor. Only adults previously deemed competent in PRICE techniques, evidenced by completion of introductory PMCB training, will receive training in the use of ligature cutters. The Caldecott Foundation Lone Working Competency Framework precludes adults awaiting PMCB training from lone working with children and young people. Suitable risk assessment and staffing arrangements must be in place to manage the risks associated with untrained adults working in a home/ area. Whilst this is always the case, for the purpose of clarity this is emphasised here due to the extreme risk that ligature behaviour can pose and the need for this to be effectively managed through robust planning.

Training will include information relating to the physiological risks and effects of ligature as well as demonstration and practice of how to open, lock open, use, unlock, and fold away the ligature cutter.

After adults have received information/training relating to ligature cutters in general practice, they must familiarise themselves with their own local arrangements regarding access, storage and replacement. This is an on-going personal responsibility throughout their employment within the foundation and is particularly important where adults have to work for periods in unfamiliar areas e.g. in a different house to their “usual” one.

Risk Assessment

Each area must have an appropriate environmental risk assessment in place. Assessments are carried out annually or in the event of a serious incident involving a ligature. They may also be reviewed in response to a “near miss” or a change to the young person’s group (new referral) or presenting behaviours.

When completing the risk assessment the Registered Manager should consider the following;

• Check all the areas to which young people have access (this may include areas which are routinely locked or where young people are not permitted but may, theoretically, gain access to – for example offices and sleeping in rooms;
• Check all areas systematically;
• Consider what controls, procedures etc. are utilised within the area to mitigate the risk (such as location in the home/ area, frequency of foot traffic, access points to the area, ability to observe all areas etc. These may be sufficient and no further action is necessary;
• There may be other, relatively achievable actions, which may quickly reduce the risks in a particular area. For example, replacing coat hooks with self-adhesive “command hooks”, shortening or removing cords from curtains/ blinds, replacing light pulls with “breakaway” or anti-ligature versions;
• Grade the residual risk as low (managed) medium (cause of concern) or high (requiring immediate action).

The following table is intended to assist in completing Environmental Risk Assessment and in the identification of likely ligature points. It must be noted that these lists are NOT EXHAUSTIVE. Consideration should also be given to potential ligatures in each area – remembering the ingenuity and creativity that may be displayed by a young person intent on harming themselves.

Caption: Environmental Risk Assessment and in the identification of likely ligature points

Bedrooms	Bathrooms/Toilets/ Showers	Kitchens/ Utility Rooms	Lounges/Quiet Rooms	Corridors/ Hallways
Windows – frames, catches Doors – handles, hinges, door closers; Curtain / blind rails Exposed pipe work Radiators Suspended ceilings Lights Wardrobes - handles, locks, doors, rails, coat hooks Beds e.g. can they turned on end? Smoke alarms	Windows – frames, catches Doors – handles, hinges, door closers; Curtain / blind rails Exposed pipe work Radiators Suspended ceilings Lights Wardrobes – handles, locks, doors, rails, coat hooks Beds e.g. can they turned on end? Smoke alarms	Doors – handles, catches, hinges, Closing device Hooks e.g. for clothes Sink, taps, grab rails. Waste pipes Rails for curtains / blinds Extractor fans Soap / Paper Towel dispensers Radiators Appliances (fridge/ cooker/ washing machines) Smoke alarms	Windows – frames, handles, catches Exposed pipe work Rails for curtains / blinds Doors – handles, hinges, closers Radiators Light fittings Suspended ceilings Smoke alarms	Cupboards Fire Extinguisher brackets Fire bells Doors – handles, hinges Rails for curtains / blinds Exposed pipe work Smoke alarms

The Use of Ligature Cutters in Practice

Whilst this guidance cannot replace the need for appropriate training relating to ligature cutters, it is important that adults remember the fundamental points for their effective use:

• To optimise the safe and effective use of the ligature cutter, its rounded and blunt end should be initially placed flat against the person’s body so that it can slide under the ligature;
• Once it has been located between the person’s body and the ligature, the ligature cutter should be turned so that the blunt tip or "nose" of the blade is directed towards the adult i.e. away from the young person;
• At this point adults should pull away from the person’s body, using a sawing/rocking motion using the full length of the blade, so that the ligature cutter cuts through the ligature material;
• Adults should always keep the cut ligature for later inspection.

Situations involving ligatures will generally fall into two main categories:

1. "Suspended strangulation" – where a person has tied a ligature around their neck and attached this to a fixed point so that their body weight is supported by the ligature and its fixing, and
2. "Ligature unsuspended" – where a ligature is tied around part of the body to restrict breathing or blood-flow. Outline advice for each of the above is provided below.

Suspended Strangulation (hanging):

In the event of suspended strangulation, it is important to elevate the person and to support their body weight wherever possible, at the earliest opportunity. If adults make attempts to do this it is important that they should try to adopt and maintain the principles of manual handling to reduce the risk of injury to themselves during this high-risk manual handling activity.

As soon as the body weight is supported, or immediately if this is not possible for any reason, the ligature should be cut at a central point between the person’s neck and the suspension point so that there is a minimal interference with any potential investigation scene. The person should then be lowered to the floor.

If the ligature remains in place around the person’s neck (or other body part) it should be removed using a ligature cutter. Adults should make every effort to cut the ligature at a point that is distant from any knot that may be present because the ligature and any knot can provide significant forensic evidence to any police investigation.

In situations where the person resists the adult’s actions to remove the ligature, it might be appropriate for adults to restrict the person’s ability to struggle, especially where the struggling behaviour increases the risk(s) presented by the ligature, or by the use of the ligature cutter by adults. In such situations it is expected that adults will employ appropriate holding skills, in line with PRICE training, that are sensitive to the needs of the person and the safe removal of the ligature.

Ligature (unsuspended):

The ligature should be removed as described. If the person resists, then adults should act in accordance with the advice provided.

Instructions for After Use

Every incident involving the use of a ligature cutter is deemed serious and therefore constitutes a Notifiable Event (Regulation 40, The Children’s Homes (England) Regulations 2015) and will trigger the completion of a Green Form, Child Protection concern report. Adults should ensure that all actions identified on the Child Protection Flowchart are adhered to.

There are additional actions specific to the use of ligature cutters which should also be followed. These are specified in the Actions Following the Use of Ligature Cutters flowchart.