23rd February 2018, Volume 131 Number 1470

Wayne de Beer, Bernard De Witt, Jules Schofield, Helen Clark, Veronique Gibbons

Suicide, the act of intentionally killing oneself (as determined by coronial ruling), is rare but remains a significant cause of mortality in 34 of the Organisation for Economic Co-operation and…

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This study evaluated how Mental Health & Addiction Services staff members, working in a busy emergency department service, adhere to the New Zealand Ministry of Health’s Clinical Practice Guidelines for DSH. This study identifies the importance of the individualised, tailored assessment. It also outlines weaknesses of the assessment and treatment of patients following a suicide attempt and makes recommendations for improving assessment of patients following attempted suicide.



The primary aim of this audit was to determine the quality of psychiatric risk assessments conducted by Mental Health & Addiction Services clinicians for patients presenting to the emergency department, Waikato Hospital, Hamilton, New Zealand following an attempted suicide.


A retrospective, randomised audit of 376 files of patients who had presented to the ED over a 12-month period from 1 July 2015 to 30 June 2016 was conducted, following the standards outlined in the present New Zealand Ministry of Health Clinical Practice Guideline for Deliberate Self Harm (DSH).


It was found that clinicians routinely focused on the historical features of the suicide attempt presentation while failing to record judgements about future suicidal behaviours. Interactions with family members were recorded in less than half of the cases. The guideline most poorly adhered to was checking whether Māori patients wanted culturally appropriate services during the assessment and treatment planning, with this recorded in less than 10% of the clinical records.


To improve the quality of the suicide risk assessments, and to better align with Clinical Practice Guidelines, the authors propose redevelopment of clinician training, including focus on cultural competence, and training in confidentiality and privacy relating to an attempted suicide episode.

Author Information

Wayne de Beer, Psychiatry Specialist, Department of Consultation-Liaison Psychiatry, Waikato District Health Board, Hamilton; Bernard DeWitt, Summer Studentship, Waikato Clinical School, The University of Auckland, Hamilton; Jules Schofield, Specialist Emergency Medicine, Emergency Department, Waikato District Health Board, Hamilton; Helen Clark, Medical Education Officer, Clinical Education & Training Unit, Waikato District Health Board, Hamilton; Veronique Gibbons, Quality & Patient Safety, Waikato District Health Board, Hamilton.


Dr Wayne de Beer, Psychiatry Specialist, Department of Consultation-Liaison Psychiatry, Waikato District Health Board, P Bag 3200, Hamilton.

Correspondence Email


Competing Interests



  1. Ministry of Health. Suicide Prevention Toolkit for District Health Boards. Wellington: Ministry of Health 2015. Retrieved from http://www.health.govt.nz/publication/suicide-prevention-toolkit-district-health-boards
  2. Ministry of Health. Suicide Facts; 2014 data. 21st December 2016. Accessed at: http://www.health.govt.nz/publication/suicide-facts-2014-data on the 31st May 2017. 
  3. OECD. Doing Better for Children. New Zealand Country Highlights. 2009. Retrieved from http://www.oecd.org/newzealand/43589854.pdf
  4. Ministry of Health. Understanding Suicide in New Zealand. Ministry of Health website: Ministry of Health 2016a. Retrieved from http://www.health.govt.nz/our-work/mental-health-and-addictions/working-prevent-suicide/understanding-suicide-new-zealand
  5. Jaiswal SV, Faye AD, Gore SP, Shah HR, Kamath RM. Stressful life events, hopelessness, and suicidal intent in patients admitted with attempted suicide in a tertiary care general hospital. J Postgrad Med. 2016 Apr–Jun;62(2):102–4.
  6. Bongar B, Sullivan G. The suicidal patient: clinical and legal standards of care (3rd ed.). Washington, DC: American Psychological Association. 2013.
  7. Chu C, Klein K, Buchman-Schmitt J, Hom M, Hagan C, Joiner T. Routinized Assessment of Suicide Risk in Clinical Practice: An Empirically Informed Update. J Clin Psychol; 2015; 71(12):1186–1200.
  8. Cupina D. Life events, gender and suicidal behaviours in the acute community setting. Australas Psychiatry; 2009; 17(3):233–236. 
  9. Foster T. Adverse life events proximal to adult suicide: a synthesis of findings from psychological autopsy studies. Arch Suicide Res; 2011; 15(1):1–15.
  10. Chesney E. Goodwin G. Fazel S. Risks of all-cause and suicide mortality in mental disorders: a meta-review. World Psychiatry; 2014; 13(2):153–160.
  11. Ministry of Health. Health Loss in New Zealand: A report from the New Zealand Burden of Diseases, Injuries and Risk Factors Study 2006–2016. Retrieved from http://www.health.govt.nz/publication/health-loss-new-zealand-report-new-zealand-burden-diseases-injuries-and-risk-factors-study-2006-2016
  12. Fässberg M, Cheung G, Canetto S, Erlangsen A, Lapierre S, Lindner R, . . . Wærn, M. A systematic review of physical illness, functional disability, and suicidal behaviour among older adults. Aging Ment Health; 2016; 20(2):166–194.
  13. Scott K, Hwang I, Chiu W, Kessler R, Sampson N, Angermeyer M, . . . Nock M. Chronic physical conditions and their association with first onset of suicidal behavior in the world mental health surveys. Psychosom Med; 2010; 72(7):712–719.
  14. Carter G, Page A, Large M, Hetrick S, Milner AJ, Bendit N, Walton C, Draper B,Hazell P, Fortune S, Burns J, Patton G, Lawrence M, Dadd L, Robinson J, Christensen H. Royal Australian and New Zealand College of Psychiatrists clinical practice guideline for the management of deliberate self-harm. Aust N Z J Psychiatry. 2016 Oct; 50(10):939–1000.
  15. Carroll R, Metcalfe C, Gunnell D. (2014) Hospital presenting self-harm and risk of fatal and non-fatal repetition: Systematic review and meta-analysis. PLoS ONE 9: e89944.
  16. New Zealand Guidelines Group (NZGG) and Ministry of Health. The Assessment and Management of People at Risk of Suicide: For Emergency Departments and Mental Health Service Acute Assessment Settings. Best Practice Evidence-based Guideline. 2003. Retrieved from http://www.health.govt.nz/publication/assessment-and-management-people-risk-suicide
  17. Ministry of Health. Preventing suicide: Guidance for emergency departments. Wellington: Ministry of Health. 2016b.
  18. Hickey L, Hawton K, Fagg J, Weitzel H. Deliberate self harm in patients who leave the accident and emergency department without psychiatric assessment: A neglected population at risk of suicide. Journal of Psychosomatic Research; 2001; 50(2):87–93. 
  19. Mahal S, Chee C, Lee J, Nguyen T, Woo B. Improving the quality of suicide risk assessments in the psychiatric emergency setting: Physician documentation of process indicators. The Journal of the American Osteopathic Association; 2009; 109(7):354–358.
  20. Statistics New Zealand. 2013 census of population and dwelling. Retrieved from www.stats.govt.nz website: http://www.stats.govt.nz/Census/2013-census.aspx
  21. Mulder R, Newton-Howes G, Coid J. The futility of risk prediction in psychiatry. Br J Psychiatry; 2016; 209(4):271–272.
  22. Pisani AR, Murrie DC, Silverman MM. Reformulating Suicide Risk Formulation: From Prediction to Prevention. Acad Psychiatry. 2016 Aug; 40(4):623–9.
  23. Hawes M, Yaseen Z, Briggs J, Galynker I. The Modular Assessment of Risk for Imminent Suicide (MARIS): A proof of concept for a multi-informant tool for evaluation of short-term suicide risk. Compr Psychiatry. 2017 Jan; 72:88–96. 
  24. Galynker I, Yaseen ZS, Cohen A, Benhamou O, Hawes M, Briggs J. Prediction of suicidal behavior in high risk psychiatric patients using an assessment of acute suicidal state: The suicide crisis inventory. Depress Anxiety. 2017 Feb; 34(2):147–158.
  25. Horwitz AG, Czyz EK, King CA. Predicting Future Suicide Attempts Among Adolescent and Emerging Adult Psychiatric Emergency Patients. J Clin Child Adolesc Psychol. 2015; 44(5):751–61.
  26. de Beurs DP, de Groot MH, de Keijser J, van Duijn E, de Winter RF, Kerkhof AJ. Evaluation of benefit to patients of training mental health professionals in suicide guidelines: cluster randomised trial. British Journal of Psychiatry; 2016; 208(5):477–483.
  27. Burgess P, Pirkis J, Morton J, Croke E. Lessons from a comprehensive clinical audit of users of psychiatric services who committed suicide. Psychiatr Serv, 2000; 51(12):1555–1560. 
  28. Rudd M, Berman A, Jr TJ, Nock M, Silverman M, Mandrusiak M, . . . Witte T. Warning signs for suicide: theory, research, and clinical applications. Suicide and Life-Threatening Behavior; 2006; 36(3):255–262.


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