The following document was written by Dr Satvir Singh FRANZCP (Aust), FRCPsych (UK), MSc (Lon), MRCPsych (UK), DPM, MBBS Consultant Psychiatrist & Lead Consultant for Undergraduate Medical Education (Psychiatry) Kent & Medway NHS and Social Care Partnership Trust Canterbury, Kent in Dec 2007.
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The Management of Suicidal patient and Deliberate Self-Harm in Accident & Emergency

This section should be read in conjunction with the article on Clinical Risk Assessment in Psychiatry – 1. It is relevant to all medical staff working in Accident and Emergency (A/E).

There are some basic principles that one should follow in all cases, whether the patient is presenting with superficial laceration of arm or a middle aged man has been brought in following a serious suicidal attempt.

Step 1 – Make sure that the patient is medically safe and all vitals signs are stable. If not, then treat accordingly.

Step 2 – In case of overdose, where possible, find out what the patient has taken and if necessary, contact the National Poison Centre for advice regarding immediate management.

Step 3 – Ask a colleague or nursing staff who is assisting you in the patient’s assessment and management to contact the patient’s family, as they will not only give you an objective account of the patient’s recent physical and mental health history, social circumstances and other relevant life events, but would also help you in the management of the patient, especially if you do decide to discharge the patient. Also, arrange the medical notes, psychiatric notes, if any, and GPs medical history/notes print out to be available to you. These days most A & E departments would have access to the patient’s notes on the computer.

Step 4 – Arrange to speak to Community Psychiatric Nursing Staff and other medical staff in psychiatry, if they have been involved with the patient in the past or indeed he/she is under their care currently. They would be able to provide you with useful information about the patient’s past/current mental health issues, social circumstances, current stressors and the past/current prescribed psychiatric treatment, and their opinion about the patient’s further psychiatric management.

Step 5 – Make sure that you have arranged the essential investigations, i.e., routine bloods, illicit drug screening, alcohol levels and glucose levels. If relevant, arrange for ECG and X-Ray chest and CT Brain Scan. For anyone who is intoxicated (alcohol/drugs), it is essential to arrange a CT Brain Scan to exclude the possibility of a subdural haematoma. Such patients have a tendency to bang their heads prior to their arrival to A/E, and they may not be able to give you the relevant history.

Step 6 – Take a brief history and carry out a detailed Mental State Examination and thereafter make a decision about the patient’s further management as follows:

  1. If the patient is at Minimum Risk for any future adverse event and is medically fit, then she/she can be discharged from the A/E.

    • Make sure that the patient is discharged in the care of a responsible adult member of family or friend.
    • Arrange for a Mental Health Crisis Assessment Team staff to see the patient in the next 48 hours, or earlier if necessary.
    • Notify the GP about the patient.
    • Give contact details of Mental Health Crisis Assessment Team for any emergency.
    • If for any reason, you cannot get hold of a responsible family member/friend, (sometimes the patient will not give you the consent to contact anyone), then you may consider involving the Crisis Assessment duty staff or Psychiatric Liaison Service, whichever is appropriate in your area, to assess the patient before you let them go.

  2. If the patient is at Moderate Risk, then he/she should not be discharged in the community. These patients will require to be assessed by the Crisis Assessment Team and/or Psychiatric Liaison Service, whichever appropriate, who will decide about the patient’s further management.

  3. If the patient is at Severe Risk, then they need to be transferred to the psychiatric in-patient unit for a period of further observation and treatment.

Consent to Treatment and Mental Capacity

It is essential that you understand fully the principles of valid informed consent and follow it at all times in clinical practice. These principles are as follows:

Refusal to Treatment

Children and the Consent to Treatment

Adults who are not Competent to Give Consent to Treatment

Assessment of Competence (Mental Capacity)

A patient may lack the capacity by reasons of:

The Process to Assess the Mental Capacity

Step 1 – Provide the relevant information in plain English with regard to the specific decision that the patient is expected to make. Also, advise the patient about the pros and cons of the other alternatives, options and decisions.

Step 2 – Assess the patient’s cognitive ability whether he/she:

Step 3 – Assess as to why the patient is unable to reach a decision. This could be due to various mental disorders or other reasons. However, presence of a mental disorder does not necessarily mean that the patient does not have mental capacity. Also, a patient may have capacity in one area but not in other.


The next section deals with The Management of Suicidal and Deliberate Self-Harm Patients in Community

Dr Satvir Singh
FRANZCP (Aust), FRCPsych (UK), MSc (Lon), MRCPsych (UK), DPM, MBBS
Consultant Psychiatrist & Lead Consultant for Undergraduate Medical Education (Psychiatry)
Kent & Medway NHS and Social Care Partnership Trust
Canterbury, Kent


  1. Shorter Oxford Textbook of Psychiatry, Fifth Edition, M Gelder et al, 2006
  2. Department of Health - Consent


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