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3.26 Oxford University Hospital Trust - Guideline on Management and Assessment of Young People Following Deliberate Self-Harm

AMENDMENT

In January 2014, this chapter has been updated and should be read in its entirety.


Contents

  1. Introduction
  2. Management of those presenting to Emergency Department at JR


1. Introduction

Self-harm can be defined as 'Self-poisoning or injury, irrespective of the purpose of the act'

In young children this is usually accidental (although not always), but from the age of 11 years onwards it becomes common for self-harm to be, at least to some extent, intentional. The term 'deliberate self-harm' is sometimes used to distinguish accidental self-harm.

Common forms of self-harm are overdosing and self-cutting, but other activities may have the same significance in terms of communicative or suicidal potential (e.g. jumping from a height, attempted hanging etc).

Many young people are admitted to hospital with excessive alcohol ingestion. The most common group consists of those who drink experimentally with friends and they have more than they are used to. More rarely adolescents may drink with intent to harm themselves, perhaps in combination with other potentially harmful chemicals - these should be treated in the same way as others who self-harm.

With this guideline we are mainly referring to young people who overdose, take excess alcohol with the intent of harming themselves, or do other potentially harmful things to themselves. A young person under the age of 16 must always be admitted (even if medically fit) generally to Melanie’s Ward / Children’s ward at Horton. Over the age of 16 they will generally be admitted to the Medical Emergency Assessment Unit (EAU) unless they are deemed medically fit and low risk, in which case they should have a full psychosocial assessment prior to discharge.

Young people who self-cut and present to A and E are generally not admitted, however they need to have a full psycho-social assessment by the Mental Health Team, prior to discharge, in order to assess risk and plan follow-up (NICE Guidelines on self harm).

Sometimes scars from previous self-cutting are noticed during an admission for another reason. The GP should be informed of this, and asked to consider referral to the Child and Adolescent Mental Health Service. However, if the self-cutting is thought to be relevant to the current admission then a psycho-social assessment should be performed prior to discharge.


2. Management of those presenting to Emergency Department at JR

  • Initial assessment - should include history, examination, and where appropriate investigation and then initiation of treatment, by ED and then paediatric team. ED nurses will check to see if young person has a child protection plan.
  • Admission - if under the age of 16, a young person should be admitted to Melanie’s Ward (the Adolescent Ward) in the Children’s Hospital / Children’s ward at Horton. If a bed is not available on Melanie’s Ward, another bed within the Children’s Hospital should be found. Over the age of 16, where admission is required this will usually be to the EAU.
  • Referral for psycho-social assessment - emergency department should refer to the Barnes Unit (Specialist Team for management of  self-harm based at the JR) or North CAMHS at Orchard Health Centre (from Horton), who will generally see the young person the day after admission. If admission is not considered appropriate or the young person wants to self-discharge, a psycho-social assessment should be performed by the Barnes Unit, or if out of hours, the duty doctor or Mental Health Crisis Team, prior to discharge.

    The morning after admission, the ward should ring the Barnes Unit / CAMHS to ensure that they know about the young person.

    The Barnes Unit only sees young people aged 13 years or above. Below that age a referral should be made to the relevant CAMHS - North Oxon (Banbury, Bicester and Kidlington), Central Oxon (Oxford City and Witney) or South Oxon (Abingdon and South Oxon) – see telephone numbers below.
  • Ongoing medical care - Paediatric team will review young people under the age of 16 the  next morning on Paediatric Acute Ward Round. Where the young person is over the age of 16 review will be by the Medical Emergency Unit team. When the young person is medically fit for discharge this should be documented in the notes. The paediatric or medical team will continue to take medical responsibility until the young person has been discharged.
  • Psycho-social assessment - The Barnes Unit ring Melanie’s Ward and EAU every morning Monday to Saturday, to check if any young people need to be seen. (There is a potential problem when a young person is admitted to a ward other than Melanie’s Ward – staff on other wards might need to be more proactive to ensure Barnes Unit is aware of young people.) The Barnes Unit worker will see the young person the day after admission. On Sundays CAMHS Crisis Team or duty doctor (rather than the Barnes Unit) will perform the psycho-social assessment. The referrer should ring the Coordination Centre based at the Warneford Hospital in the first instance (01865 741717).

    Psycho-social assessments should be done when young person is medically fit and compliant.

    The Barnes Unit / Crisis Team duty doctor will document in the medical notes a summary of their assessment and plan.

    If the mental health assessment concludes that there are significant concerns about the young persons emotional well being or social situation, but not warranting an admission to the adolescent psychiatric unit, then consideration should be given to the young person staying in hospital another night. Liaison between mental health and medical teams should occur.
  • Social concerns - if at any stage during admission the nurses, paediatric or EAU doctors, or mental health workers have concerns about social aspects, then a referral should be made to Social Services based in the JR (Samuelson house for HGH). The JR Social worker may also need to liaise with the Assessment Team relevant to where the young person lives, or if the young person is already know to a social service team – then the relevant team. Out of hours, if social services input is needed, the Emergency Duty SS Team should be contacted (0800 833408).

    Consideration should be given to a joint assessment with the Social Worker and the Mental Health Team. If a young person is deemed not fit, either because of social reasons or mental health reasons, to be discharged home, then there should be a discussion between the Social Worker and Mental Health Workers to find an appropriate place for him or her to be discharged to. It may be appropriate for the young person to stay on Melanie's Ward / HCW / EAU for another night.
  • Safety issues - if there is concern that the young person is a risk to themselves or to others, staff should contact security and / or the Police.

    If the young person absconds, then the Children's Hospital Abscond Policy should be referred to.
  • Confidentiality Issues – usual practice is for the parents to be informed if a young person is admitted following self harm. However, in some situations the young person will request that information about their admission is not passed on to parents. This request would be agreed to only if there are serious circumstances making it unsafe for confidentiality to be breached and following agreement between the Paediatric and Psychiatry Consultants.
  • Emergency advice on Mental Health - outside working hours advice can be obtained from the on call CAMHS Crisis Team via Warneford switchboard tel: 01865 741717. The duty doctor or the Crisis Team will be the first point of contact, but there will also be an SpR and / or Consultant from the CAMHS Team on call. During working hours and on Saturday during the working day the Barnes Unit should be contacted in the first instance; they can access further psychiatric advice as needed. If the Barnes Unit is not available the local CAMHS team (North Oxon, Central Oxon or South Oxon) can be contacted during working hours. In exceptional circumstances where there are difficulties with this, the CAMHS Liaison Psychiatrist (Dr. Mina Fazel) can be contacted either by E mail (mina.fazel@psych.ox.ac.uk) or by phone (07789638941). If the paediatric team need the input of a CAMHS Consultant either for advice or for direct involvement with the patient, they should make this explicit. A Consultant to Consultant call should be considered in escalating cases.

    CAMHS contact numbers:
    North Oxon: 01295 819090
    Central Oxon: 0845 219 1002 or 01993 202130
    South Oxon: 01235 205425
  • Complex cases - some young people present with more complex and recurrent problems, which may require a more detailed assessment and multi-agency working. It is suggested that the admission for a young person in any of the categories below should trigger multi-agency discussion, and possibly a multi-agency meeting, or a Team Around the Child Meeting. The aim of this would be to establish full understanding of the young person's needs, and determine whether appropriate support is in place and that all agencies are working together.

    Categories
    • A Looked After young person;
    • Three or more episodes of self-harm (not including superficial cutting);
    • The second episode of self-harm within a short space of time;
    • Where there are multiple agencies involved or other complexities.
  • Discharge - once the patient is deemed medically fit by the Paediatric or Emergency  Consultant, the Barnes Unit / CAMHS take responsibility for deciding whether the young person is safe to be discharged home. The young person should not be discharged home until agreement by the Barnes Unit / CAMHS. A discharge plan should be in place.

    The Acute Paediatric team / EAU should complete a discharge summary. This should include a summary of medical issues, psycho-social assessment, and clear plan – including other appointments, and staff who will be involved. This should be sent to GP, Parents, and Social Services (if involved) and the Barnes Unit (who will upload onto the electronic patient record and send to CAMHS if relevant).

    The Barnes unit / Crisis team will also complete a record of the psycho-social assessment which will be faxed to the Paediatric Ward / EAU for inclusion in the paediatric / medical notes.

End