4.23 Oxford Children’s Hospital – Guideline on Management and Assessment of Young People under the age of 16 who Self-Harm |
Contents
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. These young people must always be admitted, generally to Melanie's Ward.
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 the Emergency Department (ED) and then the Paediatric Team. ED nurses should check Framework - i, to see if the young person is known to Children's Social Services.
- Admission - the young person should be admitted to Melanie's Ward (the Adolescent Ward) in the Children's Hospital. If a bed is not available on Melanie's Ward, another bed within the Children's Hospital should be found.
- Referral for psycho-social assessment - The ED should refer to the Barnes Unit (Specialist Team for management of self-harm based at the JR), 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 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 (Banbury, Witney, Abingdon or Oxford City) or, if it is a new patient, the Oxford City CAMHS. - see telephone numbers below. - Ongoing medical care -The Paediatric Team will review the young person the next morning on the Paediatric Acute Ward Round. When the young person is medically fit for discharge this should be documented in the notes. They will continue to take medical responsibility until the young person is fit for discharge.
- Psycho-social assessment - The Barnes Unit will ring Melanie's Ward every morning Monday to Friday, 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 such young people.) The Barnes Unit worker will see the young person the day after admission. On Saturdays and Sundays the Mental Health Crisis Team or duty doctor (rather than the Barnes Unit) will perform the psycho-social assessment.
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 doctors, or mental health workers have concerns about social aspects, then a referral should be made to Social Services based in the JR. 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 Children's Social Care 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 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. - Emergency advice on Mental Health - Outside working hours advice can be obtained from the on call Mental Health 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 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 (Oxford City, Abingdon, Witney or Banbury) can be contacted if the patient is already known to the team, or the
Oxford City Team for patients who are not known already.
CAMHS contact numbers:
Banbury: 01295 819090
Witney: 01993 202130
Abingdon: 01235 205425
Oxford City: 0845 219 1002 - 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
- Discharge - The Acute Paediatric Team 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 the GP, parents, and local Mental Health Team (if involved) and Children's Social Services (if involved).
The Barnes Unit/Crisis Team will also complete a record of the psycho-social assessment which will be copied to the paediatrician for inclusion in the paediatric notes.
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