September is National Suicide Prevention Awareness Month, a time to look out for one another and to remind us that open conversations about suicide are not harmful, but not talking about it can be.
Suicide is the second leading cause of death among individuals between the ages of 10 and 34 and the fourth leading cause of death among individuals between the ages of 35 and 44 (NIH).
Individuals with disabilities are not immune to the risk of suicide, even when in the care of others. In fact, studies show that the rates of suicidal ideation may be higher among people with disabilities (CDC). Further, research has found that 46% of people who die by suicide had a diagnosed mental health condition (CDC).
Those providing care must be especially vigilant and ready to take action when they have concerns that a person receiving services may be facing a mental health crisis.
This month, we encourage you to read the case narrative below. Please use it as a tool to identify communication and procedural breakdowns that you can discuss with your team.
Case Narrative
Carlos had a history of suicide attempts. During their most recent appointment with their psychiatrist, Carlos shared that their suicidal thoughts had increased. The psychiatrist completed a suicide assessment and recommended several safety measures:
- Increase Carlos’ supervision from 30-minute checks to 1:1 supervision.
- Ensure all sharp objects were locked and secured.
- Schedule a follow-up appointment for Carlos to be seen again in two days.
Nikki, a direct support professional who was nearing the end of their shift, received the directives from the psychiatrist and transported Carlos home. Upon arrival at the residence, Nikki verbally informed Josh, the residence manager, that Carlos required 1:1 supervision, that any sharp objects were to be locked away, and that an appointment needed to be scheduled for Carlos to be seen by the psychiatrist in two days. Nikki was already 30 minutes past the end of their shift, so they decided to clock out and document the discharge instructions in the person’s electronic health record the next day. Josh was busy supporting other people on their shift and forgot to tell Scott, the overnight staff, about Carlos’ change in supervision and the need for sharps to be locked.
During the overnight shift, Carlos approached Scott and told Scott that they were supposed to have a 1:1 staff due to suicidal thoughts. Scott contacted Josh, who confirmed this was accurate. Scott was then assigned to provide 1:1 supervision to Carlos, ensure that the sharps were locked, and contact nursing to schedule the follow-up appointment.
What Went Wrong?
We encourage you to identify these issues and discuss how to prevent similar incidents in your own organization.
Free, Confidential Help is Here
If you or someone you know is experiencing a mental health crisis, please reach out. You can call, text, or chat the 988 Lifeline to speak with a trained crisis counselor.
