The case
A 45-year-old man was found hanged and an inquest was held. The GPs asked the MDU for support in writing a statement.
The man had experienced several periods of depression over the past 20 years and was admitted to the care of a mental health team during the 1980s following an attempted suicide.
He had been treated with a number of different antidepressants over the years, but in each case, his compliance had been poor; he did not attend for reviews with the GPs and refused referral to specialist mental health services.
The man was seen by a number of different GPs, including locums. While several of the doctors could recall asking specifically about suicidal ideation, there was no record of this. The man was seen by a locum GP the day before his death, who was unaware of previous concerns about his mental health.
The patient's wife and daughter both tried to contact the practice in the week before he died to raise their concerns, but were told by the practice manager that the doctors could not discuss the case due to the duty of confidentiality, and the messages were not passed on.
The coroner was critical of the practice's management of the case, and the family later complained to the GMC and brought a claim against the practice, alleging that negligence had contributed to the patient's death.
Fictional case scenario based on typical advice calls to the MDU
GPs are well placed to identify and manage patients with mental illness who are at risk of suicide, but as every clinican knows, managing mental health conditions can pose significant difficulties.
Signs and symptoms can be subtle, and patients may be unwilling to disclose suicidal thoughts or symptoms of depression, out of embarrassment or fear of discrimination.
There is some evidence that doctors are coming under closer scrutiny in cases involving suicide.
The number of doctors asking the MDU for guidance in this area has more than doubled over the past 10 years. In 2013, 259 cases involving suicide were notified to the MDU, an increase of 129% since 2004, when 113 cases arose.
This is despite suicide rates in the UK decreasing by about two per 100,000 people between 1992 and 2012.1
More than half of the 180 cases notified to the MDU in the first half of 2014 involved GPs, with a third of cases (29%) coming from psychiatrists and the remainder from other specialties.
Suicide awareness
It is important to know the signs that might indicate a patient at risk of suicide, how to broach the subject sensitively with them and how to respond appropriately.
Joint guidance from the RCGP and the Royal College of Psychiatrists recommends that GPs should undertake suicide awareness and skills training.2
It also identifies red flag signs, such as patients with well-formed suicide plans, feelings of hopelessness and lack of social support. These might indicate the need for referral.
GPs should not be afraid to ask a patient about depressive symptoms or suicidal ideation if they have concerns. A sensitive enquiry might encourage the patient to discuss thoughts and feelings which they might otherwise feel unable to share.
If it is impossible to discuss all of the patient's mental health concerns in one short appointment, ask them to return for a longer appointment, and aim to book this before they leave.
If the patient fails to attend a follow-up appointment, it is advisable to try to contact them to find out why. Do not rely on the patient taking action - if they have depression, they may be less able to ask for help.
The MDU is aware of cases where opportunities may have been missed to review a patient. Communicate clearly with patients about their options, including talking therapies, the risks or side-effects of medication and details of the crisis team or out-of-hours help.
Encourage the patient to allow you to involve close family members or friends, who may be able to offer additional support.
Bear in mind your duty of confidentiality and do not discuss the patient with their friends or relatives without their permission.
However, the GMC is clear that it is not a breach of patient confidentiality to listen to the concerns of the patient's relatives or friends.
Clear documentation
Document all discussions with patients in detail. If they are seen by a colleague at the next appointment, it should be made clear that the patient has had depressive symptoms or suicidal thoughts and that they may need to enquire specifically about these matters.
It is advisable to document objective measurements of mood in the patient's records, using standardised questionnaires.
Have a system in place to audit or review all patients who are taking long-term antidepressants.
When a suicide occurs, particularly if it is unexpected, relatives understandably want to know what steps were taken leading up to the death, and there will also be an inquest.
Other investigations may follow, including a complaint, claim, serious incident report, disciplinary action and, on rare occasions, a GMC complaint.
Complaints about suicide can be difficult to resolve, especially if there is an inquest in progress. GPs may need to consider informing the coroner of any additional disclosure of information made to the family. Your medical defence organisation can advise you.
- Dr Old is a medico-legal adviser at the Medical Defence Union
References
1. The Samaritans. Suicide Statistics Report 2014.
2. RCGP/RCPsych Primary care Mental Health Forum. Suicide mitigation in primary care.
