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EDITORIALS: Keith Hawton and Sue Simkin Helping people bereaved by suicide BMJ 2003; 327: 177-178 [Full text]

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Toward erasing 'untoward'.

Andrew Al-Adwani   (29 July 2003)

Bereavement and loss following suicide

Gordon W.B. Grant, Philip Seager, Rachel Abbott, Sam Young, Peter Goward, John Pugh, John Ludlow   (1 August 2003)

Bereavement by Suicide

Jane E Ralls   (20 August 2003)

Letter to the Editor: Attention for people bereaved by suicide as prevention of mental symptoms

Pirjo I Saarinen, Hintikka Jukka, M.D., Ph.D., Acting professor   (21 August 2003)

Re: Toward erasing 'untoward'.

Stuart Clarke   (11 May 2007)

Toward erasing 'untoward'. 29 July 2003
Andrew Al-Adwani, Consultant Psychiatrist Department of Psychiatry, Scunthorpe General Hospital, DN15 6QL Send response to journal: Re: Toward erasing 'untoward'.	It is curious that the stigmatisation of suicide is mirrored in psychiatric services responses to these tragedies. Just like the general public's distaste for suicide, with taking one's life seen as some sort of personal failure, so psychiatric services respond labelling suicides as 'untoward' or 'serious untoward events', depending on the level of blame/failure of services attached to the death. There is no acceptance of the fact that suicide is the natural outcome of certain disease states (schizophrenia, depression, etc.) but an insistence on attempting to find faults in service practices or practitioners. Days are spent fine tooth combing medical notes in search of 'errors', whether contributory or not, and a long report, which without exception includes an action plan, is formulated to 'correct' these supposed faults. These, of course, rarely make any difference but keep many people in work. The time and money consumed in these futile exercises would be much better spent providing help for the bereaved, but then that would be sensible and nobody ever accused NHS management of that. Competing interests:   None declared
Bereavement and loss following suicide 1 August 2003
Gordon W.B. Grant, Professor of Cognitive Disability University of Sheffield, S5 7AU, and Doncaster and South Humber Healthcare NHS Trust, DN4 8QN, Philip Seager, Rachel Abbott, Sam Young, Peter Goward, John Pugh, John Ludlow Send response to journal: Re: Bereavement and loss following suicide	Dear Editor, We agree with the opinions expressed by Hawton and Simkin about people bereaved by suicide (BMJ,327,177-178). However, we would like to comment on an additional group (or groups) of individuals who are directly involved and who may need additional help. In a recently completed study about cases of suicides and open verdicts on the railway network (SOVRN)(Abbott et al. 2003), we found that train drivers, rail and civil police, witnesses and others can all be affected, though their needs and circumstances are not always recognised or understood. By its very nature, a relatively infrequent event which any regular train driver may encounter only once or twice in a career, cannot easily be anticipated, yet those involved can show marked emotional responses, sometimes long-lasting. They may experience self-blame and difficulties in returning to work until the outcome of inquests, yet some can have difficulties in accessing line management support or, when required, debriefing and counselling. In efforts to protect others, some prefer not to seek support from their own families. Rail police, possibly because of greater exposure to suicides (60% of all fatalities on the railway are suicides), appear to be more inured to the experience and have developed coping strategies to deal with this. Others, like members of the travelling public, who may unwittingly witness railway suicides, appear to be left in a liminal world where their needs are not recognised by anyone other than themselves. All these individuals have support needs through the long procedures of inquiry, and afterwards where necessary. Reference Abbott, R.L., Young, S., Grant, G., Goward, P., Seager, P., Pugh, J. and Ludlow, J. (2003) Railway Suicide: Individual and Organisational Consequences. Doncaster and South Humber Healthcare NHS Trust. ISBN 0 9545638 0 8 Yours sincerely Competing interests:   None declared
Bereavement by Suicide 20 August 2003
Jane E Ralls, GP Perth, Western Australia 6014 Send response to journal: Re: Bereavement by Suicide	Editor, I was very pleased to see an editorial addressing the difficult issue of bereavement after suicide in your recent theme issue on death and dying. I was disappointed, however, not to see any mention of the difficulties faced by health professionals when a patient suicides. Many General Practitioners have built up relationships with their patients and their families over many years, and have become part of their patients’ communities. They may themselves grieve when their patients die, and when the death is by suicide their grief may be compounded by feelings of guilt and inadequacy. Many health professionals have experienced loss by suicide in their personal lives. They may find caring for people at risk particularly stressful, and find themselves painfully re-living their own experience as they are repeatedly exposed to different personal tragedies. Having to help grieving friends and relatives after suicide, even if they did not know the person, may be particularly hard for these people. Doctors are notoriously bad at looking after their own health, especially their own mental health, and GPs often work in relative isolation. It is very important that we, as a profession, learn to accept our own experiences and emotions as relevant to our work, and accept that they have a bearing on how we function. Only then can we begin to treat people in need appropriately, and remain healthy ourselves. Competing interests:   None declared
Letter to the Editor: Attention for people bereaved by suicide as prevention of mental symptoms 21 August 2003
Pirjo I Saarinen, M.D., Ph.D., Psychiatrist Kuopio university hospital/Department of Psychiatry , P.O. Box 1777, FIN-70211 KUOPIO, Finland, Hintikka Jukka, M.D., Ph.D., Acting professor Send response to journal: Re: Letter to the Editor: Attention for people bereaved by suicide as prevention of mental symptoms	It is known that coping with the loss after suicide is difficult. In the Swedish general population the rate of suicide was twice as high in families of suicide victims as in comparison families (1). According to this report, a family history of suicide predicted suicide independently of severe mental disorder. In their recent editorial Hawton and Simkin (2) suggested that although clinical trials are not easy to conduct, given the special circumstancies of suicide bereavement, they are none the less required to show whether specific types of care are effective. We investigated general and psychological well-being of bereaved people ten years after suicide in the family. They had been intervieweed at baseline using psychologial autopsy method soon after the event (3). At the time of follow up, half of the interviewees felt that baseline interviews had helped them to adjust to the suicide. Mental symptoms were reported to have been common after suicide but they had subsided during three years. However, it was found that suicide may be associated with mental symptoms and lack of social relationships in surviving spouses even ten years later (4). Moreover, mental symptoms had been common especially among children after their parent's suicide. We agree with Hawton and Simkin (2) that there is a need for studies on the effectiveness of psychological counselling and other interventions targeted to relieve mental distress in surviving spouses and children. References 1. Runeson B, Åsberg M. Family history of suicide among suicide victims. Am J Psychiatry 2003;160:1525-6. 2. Hawton K, Simkin S. Helping people bereaved by suicide. Editorial. BMJ 2003;327:177-8. 3. Saarinen PI, Hintikka J, Viinamäki H, Lehtonen J, Lönnqvist J. Is it possible to adapt to the suicide of a close individual? Results of a 10- year follow-up study. Int J Soc Psychiatry 2000;46:182-90. 4. Saarinen PI, Hintikka J, Lehtonen J, Lönnqvist JK, Viinamäki H. Mental health and social isolation among survivors ten years after suicide in the family: A case-control study. Arch Suicide Research 2002;6:221-6. Competing interests:   None declared
Re: Toward erasing 'untoward'. 11 May 2007
Stuart Clarke, Serious untoward incident coordinator 5 Boroughs Partnership nhs trust, WA2 8WA Send response to journal: Re: Re: Toward erasing 'untoward'.	Dr.Al Adwani,raises important questions about the dangers of increasing the stigma of suicide by attempting to apportion blame.However the prime purpose of investigating serious untoward incidents is not to blame but to learn lessons.Far more NHS money would be spent on litigation if we fail to learn lessons and take any necessary actions. We must all share responsibility for improving our services and it is a negative attitude to believe that we are never culpable. We have responsiblities to the public and to the relatives of the bereaved inparticular.It is part of the healing process for them to know that the death of their love one is being reviewed.Almost without exception the response they want is to believe it won`t happen to someone else. Competing interests: None declared