Veteran's Suicide

Released under the Access t0 Infermation Act I Divulg?(s) en vertu de ta Loi sur I?acc?s a I?information. Clinical Suicide File Review Protbcol February 2014 (000001 Divulg?ts) en vertu de ia Loi sur I?acc?s a i?information. Tabie of Contents Purpose .., .. 3 Objectives .. 3 Scope ..: .. 3 Rationale .. 3 Administrative Procedure .. 4 Sample Case Selection .. 5 Data Sources .. Use of personal information for non administrative purpose .. 5 Safeguard of information .. 5 Review Process; .. 6 ANNEX ATIP Policy Advice .. 7 ANNEX Minimum Safeguards .. 9 (000002 Reteased?under the Access to information Act Divulg?(s) en vertu cle ta Lei sur l?acces a l?information. Purpose The purpose is to describe clients with suicidality and to identify opportunities to enhance suicide prevention at VAC from the perspective of front-line staff delivering service one-to-one. Objectives 1. Using the VAC Suicide Prevention Conceptual Framework, identify: a. Suicidal triggers and influencing factors. b. Determine which suicide prevention interventions were used. 2. identify and communicate opportunities for VAC to enhance suicide prevention in Veterans and others receiving services from VAC. Scope his ?le reViewyvill be from the public health, perspective 'of VAC, policy and programs?i Rationale Factors leading to suicide are highly individual, variable and complex; it is not possible to accurately predict all suicides; and suicide is rare. For these reasons, organizations participating in suicide prevention conduct suicide reviews. Protocol Development and Conceptual Framework This protocol is based on reviews of published protocols, scientific evidence about suicide, clinical experience dealing with suicide, experience working with Veterans, and knowledge of VAC's policies, programs and services. The protocol was structured on the VAC Suicide Prevention Framework (Figure 1). The first version of the protocol Was tested and modified during a file review conducted by VAC clinicians in 2010 and then updated in 2014. The protocol was structUred on the VAC Suicide Prevention Framework (Figure 1) and developed by consensus in discussion with the review team. Page 3 (000003 Figure 1. Conceptual framework, 2014 Revision (DRAFT) Pathway, Triggers and In?uencing Factors: Disorders I 'Physicatt-iealth'; I Stressful - i . . Mood and other" the? Event SocraiSituatIon . I Modifiable {Suicidal}; System Factors: -. i-?ldeation Modifiabie "31337-095 1053? I W: ?rEffective care 2' i? - Emotion Regulation ?Soci?aland .. and Cognitive Function occupational -Access to lethal means integration .5: - imitation 8: contagion .. .v S?i'c?diaiic?tf23% Administrative Procedure Panel Composition There will be 4 reviewers: Reieased under the Access to information Act! Divulg?(s) en vertu cle ta Lci sur l?acc?s a l?information. Interventions: Knowledge exchange Screening St assessment Crisis intervention Foilowup care for suicide attempts . Overcome barriersto effective care Pharmacotherapy 8t Social support Re?estabiishment and disability programs Restriction of access to iethai means Media and social media awareness Multiagency participation Review and surveillance Dr. Juan Cargnello NCOSI (French and English) Kelly Carter, Clinical Social Worker, National Mental Health Consultant (English Files) Peggy Nash-Butt, Clinical Social Worker, Case Manager (English Files) Dr. Jim Thompson MD, Medical Advisor, Head Of?ce (Engiish Files) Page 4 (000004 Released under the Access to information Acti - Divulg?ls) en vertu cle la Loi sur l?acc?s a l?information. Sample Case Selection 1. Cases of suicidal ideation, attempts and completed suicide will be identified from the sample frames (see overview document). 2. 15 cases will be assigned to each pair of the 4 reviewers (total of 30 files) for independent review. Data Sources The panel will examine the clients' VAC records. This will include: all client notes, client screening, assessment, summary of assessment, case plan, work items, the documentation section and relevant paper files.. Clinical information in files owned by FPIGPs and other clinicians, service providers and gatekeepers police) will not be available to the reviewers so they might not be aware of the care and services provided to the client outside VAC except as documented in CSDN. People will not review files within which they were involved. Use of personal information for non administrative purpose All reviewers will have to review the outline that describes the privacy requirements while collecting, using and disclosing the personal information in relation to this activity, and in developing the resulting report. It will be important to follow these requirements to ensure that the privacy is respected (annex A). Discussions in regards to observations/findings as a result of the file reviews are to be held only within the working group colleagues at assigned meeting times. When accessing CSDN for a file review, please.use the Drop Down Box Select Inquiry and enter the following information as to reason for CSDN access: Research - File Sample. Only the identified CSDN ?les can be accessed. Safeguard of information In order to safeguard the client information that will be collected/transmitted in the process, please look at the following requirements: . Completed forms are to be identified as Protected and transmitted accordingly, is, double envelope - inner addressed to Dr Jim Thompson and consecutively numbered, marked "To be opened by Addressee Only" and the outer envelope addressed to the unit at HO, with the Internal Box number. (000005 Released under the Access to information Acti Divulg?ls) en vertu cle ia?Loi sur l?acc?s a l?information. .f Veterans Affairs Canada Dr Jim Thompson Branch: Policy, Communications and Commemoration Division: Policy Directorate: Research Location: CHARLOTTETOWN HO AC CHARLOTTETOWN Mail Drop: DJM 041 Building: Daniel J. MacDOnald Room: 406 Province: Prince Edward Island 2.. Take the time to review the Minimum Standards for the Transport or Transmittal. of Designated or Classified Documents (annex B) the completed form is under the Client Files category. 7 3. Do not use the reusable envelopes with the holes. 4. All envelopes should be securely sealed, and you should have a tracking system to acknowledge and confirm receipt so that you are immediately aware of packages that may become delayed/lost in transit. Review Process 1. Head Of?ce will assign the files to the reviewers . 2. Each member of the panel will review 15 files independently, but two members will review the same cases for multidisciplinary perspectives. 3. They will record their observations on a form that we will supply and submit the form to Dr. Jim Thompson at Head Office as identified under Safeguard Information. 4. Dr. Thompson and Kelly Carter will collate the findings into a summary report and will convene a teleconference of the reviewers to go over the summary ?ndings and discuss recommendations. Page 6 (000006 Reieased under the Access to Information Act I Divulg?is) en vertu de fa Lei sur l?acces a l?information. ANNEX ATIP Policy Advice Re: Suicidality File Review Date: 31 January 2014 VAC is considering conducting a qualitative, retrospective review of VAC client suicide cases to identify learning opportunities to enhance suicide prevention in VAC systems. To do this review the project authority has requested to identify and consider the following personal information: Biographical information; year of birth, date of death, service information, employment equity information, gender, medical information, place of death. VAC's provide that, "Information may be used and disclosed for planning, research, development, evaluation and/or reporting of programs, policies and services. The use and disclosure are limited to VAC Areas that re involved in the identified The following details outline the expectations of the VAC project team while collecting, using and disclosing the personal information in relation to this activity, and in developing the resulting report. With the authorization of the collection, use, or disclosure of personal information for a non- administrative purpose, your team will need to ensure that the personal information relates directly to an operating program or activity of VAC (Disability Awards, Disability Pensions and Rehabilitation) for which it has legal authority; the personal information or data elements being collected, used or disclosed will be limited to what is essential to meet the objectives of this activity; and adequate reasons for accessing these deceased client's information will be provided in the electronic file and/or hard copy file, related to the non-administrativepurpose for which the personal information will be collected and used. The project authority along with the team members of the Suicidality File Review will ensure that: The collection, use or disclosure of personal information for this non-administrative purpose is in compliance with the Privacy Act, the Privacy Regulations and related privacy policy requirements of TBS. The personal information will nOt be used or disclosed for any other purpose beyond the original non-administrative purpose for which it was collected. 0 The access to personal information will be limited to those individuals who are 7 authorized to have access and who have a genuine need to know to perform functions or duties related to this non-administrative activity. All authorized individuals, with a need to know, are made aware of their obligations and responsibilities for privacy and confidentiality in relation to the handling of the' personal information. - They have adequate security safeguards in place to ensure the confidentiality and security of personal information that has been collected, used or disclosed for this non- administrative purpose. 0 The personal information collected, used and disclosed for a non-administrative purpose will be stripped of all personal identi?ers (de-identified) once the non-administrative Page 7 (000007 Reieased under the Access to Information Act I. Divulg?is) en vertu de ia Loi sur l?acces a l?information. L:r' - activity has been completed. Your unit will also protect the privacy of individuals, and ensure that the results of its non-administrative activity is, written and presented as aggregate information, or in such a manner that the [identities of the subject individuals can no longer be determined by any method that can be reasonably foreseen. a At the earliest reasonable time after completion of the non-administrative activity, remove personal identi?ers from the personal information that has been collected and used: As well, if in the alternative it is determined that VAC must retain the personal information, it will establish and apply a retention and disposal schedule to the information, including any information generated by the non-administrative program or activity. . - Ensure that the retention period and the final disposition of the information are covered by an approved records retention and disposal schedule, and will dispose of the personal information in accordance with its security practices and procedures. 0 The results of this nonfadministrative activity will not be used to subsequently make any decisions that would directly affect the individuals to whom the information relates. - The results of this non-administrative activity will not be published in a way that could potentially identify the individuals to whom the information relates. My understanding is that you will not be disclosing any personal information outside of VAC. However, if this were to be considered, you should contact ATIP, as your area will also need to ensure that any disclosures of personal information to parties outside of VAC, including other federal government organizations, research institutes, private researches, etc., for non administrative?purposes are made in compliance with Section 8 of the Privacy Act. The project team will need to advise of the descriptions of personal information once it has been used or disclosed for a non-administrative purpose, so that we can ensure that they are reflected in the appropriate PIB description within Info Source. If you have any questions or concerns, please feel free to contact me directly. My contact information is below. Thanks . Renilda MacRae Senior Privacy Policy Advisorl Conseill?re principale en politiques sur la protection des renseignements personnels Access to Information and Privacy 1 Acces a l'information- et protection de la vie priv?e Veterans Affairs Canada Anciens Combattants Canada P.O. Box 7700 7700 CharlottetowanE C1A 8M9 Charlottetown C1A 8M9 Tel. 902-368-4839 Fac T?l?c 902-368-0496 Government of Canada Gauvernement du Canada Page 8 (000008 Reieased under the Access to information Acti I Divulg?(s) en vertu de la Loi sur i?aoc?s a i?information. 1? Suicide General' File Review Protocol Febiuary 2014 VAC Suicide General File Review Protocol I I Page 1 (000009 Released under the Access to information Act Divulg?(s) en vertu cle la Loi sur l?acc?s a l?information. Table of Contents Purpose..' Objectives . .3 Scope Rationale ..3 ConCeptual Framework ..4 Administrative Procedure ..4 Sample Case Selection . .: . .i ..5 Data Sources ..5 Use. of personal information for non administrative purpose ..5 Safeguard of information . . .0 ..5 Review Process Reporting . .6 Annex A ..7 Annex ..9 Annex . ..10 VAC Suicide General File Review Protocol Page 2 (000010 Released under the Access to information Act! Divulg?ls) en vertu ole la Loi sur l?acces a l?information. Purpose The purpose is to describe clients with suicidality and to identify opportunities to enhance suicide preVention at VAC from the perspective of front-line staff delivering serviceone-to-one. The purpose is not to lay blame or ?nd fault. Objectives 1. Using the VAC Suicide Prevention Conceptual Framework, identify: 0 I a. Suicidal triggers and influencing factors. b. Determine which suicide prevention interventions were used. 2. Identify and communicate opportunities for VAC to enhance suicide prevention in Veterans and others receiving services from VAC. Scope This ?le review will be from the perspective of front line staff and mental health consultants who work directly with or in support of clients. Rationale Factors leading to suicide are highly individual, variable'and complex; it is not possible to accurately predict all suicides; and suicide is rare. For these reasons, organizations participating in suicide prevention conduct suicide reviews. VAC Suicide General File Review Protocol Page 3 (000011 Released under the Access to lnformation Act! Divulg?(s) en vertu cle la Loi sur l?acces a l?information. Conceptual Framework The protocol was structured on the VAC Suicide Prevention Framework (Figure 1)1 and developed by consensus in discussion with the review team. Figure 1. Conceptual framework 2014 Revision (DRAFT) Pathway, Triggers and In?uencing Factors: Interventions: Physical earth i Knowledge exchange Screening assessment Socials-imatio? Q: Mooda??d OFher; Crisis intervention we Event 7 3-4 - Followup carefor suicide . Disorders ifi- - Addiction - attempts _r Overcome barriers to effective I care Pharmacotherapy . . CISuicidei . - . StemrFamm T-ldeation -. ??M?di?ab?e and disability __f__Barr_iersrt9 care W: rams ?-Effect'ive Care 4: - Emotion RegulationRestriction ofaccess to lethal ?Socaaland and Cognitive Function . - . . . means occupational . 'Access to lethal means . . . i . - . . . Media and social media . integration imitation contagion - awareness Multiagencv participation 3 suitgdaiAgjtajtj Review and surveillance Administrative Procedure Panel Composition There will be 6 reviewers: Vanessa Bowman, Edmonton?Field Operation-CM (English Files) Yvonne Filion, Montreal-NCMU, MHO (English and French Files) Danica Arseneault, Campbellton-NCMU, NHO (English and French Files) Claudine Hoskins, Winnipeg-NCMU, MHO (English Files) Sylvie Bourgeois. Ottawa- NCMU, MHO (English and French Files) TimMarshall, Montreal, MHSU-MC (English Files) John Goedike, Montreal, MHSU-MC (English Files) VAC Suicide General File Review Protocol I Page 4 (000012 Reieaseci under the Access to information Acti Divulg?ls) en vertu cle la Loi sur l?aoc?s a l?information. Sample Case Selection 1. Cases of suicidal ideation, attempts and completed suicide will be identified from the sample frames. (See the overview document) 2. 10 cases will be assigned to each of the 6. reviewers (total of 60 files). Data Seurc?s . The panel will examine the clients' CSDN records. This will include: all clients notes, tranisition interview, client screening, assessment, summary. of assessment, case plan, work items and the documentation section. Clinical information in files owned by and other clinicians, service providers and gatekeepers police) will not be available to the reviewers so they will not be aware of the care and services provided to the client outside VAC except as documented in CSDN. I People will not review files within which they were involved. . Use of personal information for non administrative purpose All reviewers will have to review the outline that describes the privacy requirements while collecting, using and disclosing the personal information in relation to this activity, and in developing the resulting report. it will be important to follow these requirements to ensure that the privacy is respected (annex A). Discussions in regards to observations/findings as a result of the file reviews are to be held only within the working group colleagues at assigned meeting times. When accessing CSDN for a ?le review, please use the Drop DoWn Box Select Inquiry and enter the following information as to reason for CSDN access: Research - File Sample. Only the identified CSDN files can be accessed. Safeguard of information in order to safeguard the client information that Will be collected/transmitted in the process, please look at the following requirements: 1. Completed forms are to be identified as Protected and transmitted accordingly, ie, double envelope - inner addressed to Dr Jim Thompson and consecutively numbered, marked ?To be opened by Addressee Only" and the outer envelope addressed to the unit at HO, with the Internal Box number. Client identi?ers cannot be included on the completed form. VAC Suicide General File Review Protocol Page 5 (000013 2. 3. 4. Reieased under the Access to information Acti Divulg?(s) en vertu cle la Loi sur l?acc?s a l?information. Veterans Affairs Canada Dr'Jim Thompson Branch: Policy, Communications and Commemoration Division: Policy Directorate: Research A Location: CHARLOTTETOWN HO AC CHARLOTTETOWN - Mail Drop: DJM 041 Building: Daniel J. MacDonald Room: 406 Province: Prince Edward Island Take the time to review the Minimum Standards for the Transport or Transmittal of Designated or Classified Documents (annex B) the completed form is under the Client Files category. Do not use the reusable envelopes with the holes. All envelopes should be securely sealed, and you should have a tracking system to acknowledge and confirm receipt so that you are immediately aware of packages that may become delayed/lost in transit. Review Process 1. Head Of?ce will assign the files to the reviewers 2. Each member of the panel will review 10 files independently. 3. They will record their observations on a form that we will supply and submit the form to Dr Jim Thompson at Head Of?ce as identified under Safeguard information. 4. Dr Thompson and Kelly Carter will collate the findings into a summary report and will convene a teleconference of the reviewers to go over the summary ?ndings and discuss recommendations. VAC Suicide General File Re view Protocol Page 6 '1000014 .2 Reieased under the Access to Information Act! Divulg?ts) en vertu de ia Lei sur l?acces a l?information. ANNEX ATIP Policy Advice Re: Suicidality File Review Date: 31 January 2014 VAC is considering conducting a qualitative, retrospective review of VAC client suicide. cases to identify learning opportunities to enhance suicide prevention in VAC systems. To do this review the project authority has requested to identify and consider the following persOnal information: Biographical information; year of birth, date of death, service information, employment equity information, gender, medical information, place of death. VAC's provide that, "Information may be used and disclosed for planning, research, development, evaluation and/or reporting of programs, policies and services. The use and disclosure are limited to VAC Areas that re involved in the identified - The following details outline the expectations of the VAC project team while collecting, using and disclosing the personal information in relation to this activity, and in developing the' resulting report. With the authorization of the collection, use, or disclosure of personal information for a non? administrative purpose, your team will need to ensure that the personal information relates directly to an operating program or activity of VAC (Disability Awards, Disability Pensions and Rehabilitation) for' which it has legal authority; the personal information or data elements being collected, used or disclosed will be limited to what is eSsential to meet the objectives of this activity; and adequate reasons for accessing these deceased client's information will be provided in the electronic file and/or hard copy file, related to the non-administrative purpose for which the personal information will be collected and used. - The project authority along with the team members of the Suicidality File Review will ensUre that: The collection, use or disclosure of personal information for this non-administrative purpose is in compliance with the Privacy Act, the Privacy Regulations and related privacy policy requirements of TBS. The personal information will not be used or disclosed for any other purpose beyond the original non-administrative purpose for which it was collected. - The access to personal information will be limited to those individuals who are authorized to have access and who have a genuine need to know to perform functions or duties related to this - non-administrative activity. All authorized individuals, with a need to know, are made aware of their obligations and responsibilities for privacy and confidentiality in relation to the handling of the personal information. - - They have adequate security safeguards in place to ensure the confidentiality and security of personal information that has been collected, used or disclosed for this non?administrative purpose. 0 The personal information collected, used and disclosed for a non?administrative purpose will be stripped of all personal identi?ers (de-identified) once the non-administrative activity has been completed. Your unit will also protect the privacy of individuals, and ensure that the results of its VAC Suicide General File Review Protocol I Page 7 (000015 Released under the Access to Information Act! Divulg?is) en vertu de ia Loi sur l?acces a l?information. non?administrative activity is written and presented as aggregate information, or in such a manner that the identities of the subject individuals can no longer be determined by any method that can be? reasonably foreseen. 0 At the earliest reasonable time after completion of the non-administrative activity, remove personal identifiers from the personal information that has been collected and used. As well, if in the alternative it is determined that VAC must retain the personal information, it will establish and apply a retention and disposal schedule to the information, including any information generated by the non-administrative program or activity. 0 Ensure that the retention period and the final disposition of the information are covered by an approved records retention and disposal schedule, and will dispose of the personal information in accordance with its security practices and procedures. 0 The results of this non-administrative activity will not be used to subsequently make any decisions that would directly affect the individuals to whom the information relates. The results of this non-administrative activity will not be published in a way that could potentially identify the individuals to whom the information relates. My understanding is that you will not be disclosing any personal information outside of VAC. However, if this were to be considered, you should contact ATIP, as your area will also need to ensure that any disclosures of personal information to parties outside of VAC, including other federal government organizations; research institutes, private researches, etc., for non administrative purposes are made in compliance with Section 8 of the Privacy Act. The project team will need to advise ATIP of the descriptions of personal information once it has been used or disclosed for a non-administrative purpose, so that we can ensure that they are reflected in the appropriate PIB description within Info Source. If you have any questions or concerns, please feel free to contact me directly. My contactinformation is below. - Thanks Renilda MacRae Senior Privacy Policy Advisor Conseillere principale en politiques sur la protection des renseignements personnels Access to Information and Privacy [Acces a l'information et protection de la vie priv?e Veterans Affairs Canada Anciens Combattants Canada PO. Box 7700 7700 Charlottetown PE C1A 8M9 Charlottetown C1A 8M9 Tel. 902-368-4839 Fac T?l?c 902-368-0496 Government of Canada Gouvernement du Canada VAC Suicide General File Review Protocol Page 8 (000016 911:] [?Jeueg aprorns OVA 6 359d VETERANS AFFAIRS CANADA Minimum Safeguards for the: Transport and Transmittal of Designated and Classified Information and Assets Reieased under the Access to information Act! Divulg?{s) en vertu de ia Loi sur i?acc?s a i?information. Preparation forTransmItIai Moihod of ?l?ransmluai or Damnation "mung 9.3903110" mm? or Proof of Receipt "1:313 First Class Maggy I Courlor? In Parson DOUBLE . . Client Flies on {cider (unwrapped if . - Authorized and securiiy cleared musing Within and berween Frie Tmnm?ai and . (Protected or mums as a minimrn. Also an inner using VA Raw. tom VAC 231 3? I locked case. c) envelope. if appiiubie approved mamnn sea Notes container) . - 7 - Authorized on page one -. - A Dorside Canada on?: cube Wm SINGLE I 7 A I 4? . Protocin page-me . 3 I If med and security cleared person r:st ?mu? orfaeeorihe documenr . - - a case. see Notes a '4 . Authorized PROTECTED momentum Wm DOUBLE iocired casepage one . . - a? 5? - 9 Oman orface .ofihe dammed Doug-LE I I on page ore, Armed nod. gram! persm Outsioe Canada. or. face ofthe as 3 DOUBLE lriqlugeoin ?ocked case? minimum. sea Notes an; Authorized and security-cream person using Wu Canada or face oithe deemed an DOUBLE I u" v? I locked case. minimum so: Notes . - . I Ausz and sunny deared'person-using I on [>890 cal-1mm? Outside Canada me {m of the DOUBLE v? v? 03550. [ciasslnedi Authorized and security dented person usiog . moans r" - \MihrnOarIlda one ?face 9mm DOUBLE 3/ ?f 4? a! 2? locked case. - - -- soc Notes page at, m?ng? mm?dznd. andsme erranch using Outside Canada the.li moon DOUBLE . i . . locked case. sum ENVELOPE oniy- I mm? "om (Classi?er!) transmits! siip Authorized'onriseciriiy {feared persog'rrusino- Canada DOUBLE included inerweiopev I looked case, 7 see Notes "Coa?erServIce maroer ofma?mo, trucking: while In mask and record. of delivery. When appropriate, envelopes shn?rbe marked "To be opened bro: ?For the personal attention or". Notes; In. use or alockabia camping cos: dispatch use shall be used mm: Dosignaied or Classified iniormailon is- in be Emsporied Within Canada. in nature an: nun-visible to the general public. When transpoan Designated (Proiociw No?rtiassi?ad (Protected or Secret) information in a vehicle, employees shall place this information ?00001 7 Released under the Access to information Act! Divulg?ls) en'vei?tu de la Loi sur l?acces a l?information. ANNEX Suicide General File Review Questionnaire PART I CLIENT PROFILE Demographic data: Please transcribe the profile information that you received onto the form. No client identi?ers can be found on the completed form. Put a check for the correct answer. i ?No? can mean both that the characteristic was documented not present or that there was no indication in the file whether the characteristic was present. Age at date of suicide or date of last contact: Sex: Male 0 Female 0 Category (check one only): - War Service Veteran CAF Regular Force Veteran CAF Reserve Force Veteran RCMP Veteran 0 Family member (specify) I Is the client in receipt of VAC Disability Bene?t? 0 Yes No Was the client in the Rehabilitation Program? 0 Yes 0 No Where was the client on the suicide pathway (check one)? Suicidal ideation Suicidal attempt 0 Completed suicide?(see following question) For completed suicide: How did you confirm the manner of death was suicide? Means of death: Location of death: VAC Suicide General File Review Protocol Page 10 (000018 Released under the Access to lnfermatien Act i Divulg?(s} en vertu cle ia Loi sur l?acc?s a l?information. At what stage on the pathway did VAC first engage for suicidality (check only one)? 0 Suicidal ideation Suicidal?attempt 0 Completed suicide Duration of contact with the client for suicidality: 0 None 0 Days 0 Weeks I 0 Months 0 Years PART II - TRIGGERS AND INFLUENCING FACTORS I What triggers and influencing factors were operating in hislher life? Were there any stressful life events 6-12 months prior to the suicide ideation, 0 Yes 0 No attempt or completed suicide increase of social isolation, separation, financial dif?culties, physical or mental health problems, workplace problems, legal difficulties, administrative stressors, unfavorable decision for a VAC Program or Benefit, etc)? Based on information available in the file, note signi?cant life stressors: According to your assessment, categorize the degree of life stress: 0 Low 0 Medium 0 High Did the client have any diagnosed mental health problems or conditions? 0 Yes - No Was the client in receipt of a disability award or disability pension for a medical diagnosis? - 0 Yes No Did the client have any chronic physical health conditions? 0 Yes No Did the client have chronic pain? 0 Yes 0 No Did the client have any addiction issuesWas there suggestion of in?uence of media or social media suicide reporting? 0 Yes 0 No VAC Suicide General File Review Protocol - - Page 11 (000019 Released under the Access to information Act i Divulg?(s} en vertu de ta Loi sur l?acc?s a l?information. 4? PART INTERVENTIONS Screening and Assessment Did the client have a transition interview? 0 Yes 0 Ne Was the client assessed for Suicidal Ideation? - 0 Yes 0 No Was the client assessed for Suicide Attempt? . 0 Yes 0 No Was there follow-up care for suicide ideations or attempts by a VAC staff? 0 Yes 0 No Was there notice received that the client had been denied or received unsatisfactory disability benefit for a conditionso, was there follow up to assess coping and suicidality? 0 Yes No Was an area counsellor client-centered assessment available? 0 Yes 0 No Was suicidality identified in the AC assessment? - 0 Yes No Was there a Case Manager involved in the case? A 0 Yes 0 No Did the client have a case plan? 0 Yes 0 No Was suicidality identified in the case plancompleted? 0 Yes No Was suicidality identified in the . 0 Yes No What was the case complexity: 0 Low 0 Medium 0 High Was the VAC Suicide Awareness and intervention Protocol applied? 0 Yes No Was the client screened for substance use disorders? . 0 Yes 0 No Was there ongoing screening for suicidality? I 0 Yes No Treatment Interventions -Was there a referral to or consult with a health care provider? Check all that apply: 0 Emergency medical services (ambulance), police or a hospital emergency department or_ equivalent IDT MHO Clinical Care Manager Senior District Medical Of?cer or other physician nurse or social worker VAC Suicide General File Review Protocol .. Page 12 4 (000020 Released under the Access to information Act! Divulg?ls) en vertu de la Loi sur l?acces a l?information. Was a safety plan developed with the client such as in the assist model? 0 Yes 0 No Was there follow-up for suicidality in those with ideatiOn or attempts? 0 Yes 0 No Did the client have a regular physician? 0 Yes No 7 Was the client being treated for mental health problems? 0 Yes 0 No Was the client engaged with a or 0 Yes 0 No Was the client being treated for physical health problems? 0 Yes 0 No Was the client being treated for chronic pain? 0 Yes 0 No Was the client being treated for addiction? 0 Yes 0 No Did the client accept referral and follow up with the health professional? 0 Yes 0 No Were service barriers present? 0 Yes 0 No If service barriers were present, did the client receive help negotiating them? 0 Yes No Was the client referred to or engaged with I 0 Yes 0 No Was the family engaged as part of the treatment plan? 0 Yes 0 No Were family services offered? . 0 Yes No Was client engaged in the interventions? 0 Yes No VAC Suicide General File Review Protocol Page 13 (000021 Released under the A6cess to information Act! Divulg?ls) en vertu de la Loi sur l?acc?s a l?informaticn. LA PART IV WHAT WORKED What was helpful for the staff involved with the client in identifying that the client was suicidal? Based on your analysis, what was helpful in reducing the client?s suicide risk or preventing suicide? Other comments Thank you for your participation (revised 2014-0241) VAC Suicide General File Review Protocol Page 14 (000022 Preventinn Pat: ways QF jewnirk Clients Vet-em m: Regaised unde;the Access to lnformgtion Act 1? Divulg?(s) en vertu de la Loi sur t?acc?s a I?infermation. Bis 31 S-Cial S?pp'?g; game-raj: ill 715i . ram? "air 2L :Fie??i?tin Ma?a Released under the Access to Information A:t i Divulg?(s) en vertu de la Loi sur l?acces a l?information. 2014 SUICIDALITY FILE REVIEW (Note to seek approval from Director General, Policy) DATE July 22, 2014 PURPOSE To provide results of the 2014 Suicidality File Review and to seek approval for release. . SUMMARY. 0 Departmental staff conducted a review of 80 client files in February 2014, with the purpose of describing clients with suicidality (ideation, attempts and completed suicides) and to inform suicide prevention at Veterans Affairs Canada (VAC). A report entitled ?2014 Suicidality File Review? was finalized in July 2014 (see Annex A). - 0 Results of a similar suicide case review by the Canadian Armed Forces are publically available. This study was conducted jointly by Research and Strategic Policy. The Research Directorate is seeking approval to release this report internally to those who need it to further their work. RECOMMENDATION 0 Release report to inform the Suicide Action Plan and demonstrate ongoing commitment to suicide prevention. BACKGROUND 1" 0 Departmental staff conducted a review of 80 client files in February 2014, with the purpose of describing clients with suicidality and to inform suicide prevention at Veterans Affairs Canada (VAC). . (000024 Released under the Access to information Act if Divulg?ts} en vertu de la Loi s_ur l?acc?sa l?information. -2- The review had two specific objectives: . 0 Using the VAC Suicide Prevention Conceptual Framework identify suicidal triggers and influencing factors and determine which suicide prevention interventions were used; and 0 Identify and communicate opportunities for VAC to enhance suicide prevention in Veterans and others receiving services from VAC. 0 The file review had two components: a ?front-line? perspective and a ?head office? perspective. 0' There were a few limitations associated with this work: short development time frame, incomplete documentation, reliance on CSDN and the use of qualitative, rather than quantitative, measures due to limitations in the administrative data base. In spite of these limitations, the review provides valuable insights into the nature of VAC clients with suicidality, and VAC suicide prevention activities. CURRENT STATUS A report entitled ?2014 Suicidality File Review? was finalized in July 2014 (see Annex A). a Service delivery is working with a draft of this report with respect to considerations for the Suicide Action Plan. 0 The Research. Directorate is seeking approval to release the final report. 0 The key findings show: I VAC staff are working with Veterans who have the most complex problems in the health care system. - 0 Very elderly Veterans had distinct and troubling suicidality profiles. Suicidality is not only influenced by disorders; predisposing characteristics, chronic physical health problems and socioeconomic difficulties played prominent roles in influencing suicidality. 0 Improved suicide prevention practices at VAC since a 2010 file review. 0 Opportunities to further enhance suicide prevention. 0 The work of VAC staff is has a clinical component; reviewers identified opportunities to enhance infrastructure with respect to suicide prevention. - . 0 Confirmation that the 2010 VAC Suicide Prevention Framework is valid and appropriate. i (000025 Released under the Access to information Act! Divulg?ts) en vertu de la Loi sur l?acces a l?information. CONSIDERATIONS The study was conducted jointly by Research and Strategic Policy,hence seeking DG Policy comment and advice on approval route. A draft of this report has already been shared with the Case Management Support Services Directorate within Service Delivery Branch for comment and consideration. Results can increase staff awareness and inform case management practice and suicide prevention activities at VAC. - The report provides a measure of how VAC is doing in terms of suicide prevention and demonstrates improvement. These findings show that VAC staff who do not have clinical backgrounds are doing work that could be considered clinical. A Not making the report available prevents the results from informing practices in suicide prevention and the development of the mental health strategy. - The report of a similar suicide case review by the Canadian Armed Forces is publically available on the "Surgeon General's Health Research Program? web page on the Canadian Institute of Military Veteran Health Research website. There has been no negative impact of this release. VAC could release this report publically as well to demonstrate ongoing work to improve suicide prevention practices and inform service providers. OPTIONS Do not release report, either internally or externally. Release internally to inform the Suicide Action Plan and mental health strategy Release publically like the CAF suicide case review report. (000026 . Released under the Access to information Act! Divulg?ls) en vertu de la Loi sur l?acces a?l?information. d' 7 a. RECOMMENDATION 0 Release internally to inform the Suicide Action Plan and mental health strategy as well as externally to demonstrate ongoing commitment and knowledge transfer. . NEXT STEPS 0 Follow DG Po'licy advice with respect to getting this file review report approved for release. ,0 Release the report. Director of Research Annex A-2014 Suicidality File Review (000027 Released under the Access to tnformation Acti Divulg?(s) en vertu de la Loi sur l?acces a i?infermation. I?d VatamnsA?aite ms Combattants a a PROTECTED Suicide General File Review Questionnaire PART I CLIENT PROFILE Demographic data: Please transcribe the profile information that you received onto the form. No client identifiers can be found on the completed form. Put a check for thecorrect answer. "No" can mean both that the characteristic was documented not present or that there was no indication in the ?le whether the characteristic was present. Age at date of suicide or date of last contact: Sex: - Male 0 Female 0 Category (check one only): 0 War Service Veteran CAF Regular Force Veteran CAF Reserve Force Veteran RCMP Veteran 0 Family member (specify) I Is the client in receipt of VAC Disability Benefit? 0 Yes 0 No Was the client in the Rehabilitation Program? 0 _Yes No Where was the client on the suicide pathw'ay (check one)? 0 Suicidal ideation Suicidal attempt 0 Completed suicide (see following question) For completed suicide: How did you confirm the manner of death was suicide? Means of death: Location of death: 1 Canada.I (000028 Reieasea unaei? Access :9 iniormaglon Divulg?(s) en vertu cle la Loi sur l?acces a l?information. - t? . ?wc Veteransz AnciensCombattants Canada Canada PROTECTED At what stage on the pathway did VAC first engage for suicidality (check only one)? 0 Suicidal ideation Suicidal attempt 0 Completed suicide Duration of VAC's contact with the client for suicidality: 0 None 0 Days 0 Weeks 0 Months 0 Years PART II TRIGGERS AND INFLUENCING FACTORS What triggers and influencing factors were operating in hislher life? Were there any stressful life events 6-12 months prior to the suicide ideation, 0 Yes No attempt or completed suicide increase of social isolation, separation, financial dif?culties, physical or mental health problems, workplace problems, legal difficulties, administrative stressors, unfavorable decision for a VAC Program or Benefit, etc)? Based on information available in the file, note signi?cant life stressors: According to your assessment, categorize the degree of life stress: 0 Low 0 Medium 0 High Did the client have any diagnosed mental health problems or conditions? 0 Yes No Was the client in receipt of a disability award or disability pension for a medical diagnosis? 0 Yes No Did the client have any chronic physical health conditions? 0 Yes 0 No Did the client have chronic pain? I ?0 Yes 0 No Did the client have any addiction issuesWas there suggestion of influence of media or social media suicide reporting? 0 Yes I No 2 Canad'a' (000029 Released under the Access to information Acti Divulg?(s) en vertu ole la Lei sur l?acc?s a l?informatien. msCombattants . a PROTECTED PART INTERVENTIONS Screeninq and Assessment Did the client have a transition interview? Yes No Was the client assessed for Suicidal Ideation? 0 Yes No Was the client assessed for Suicide Attempt? 0 Yes 0 No Was there follow-up care for suicide ideations. or attempts by a VAC staff? 0 Yes 0 No Was there notice received that the client had been denied or received unsatisfactory disability benefit for a condition? 0 Yes 0 No If so, was there follow up to assess coping and suicidalityarea counsellor client-centered assessment available? - 0 Yes 0 No Was suicidality identified in the AC assessment? 0 Yes 0 No Was there a Case Manager involved in the case? 0 Yes 0 No Did the client have a case plan? 0 Yes 0 No Was suicidality identified in the case plancompleted? 0 Yes 0 No Was suicidality identified in the 0 Yes 0 No What was the case complexity: 0 Low 0 Medium 0 High Was the VAC Suicide Awareness and Intervention Protocol appliedWas the client screened for substance use disorders? 0 Yes 0 No Was there ongoing screening for suicidality? 0 Yes 0 No Treatment Interventions Was there a referral to or consult with a health care provider? Check all that apply: 0 - Emergency medical services (ambulance), police or a hospital emergency department or equivalent IDT MHO Clinical Care Manager Senior District Medical Of?cer or other physician nurse or social worker 00000 3 Canad'?' (000030 Reteased under the Access to information Acti Divulg?(s) en vertu cle la Lei sur i?acc?s a l?infermatien. ?4 .7 i? I ms Affairs Anciens Combattants a ?ma - PROTECTED Was a safety plan developed with the client such as in the assist model? 0 Yes 0 No Was there follow-up for suicidality in those with ideation or attempts? . 0 Yes 0 No Did the client have a regular physician? - 0 Yes No Was the client being treated for mental health problems? . 0 Yes 0 No Was the client engaged with Was the client being treated for physical health problems? 0 Yes 0 No Was the client being treated for chronic pain? 0 Yes No was the client being treated for addictionDid the client accept referral and follow up with?the health professional? 0 Yes 0 No Were Service barriers present? 0 Yes 0 No If service barriers were present, did the client receive help negotiating them? 0 Yes Or No Was the client referred to or engaged with 0 Yes. No Was the family engaged as part of the treatment plan? 0 Yes 0 No Were family services offered? i 0 Yes No Was client engaged in the interventionsCanada (000031 Released under the Access to information Act I Divulg?(s) en ver?tu de la Loi sur l?acc?s a l?information. memes PART IV WHAT WORKED - What was helpful for the staff involved with the client in identifying that the client was suicidal? Based on your analysis, what was helpful in reducing the client's suicide risk or preventing suicide? Other comments Thank you for your participation (revised 2014-02-11) . Ii! 5 Canada (000032 Released underethe Access to lnfermation Act 1? Divulg?(s} en vertu de ia Loi sur l?acces a l?information. VeteransA?alrs mummttams We a a Protected VAC Suicide Clinical File Review Questionnaire File Review The reviewer will examine VAC administrative files to retrieve the following information about the client profile, sUicide triggers and influencing factors, and suicide prevention interventions. "No" means that evidence was not found in the file, however this does not mean that the item was not present, merely not documented in the VAC file. For example, the item might be well be documented in service records of other agencies, such as provincial and private health care providers. Reviewer: Date of Review: Part 1. Client Prefile Category: Veteran War Service (WW II or Korean War) Veteran QAF Regular Force El - Veteran CEAF Reserve Force Family or Other type of client, specify Age at death or [2 st contacti Sex: Male Female VAC Region: Marital status: Rank at release: Service Branch: Army Navy Air Force Length of service Deployment history: Homeless yesD no Page 1_ I Canad?' (000033 Released under the Access to information Act 1? Divulg?(s} en vertu cle ia Loi sur l?acc?s a l?information. 'd .VeteransAflalrs WOOmbattants ?Md? 3 Protected Part 2. Where was the client on the suicide pathway? Check one: Suicidal ideation El Suicide attempt El Completed suicide At what stage on the pathway did VAC ?rst engage for suicidality? Suicidal ideation Cl Suicide attempt Completed suicide For completed suicide: How did you confirm the manner of death was suicide? Means of death: Site of death: Had the client been known to VAC to be suicidal prior to their suicide? I yes El no El Duration of VAC's contact with the client for suicidality: None El Days El Weeks Months Years Part 3. Suicide Triggers and Influencing Factors Stress: Were there any stressful life events 6-12 months prior to the suicide ideation, attempt or completed suicide increase of social isolation, separation, financial dif?culties, physical or mental health problems, workplace problems, legal dif?culties, administrative stressors, unfavorable decision for a VAC Program or Bene?t, etc)? Yes No Based on information available in the file, note significant life stressors: Degree of life stress burden: low medium 1] I high Health: 0 Mental health problems yes no [1 0 Physical health problems yes El no Co?morbidity of either or physical health conditions or co-occurrence of both a condition and a physical health condition yes no Addiction or substance misuse yes no Page 2 C3113 3 (000034 Released under the Access to information Act! Divulg?is) en vertu de la Loi sur l?acces a l?information. Protected Emotion regulation, personality and/or cognitive function factors potentially predisposing to suicidality Disability: . 0 Restricted role or function in work, family or com munity yesEl noEl yeleI noEl Needed help with a basic or instrumental activity of daily living yes no El Social factors: . 0 Marital or family relationship problems 0 Workplace problems 0 Social interaction problem yes [Appeared unstable in any dimension of health, disability or social situation yes no [1 Evidence of media influence yes no Evidence of social media influence yes [1 no El Part 4. Suicide Prevention Interventions Swoldallty screening and assessment, management Was the client assessed for Suicidal Ideation? . Was the client assessed for Suicide Attempt? Screening] assessment for suicide by service providers other than VAC staff I I VAC response to clients who appeared to be at risk for suic DescribeWas there a referral to. or consult with a health care provider? Check all that apply: a hospital emergency department . . . Emergency medical serVIces (ambulance), police or IDT MHO . Clinical Care Manager Senior District Medical Of?cer or other physician nurse or social worker Barriers to Care Was ?client engaged inlinterventions? . Stigma issues yes'EI no El Page 3 Canard? (000035 Reieased under the Access to information Act! Divulg?is) en vertu de la Loi sur l?acces a l?informatien. ?5 VeteransAifali-s meombattants cm? a Protected Had a regular primary care physician yes El no Evidence of coordinationlcollaboration: 0 Collaboration among health care providers yes El no or Collaboration among an interdisciplinary mental health team yes no Issues accessing care, e.g. waiting times or problems with referral yes no Pharmacotherapy and for Mental Health Problems Treatment for mental health problems . yes no Taking medications for mental health conditions yes no Referred to OSI clinic yes no In treatment at an OSI clinic yes no El Seeing a . yes El no Seeing a or social worker or nurse yes no Couple or family counselling yes no Other Treatment Treatment for physical health conditions yes no Treatment for chronic pain - - yes no Assessment and treatment at interdisciplinary pain clinic yes no Addiction treatment yes El no Occupational Therapy and/or Physiotherapy assessment and treatment yes no El Follow-ug Care Follow up with clients for suicidal ideation or attempts yes no Contact with family members when VAC concerned about client's suicidality yes no Follow up with survivors after suicide: - yes no Social Supports Degree of VAC Case Manager involvement not only for suicidality low medium high Referred to or using a Clinical Care Manager yes i] no Ci Involved with OSISS yes no Receiving assistance from CAF Assisting Officer yes no Receiving social assistance from provincial or municipal sources yes no VAC Programs and Services Was the client in receipt of a disability benefit for a mental health condition? yes El no El Was the client in receipt of a disability benefit for a phySical health condition? yes no Page 4 Canada 1 (000036 f4 ?44 '44 Affg??gg?' W4 44444? I Received disability pension/award posthumously Released under the Access to information Act! Divulg?ls) en vertu de la Loi sur l?acces a l?information. Veteran: Affairs Was the client in the Rehabilitation Program: . For a physical health problem yes El no For a mental health problem yes El no El 1 Receiving VAC Earnings Loss support yes El no yes El no [1 Determined to be Totally and Permanently lncapacitated (unable to work) yes El no Multi-aqencv Collaboration Collaboration specifically for suicide prevention yes El no Reduction of Access to Lethal Means Access to lethal means limited by some provider or agency yes no El I Svstematic Quality Improvement VAC staff conducted a? review following death yes no Part 5. What worked? 1 7 Protected What was helpful to the staff involved with the client in identifying that the client was suicidal? Based on your analysis, what was helpful in reducing the client's suicide risk or preventing suicide? Thank you for your participation Page 5 C3113 [vi 3 (000037 WV 7 . '7 - Reieased under the Access ta information Act I- Divulg?(s) en vertu de ta Lqi sur I?acces a I?information. Veterans A: ff;- Canada wiereeageca individual Suicidality File. Review Briefing to the Senior Management Committee by Service Delivery Branch June 2015 Canada '000038 Reieased under the Access is information Act I Divulg?(s) en vertu de 1a Loi sur I?acces a I?information. Canada, veier-an-sgerca AIM . To determine whether VAC should conduct formal file reviews in cases of individual suicidality. - Canada 2' . '000039 Released under the Access to information Act 1 Divulg?ts} en vertu cle la Loi sur l?acc?s a l?information. veteran'sgmca BACKGROUND The report ?Suicide Prevention at Veterans Affairs Canada: Activities and Recommendations? (August, 2010) recommended that VAC: Establish a formal, standardized mechaniSm and requirement to record, report and review VAC client completed suicides; - - A Assist Area Office management in conducting and reporting reviews of client suicides to inform VAC suicide prevention activities and support staff. There was also great-concern over the reported suicides of Veterans in- the last few years, creating an urgent need to better understand risk assessment and prevention at VAC. Canada a 000040 Released under the Access to lnformation Act I Divulg?(s} en vertu cle la Loi sur l?acces a l?information. Veterans veteransgma General File Review I VAC has completed general suicidality file reviews in 2010 and 2014. Approval to conduct these reviews was obtained from ATIP. A . *Data from these reviews is aggregated, the identity of individual Veterans is protected. Data from these reviews has provided VAC with significant information regarding suicide triggers and influencing factors . as well as the efficacy Of our suicide prevention and. intervention practices. - I Canad 4 000041 Released under the Access to information Act! Divulg?(s) en vertu cle la Loi sur l?acces a l?information. - velar-333$ch Fomal Individual FileReview Advantages: Provides reassurance and/or feedback to employees involved regarding their interactions in the case and their application of the VAC Suicide'Awareness and Intervention Protocol; - . - Offers the opportunity 'for learning and improvement through case-specific quality control and feedback; - Ensures employees are directed to appropriate supports. - Canada 5 000042 Released under the Access to information Act! Divulg?(s) en vertu cle la Loi sur l?acces a l?information. aw Veteran's- Aff' Canada Formal Individual File Revi Considerations: - Privacy/Access to Information: - VAC will need clear guidelines on authority to pro_Ceed with reviews and who will have access to the review findings. Consent IConfidentiality: The consent requirements for the Veteran and their family will need ,to be clear. . The confidentiality of the Veteran and their family will need to be assured. - Access to EXternal Reports: Given that VAC is not a direct provider of care, it has only limited information as to the circumstances that led to suicidality. For example access to family members, coroners report and external medical and mental health reports. Individual file reviews therefore can only provide limited learning. ?m i anada 6 9W 000043 Released under the Access to information 71* Divulg?(s) en vertu cle la Loi sur l?aoces a l?information. Veterans Formal Individual File Review Considerations There are ethical and legal considerations regarding reporting to I family members; Professional, ethical and legal considerations f0r employees whose actions will be reviewed; - Supporting employees Who may be traumatized or emotionally impacted by the event being reviewed and ensuring that a safe and supportive atmosphere is created; Developing a structured, clear, and supportive process feedback process for the employees involved. l+l Canada 7 I ?000044 Released under the Access to information Act I Divulg?(s) en vertu cle la Loi sur l?acces a l?information. Veterans Canada, vetereesgcica Recommendations - That VAC continue to periodically perform general suicidality file reviews; - That the process used for the general 2014 file review be maintained and that the data obtained from future reviews be used to update our suicide prevention strategy and suicide prevention action plan. - That VAC encourage informal individual file reviews at the District level to . ensfure 1) appropriate documentation; timely support to family and impacted sta . a - Continue to inv'eSt in population research on Veterans in order to better understand the complex issues related to suicidality. Canad?' 8 ?000045 Reieased under the Access to Information Act I Divulg?is) en vertu cle ia Lei sur l?acc?s a l?information. VAC Suicide PreVention Conceptual Framework '03 February 2014; NOTFOR DISTRIBUTION Suicide occurs at the end of highly individual pathways that begin with suicidal ideation I (thoughts), progress in some to suicide attempts, and end for a small number in death by suicide. All three stages together are called "suicidality". Suicide is a relatively rare cause of death, about 12 per 100,000 Canadians per year. In 2009, suicide was the second most common cause of death in Canadians aged 15-34, the cause of death overall, more common in men, and most common in Canadians aged 40-59. Why Does Suicide Occur? There are multiple factors in suicides that vary in relative importance from person to person. Typically, there is ongoing stress and a recent stressful life event related to a physical and/or mental health problem, social problems such as loss of relationship orjob, financial difficulty or some other difficulty, often in combinations. A condition is commonly present, particularly depression, often along with a chronic physical health condition and sometimes substance misuse. Depending on the person's ability to regulate their emotions and their problem?solving style, the person begins to feel disconnected from and a burden on others, and eventually loses their fear and pain of dying by suicide. If they have access to a lethal means in this state, they might attempt suicide. Suicide can be triggered in people at this point when they hear about another person's suicide, particularly if they identify with the person. Research has shown that factors which move military personnel and Veterans along suicidal pathways generally are similar to those in civilians. The 2010 Survey on Transition to Civilian Life reaffirmed that mental health conditions were strong factors in suicidal ideation, particularly depression. The study strengthened emerging evidence that physical health conditions and social factors also play roles in suicidality, and found that deployment was not associated with suicidal ideation. The study showed that chronic physical health problems affecting quality of life such as painful musculoskeletal conditions and related activity limitations were more common in recent CAF Veterans than in the general population. While deployment itself does not appear to be a risk factor for suicide, a recent study of CAP personnel deployed in support "of the Afghanistan mission found that the incidence of deployment-related mental health diagnoses was highest in those deployed to a high threat location. Suicide also occurs in military personnel and Veterans who have never deployed. What Helps to Prevent Suicide? . Although progress has been made in understanding suicide, death by suicide continues to occur unexpectedly, even when people receive expert care. Suicide is a dif?cult public health problem for both civilian and military populations. Suicides can be prevented by reducing barriers to receiving timely, effective care for mental and chronic physical health problems; providing social support; managing stressors; removing access to lethal means; and appropriate public discussion about suicides so as to reduce contagion and promote the spread of good information. Suicide Prevention Conceptual Framework Page 1 (000046 Released under the Access to Information Act! Divulg?is) en vertu de la Loi sur l?acces a l?informaticn. Conceptual Framework The file review is based on the VAC Suicide Prevention Framework? The ?gure captures 3 core concepts: 1. The pathway from ideation to act. 2. Triggers and influencing factors. .x 3. Interventions. 2014 Revision (DRAFT) . Pathway; Triggers and Influencing Factors: interventions: PhysicaiHealth' Knowiedgeexchange .th. .. Screening&assessment - res "iifeiiven't I Sedalsmat?on 6?9 '3 PS Chiatric cr'SIsmtewentlon - - .. DY d. - Foiicwup carefor smelde - . .- ers Addiction attempts . . - - Overcome barriersto effective I care I Pharmacotherapy Modifiabie (Snicidalj. Sodafzgg?erapy 5y" stern Factors: ideation Modifiable . . .. 1ulsarrit-zt?sto car.e_' I I I individual Factors: Re 83:22::3m and dlsab'hw ff-?Effective care - Emotion Regulation . . . .?is?cia! and . and Cognitive Function Restrgiiggsof access to lethai occupationai -Access to iethai means Media and soda: media integration ?i imitation 8: contagion - . I awareness Muitiagency participation Review and surveillance Framework History 0 Initial framework created by a meeting of experts from 15 countries in Salzburg Austria (Mann et al 2005). 0 Framework modified by the CAF International Expert Panel for serving CAF personnel in Halifax in 2009 (Zamorski 2010). 0 Framework modified far Veterans and VAC clients by VAC Suicide Prevention Working Group in 2010 (Thompson et al 2010) based on review of new literature since Mann et al 2005. Validated by analysis of ideation and attempt data from the 2010 Survey on Transition to . Civilian Life. . 0 Updated literature search conducted in January 2014 to inform the 2014 update (Thompson 2014). 1 Thompson JM, Carrese L, Carter K. Conceptual Framework for Suicide Prevention at Veterans Affairs 7 Canada. Veterans Affairs Canada. Research Directorate Technical Report. DRAFT in preparation. 2014. Suicide Prevention Conceptual Framework Page 2 (000047 Released under the Access to lnformation Act I Divulg?ts} en vertu cle la Loi sur l?acc?s a l?information. 19(1) i VAC Suicidality General File Review Sui?cide?_ Completed . Attempt I. ._S"uicide' :3 TOtal :1 n=1-8 1 5? PARTI PRQEILE Age at Last contact 34 or less 35-54 55-64 65+ 73 Age at Death 34 or less 35-54 55-64 1, 65+ Male Female Client Type: Veteran War Service Veteran CAF Regular Force Veteran CAF Reserve Force Family or Other type of client Is the client in receipt of VAC Disability Benefit? 18 45 Was the client in the Rehabilitation Program? 23 At?what stage on the pathway did VAC ?rst engage for suicidality . Suicidal ideation 17 Suicide attempt 14 Completed suicide 20 Duration of contact with the client for suicidality: None Days Weeks Months Years PART II TRIGGERS AND INFLUENCING FACTORS Were there any stressful lifeevents 6- 12 months prior to the suicide 10 13 17 40 ideation, attempt or completed suicide According to your assessment, categorize the degree of life stress: Low Medium High Page 1" "We. (000048 Released under the Access to information Act I Divulg?ts} en yertu cle la Lei sur l?acces a l?informatjen. 5379(1) -- Suicidal ;;Suicid__e Completed lde t' 4 "?rr'Attempt arr--5.suigiuq . T?ta' . a 31in=18 1.7 D/idthe client have any diagnosed 14 15 mental health problems or conditions? Disability benefit for a 10 11 medicalx?diagnosis Did the client have any chronic 17 13 physical health conditions Did the client have chronic pain 15 12 Did the client have any addiction issues Was there suggestion of influence of media or social media suicide reporting? PART INTERVENTIONS Screening and Assessment Did the client have a transition interview? Was the client assessed for Suicidal a Ideation? Was the client assessed for Suicide 7 Attempt? Was there follow-up care for suicide ideations or attempts by a VAC staff? Was there notice received that the client had been denied or received unsatisfactory disability benefit for a condition? If so, was there follow up to assess coping and suicidality? Was an area counsellor client- centered assessment available?- Was suicidality identified in the AC assessment? Was there a Case Manager involved in the case? Did the client have a case plan? Was suicidality identified in the case plan? Was a RRIT completed? Was suicidality identified in the What was the case complexity: Low - Medium High 0 Was the VAC Suicide Awareness and Intervention Protocol applied? Was the client screened for substance use disorders? Was there ongoing screening for suicidality? Page 2 I - (000049 Released under the Access to information Act I Divulg?ts) en vertu de la Loi sur l?acces a I?information. .Vldeatgion ,i Suicide. Attempt .: in=18 tsmamr; :123- f-raal1 j? Treatment Interventions Was there a referral to or consult with a health care provider? Check all that apply: Ambulance, police or ED IDT MHO Clinical Care Manager Senior District Medical Officer or other physician nurse or social worker Was a safety plan developed with the client such as in the assist model? -- I I nil Was there follow-up for suicidality in those with ideation or attempts? Did the client have a regular physician? Was the client being treated for mental health problems? Was the client engaged with a or Was the client being treated for physical health problems? Was the client being treated for chronic pain? Was the client being treated for addiction? Did the client accept referral and follow up with the health professional? Were service barriers present? If service barriers were present, did, the client receive help negotiating them? Was the client referred to or engaged with Was the family engaged as part of the treatment plan? Were family services offered? Was client engaged in the interventions? s.19(1) (000050 Released under the Access to information Act i Divulg?(s} en vertu de la Loi sur l?acces a l?information. OVERALL SUMMARY VAC Suicidality Clinical File Review *Total numbers are provided for columns and rows, but readers are reminded that owing to large uncertainties in documentation and the way the sample was stratified then resulting proportions merely illustrate qualitatively and are not quantitatively representative. Suicidal - Suicide Completed . Ideation {Atte pit Total: 5 =15t~ .'n5;30* Client Type Veteran War Service Veteran CAF Regular Force Veteran CAF Reserve Force Family or Other type of client Age at Last contact 34 or less 35-54 55-64 65+ Age at Death 34 or less 35-54 55-64 65+ Years between service ending and suicide 2 or less 3-5 6-10 10+ Male Female VAC Region West Ontario Quebec Atlantic Marital status Married Common Law s" Widowed, Separated, Divorced Single Never Married Rank at release; Officer NCM Service Branch Army Plavyr I Page 1 i/ (14" :1 Clinical Review s.19(1) r'r (000051' Released under the Access to information Act 1? Divulg?(s} en vertu de la Loi sur l?acces a l?information. s.19(1) gsuiCidal Suicide- ._C_ompleted . geldeation ,Suicide, Total . tin .n - 7- i'n- 30* "yea-Air Force 2 .- it-? - Length of service 5 years 5-9 years 10-19 years 20-24 years 25 years+ Deployed Homeless Part 2. Where was the client on the suicide pathway? At'what stage on the pathway did VAC ?rst engage for suicidality? Suicidal ideation 7 14 Suicide attempt Completed suicide For completed suicide Means of death Site of death Client known to VAC to be suicidal prior to suicide - Duration of VA C's contact with the client for suicidality None Days Weeks Months Years Part 3. Suicide Triggers and Influencing Factors Stressful life events 6-12 months prior to the suicide ideation, attempt or completed 14 suicide - Degree of life stress burden Low 26 Medium High 19 Health Mental health problems 15 2 28 Physical health problems . 15 29 Page 2 . Clinical Review .-. . 7 4-;2 (000052 Released under the Access to information Act 1? Divulg?ts} en vertu de ia Loi sur l?aco?s a l?information. s.19(1) j;Suicide1__COmpleted .- 32' gmai Suicidal. . Ideation Suic'd' n=15*? n=30*: Co?morbidity of either or physical health conditions or co-occurrence of both a 14 25 condition and a physical health condition Addiction or substance misuse Emotion regulation, personality and/or cognitive function factors potentially predisposing to suicidality 13 Disability Restricted role or function in work, family or community Needed help with a basic or instrumental activity of daily living Social factors Marital or family relationship problems Workplace problems Social interaction problem Appeared unstable in any dimension of health, disability or social situation Evidence of media influence Evidence of social media influence Part 4. Suicide Prevention Interventions Suicidality screening and assessment, crisis management Was the client assessed for Suicidal Idea?on? Was the client assessed for Suicide Attempt? Screening] assessment for suicide by service providers other than VAC staff VAC responded to clients who appeared to be at risk of suicide Was there-a referral to or consult with a health care provider? Check all that apply Ambulance, police, ED IDT MHO Clinical Care Manager Senidr District Medical Of?cer or other physician nurse or social 14 10' worker Barriers to Care: - Client engaged in interventions 17 Stigma issues 10 Page 3 ?Clinical Review(000053 Released under the Access to information Act 1? Divulg?ts} en vertu de ta Loi sur l?aco?s a l?information. s.19(1) . f-Suicidal?g' Suicide; compietea?""i??if . - Attempt}, Suicide 5' Total ctr-W - . Vn=8* ?13, Had a regular primary care physician 10 16 - Collaboration among health care providers 11 Collaboration among an interdisciplinary mental health team Issues accessing care, e.g. waiting times or problems with referral Pharmacotherapy and Mental Health Problems Treatment for mental health problems Taking medications for mentalhealth conditions KR Referred to OSI clinic In treatment at an OSI clini'ci Seeing a Seeing a or socialworker or nurse av Couple or family counselling Other Treatment a Treatment for physical health conditions Treatment for chronic pain \l 7 Assessment and treatment at ?3 interdisciplinary pain clinic . Addiction treatment - Occupational Therapy assessment and treatment Follow-up Care Follow up with clients for Suicidal ideation or attempts Contact with family members when VAC concerned about glient's suicidality Follow up with survivors after suicide Social. Supports Degree of VAC Case Manager involvement not only for/suicidality Low Medium High Referred to or using a Clinical Care Manager l/nVolved with OSISS t-er/Receiving assistance from CAF Assisting if?? Officer Receiving social assistance from provincial or municipal sources VAC Programs and Sen/ices Disability benefit for a mental health condition Page 4 (000054 Released under the Access to information Act! Divulg?ls) en vertu de la Loi sur l?acces a l?information. In the Rehabilitation Program For aphysical health problem For a mental health problem Receiving?VAC Earnings Loss support Received disability pension/award posthumously A Totally and Permanently Incapacitated -. ?n it Completed-g.- Ideation Attempt?? Suiciqe; ,Tot? ?ix - ?ns-15* [n Disability benefit for a physical health 12 -- i? 21 . condition Access to lethal means limited by some Mum-agency Cellaboration Collaboration specifically for suicide prevention Reduction of Access?to Lethal Means provider or agency **In one case the client vilas recorded as reporting that social media was pretective. '7 7- 53 tr - s.19(1) Page 5 Clinical Review (000055 Released under the Access to lnformation Act! Divulg?ls) en vertu de la Loi sur l?acces a l?informatien. 1 Veterans Affairs Anciens Combattants Canada Canada 2014 Suicidality File Review Jim Thompson MD FCFP, Medical Advisor, Research Directorate Kelly Carter MSW, National Mental Health Consultant, Strategic Policy Integration Veterans Affairs Canada Charlottetown PE Canada E-mail: 21 July 2014 Citation: Thompson JM, Carter K. Findings from the 2014 Suicidality File Review. Charlottetown PE: Research Directorate, Veterans Affairs Canada. Research Directorate Technical Report. Charlottetown. 26 May 2014. - Research Directorate Report I Can (15' (000056 Released under the Access to information Act I Divulg?ts) en vertu de la Loi sur l?acces a l?information. VAC Suicidality File Review Contents Executive Summary .. 3 Sommaire ex?cutif .i .. 5 Introduction .. 6 Method .. 6 Conceptual Frameworks .L .. 6 File Review Components 6 Conceptual Frameworks .. 7 Sample Identi?cation .. 8 Limitations .. 10 Reliance on CSDN .. 10 Findings: Triggers and Influencing Factors ..- ..10 Life Stressors .. 10 Disorders .. 10 Physical Health .. 1 1 Addictions .. 1 1 Social Situation .. 1 1 Barriers to Effective Care .. 11 Social and Occupational Integration .. 1 1 Factors Predisposing to and Protecting Against Suicidality .. 12 Access to Lethal Means .. 12 Imitation/Contagion .. 12 Findings: Suicide Prevention Interventions ..12 Knowledge Exchange/Gatekeeper Role/Screening, Assessment and Monitoring .. 12 Crisis Intervention .. 13 Overcoming Barriers to Effective Care .. 13 Pharmacotherapy and .. 13 Social Supports .Q .. 13 Follow up Care for Suicidal ldeation and Attempts .. 13 VAC Benefits, Programs and Services .. 14 Muitiagency Collaboration ..14 Restriction of Access to Lethal Means ..14 Media and Social Media Influence ..14 Systematic Quality Improvement . ..14 Recommendations ..14 Appendix 1. Previous VAC and CAF File Reviews ..15 VAC 2010 Suicide Case Review .. 15 CAF 2011-12 Suicide Case Review .. 15 Appendix 2. Findings from the "head office" file review ..17 Appendix 3. Findings from the "front line" file review. ..- ..23 2 I - Suicidality File Review 2014 (000057 Reieased under the Access to information Act I Divulg?(s) en vertu de ia Loi sur I?acces l?information. Executive Summary Veterans Affairs Canada (VAC) conducted this file review of 80 clients1 with suicidality (suicidal ideation, suicide attempts or completed suicide) in February 2014. The purpose was to describe clients with suicidality and to identify opportunities toenhance suicide prevention at VAC. The objectives were: i 1. Using the VAC Suicide Prevention Conceptual Framework, identify suicidal triggers and influencing factors and determine which suicide prevention interventions were used. 2. Identify and communicate opportunities for VAC to enhance suicide prevention for Veterans and others receiving services from VAC. Findings Kev qeneral observations: 0 VAC staff work with Veterans who have the most complex problems in the health care system. 0 Suicidality is not only influenced by disorders. - 0 Chronic physical health problems played prominent roles in in?uencing suicidality and were present in the majority, and addiction appeared to play a role in several cases. 0 Predisposing characteristics and social and economic problems also played key roles. . The review confirmed that the 2010 VAC Suicide Prevention Framework is generally valid and supports the draft 2014 modification. 0 The review demonstrated improVed suicide prevention practices since the 2010 file review. Reviewers found some "best practice" case examples where it was thought likely that VAC front line staff were effective in preventing suicides. -o However the reviewers also identified opportunities to enhance suicide prevention. The work of VAC staff has a clinical component and the reviewers identified relevant opportunities to enhance infrastructure within the organization with respect to suicide prevention: . The VAC administrative database was designed for administrative purposes not the clinical function of documenting client progress with respect to their complex health and disability problems or for tracking suicidality in VAC clients for either individual client care or population surveillance. 0 Work processes did not seem to facilitate consultation by VAC front line staff with health professionals, both within VAC and with clients' health care providers outside VAC. Suicide prevention is complex and there were opportunities for ongoing continuing education designed to support this kind of clinical activity. - Very elderly Veterans had distinct suicidality profiles, including stresses from social isolation, housing transitions and the presence of multiple chronic physical health problems and frailty; relatively less documentation of mental health problems; and relatively less documentation of collaboration among service and health care providers. Some died by suicide in socially isolatedcircumstances but were not homeless. 1 "Client" means a person with a client ID and participation in VAC programs. 3 I . . Suicidality File Review 2014 (000058 Released under the Access to information Act Divulg?(s) en vertu ole 1a Loi sur l?acc?s a l?information. Sociodemographic profile of the reviewed cases: There were 24 cases with ideation, 25 with attempts and 31 completed suicides. Sixteen were women and most were male (63/79). There were 45 Canadian Armed Forces (CAF) Regular Force Veterans, 12 War Service (Second World War and Korean War) Veterans, 8 CAF Reserve Force Veterans, client family s.19(1) Health profile: The majority had chronic physical health conditions (67/80) or mental health conditions (65/80) or both (25/30). - 21/30 had disability benefits for physical health diagnoses. About half had disability benefits for a diagnosis. The majority had significant life stress burdens from a variety of sources (66/80), including living with physical and mental health problems, disability, addiction/substance misuse, and social, financial, employment/workplace, legal and housing problems. In many cases dif?culties with social and occupational integration were noted to be factors. . The majority had an unstable health or socioeconomic situation (23/30). In terms of accessing care: The reviewers were of the opinion that VAC case management and provision of social and financial supports appeared to be effective in some cases in preventing progression in suicidality along with care by health care professionals and other agencies. A wide variety ofbarriers to care were identified including lack of engagement by clients with interventions and/or stigma (the most common), lack of a regular primary care physician (uncommon), and little documentation of collaboration among service providers. In several cases, suicidal Veterans avoided or resisted engaging with VAC front line staff and/or health professionals. Specific to VAC practices: The reviewers noted significantly more attention among front line staff to asking about and documenting suicidality in files after the 2010 file review; however in several cases - there was little or no documented evidence of screening for suicidality. The reviewers noted increased documentation of suicide prevention interventions compared to the 2010 review; however there were several cases where reviewers felt that IDT, RMHO, COM and external health care provider consultations could have been utilized. Follow-up care for suicidality frequently might have occurred but was not documented in the files. In many cases the business focus rather than clinical focus of the VAC's electronic documentation tools made it dif?cult for the reviewers to determine whether suicidality had been assessed, was present, or was addressed. VAC front line staff including case managers sometimes were very engaged with suicidal serving CAF personnel prior to release, for example those living remote from a CAF base. 7 4 Suicidality File Review 2014 (000059 Reteased under the Access to Information Act I, Divulg?ts) en vertu de la Lei sur I?acces a l?informatien. - In no case was it documented that a formal review was conducted after suicide in Veteran clients who had been released from service. Recommendations 1. It is recommended that the findings inform an update to the 2010 Suicide Prevention and Intervention Action Plan. 2. A single template should be developed to conduct future suicidality reviews, rather than . the two different templates used in this review. File Review Method To ensure comprehensiveness and consistency with the evidence base on suicide prevention, the file review questionnaires were based on the draft 2014 revision of the 2010 VAC Suicide Prevention Framework and on the Veteran?s Well-Being Conceptual Framework. The file reviews were conducted by 10 reviewers: a physician, a two social workers, case managers, mental health officers and an addiction specialist to ensure both the "head of?ce" (30 cases) and "front line" perspectives (50 cases). Owing to limitations in the VAC administrative database, which was designed to administer VAC's business not conduct surveillance of health conditions, cases were identified by searching the first 102 characters of variables in the database for the partial word "suicid". Screeners then identified 80 cases to represent male and female Second World War, CAF Regular Force and CAF Reserve Force Veterans of all ages and at all stages of the suicidality pathway (ideation, attempts and completed suicides). Serving personnel were excluded. Reviewers used CSDN documentation to fill out questionnaires which were anonymously summarized. Interpretation Guidance - Owing to limitations in the VAC administrative database and the sampling method, the suicidality findings yield valuable qualitative insights to suicidality in VAC clients but cannot be used to derive estimates of numbers of clients with ideation, attempts or completed suicide. We oversampled key subgroups that would be under-represented in a random sample Reserve Force Veterans, women and all four age groups). 0 Even if every file or a statistically Signi?cant subsample was hand-searched, it would not be possible to identify all clients who had suicidality because VAC's files are not clinical records like those kept by health professionals and health care facilities, and VAC only learns of client suicides as required for business purposes. 0 Since clients receive direct care for suicidality from health professionals outside VAC in the provincial and private health care systems, the VAC database does not provide a complete picture of factors associated with suicide, whether clients were screened for suicidality by health care providers, or the interventions employed by outside health care providers. Clients might have experienced triggers and influencing factors or received suicide prevention interventions that were not documented in the ?les available to the reviewers, or were not easy for the reviewers to find. i - - Sommaire ex?cutif 5 I . Suicidality File Review 2014 (000060 Reieased under the Access to lnformation Act! Divulg?is) en vertu de la Loi sur l?acces a l?information. ?1 Introduction Suicide is an important public health problem in civilian and military populations. Suicides are statistically rare and individual pathways to suicide are highly variable. The research literature on suicide prevention is rapidly evolving and continues to mature. For these reasons, reviews of Veterans with suicidality who are participating in VAC programs are necessary to improve both the understanding of suicidality in Veterans and suicide prevention practices and inform suicide prevention activities. VAC conducted this ?le review of 80 clients2 with suicidality (meaning suicidal ideation, suicide attempts or completed suicide) in February 2014. The purpose was to describe clients with suicidality and to identify opportunities to enhance suicide prevention at VAC. The objectives were (1) Using the VAC Suicide Prevention Conceptual Framework, identify suicidal triggers and influencing factors and determine which suicide prevention interventions were used, and (2) Identify and communicate opportunities for VAC to enhance suicide prevention in Veterans and others receiving services from VAC. The task began in the last week of January and initial findings were required during mid-February. Method Conceptual Frameworks- The review was based on the draft 2014 revision of the updated 2010 VAC Suicide Prevention Framework. The framework identifies factors that trigger suicidality and in?uence people on suicidal pathways on the one hand, and evidence-based suicide prevention interventions on the other. File Review Components The file review had two components, each using a somewhat different questionnaire to collect data based on the two different perspectives: 1. Front line perspective. The "front line" component was a review of 50 files that was undertaken from the perspective of front line staff and mental health consultants who work directly with or in support of clients. The purpose was to describe clients with suicidality and to identify opportunities to enhance suicide prevention at VAC from the perspective of front-line staff delivering service one-to-one. There were 6 reviewers including case managers, mental health of?cers and an addiction specialist. 2. Head office perspective. The "head office" component was a review of 30 ?les that was undertaken from a clinical, policy and programming perSpective. The purpose was to describe clients with suicidality and to identify opportunities to enhance suicide prevention at VAC from the perspective of program and policy. There were 4 reviewers including a physician, a and two social workers. 2 "Client" means a person with a client ID and participation in VAC programs. 6 I . Suicidality File Review 2014 (000061 Conceptual Frameworks Reteased under the Access to information Act! Divulg?ls) en vertu de la Loi sur l?acces a l?information. Each component of the file review was consistent with the ecological and nature of VAC Suicide Prevention Framework. VAC suicide Prevention ,Fra mework 2014 Revision) Pathway, Triggers and In?uences: 1 Physical Health - Mood'endot?er _-Stre_ssfui .- . . - . . -r Addiction . ?Lif?eEvent - - - -- -- . - -r Disorders Sociai Situa (ion- - 7 1 FBar?riers :to- care I silica-a]; .i'deation?. . f?EffectNe'care . . - - - --50ciai_and. . Cognitivepr'edispositicin occupational -Access to lethal means T. integratin Evidericersqseq' ?Knc?w?ll?dge role Screening &.assessmem Crisis intervention Ottercome barriers. to effective care 'Phamaco'therapy 8r Social supports FoiiQWUp care fors'uic'ide? attempts- Benefits, Progra ms, Services Mu'ltiagencv Participation Restriction of-access to .i?thai means 'elVledia social media, Review-end surveillance, The design of the review was also based on the VAC Veteran Well-Being Conceptual Framework. Suicidality is much less commonin those with good well-being. Well-being is determined by the core concepts of determinants Of health and well-being, health status, disability experience, recovery experience, and roles of the Veteran and his/her family, roles of public and private sector agencies and communities, all operating over the life course. mmwm.x ?c'rivity nndi?pm?cipatiaii Limitation Lint?ei'ria?igad?aptlvecoptng ??v?b?n?tggit - veteran's Wen-Being Health . Conditions 8 Impairments Rolesioi Public - Sector, Private sector and Community Edutatiim - Gender - Culture Determinants of Health," - - Disability and Well-Being ihcome &sociaistatus' Smiai=su_pgortnehvorks . .f Healtiia?ehabi?taticnwrites Emplayntent &wOrkin3conditlons I Soc'i?i?hvironments& Recognition. Physical ?ndironments' .: - Personaineaith practices coping A Healthy childhood dev elopment- Suicidality File Review 2014 (000062 Reieased under the Access to lnformation Act! .Divulg?(s) en vertu de la Lei sur l?acces a l?informatien. Sample Identification. .The VAC administrative database does not cdntain a suicidality indicator, so we had to use indirect methods to find cases for the ?le reviews. The following method was used to identify the file review samples from both those who had disability benefits for diagnoses and those who did not. The CSDN records searched for occurrences of the word stub "suicid" using automated computer'software from 20 January 2000 to 10 January 2014 (13 years). Owing to software limitations, only the first 102 characters of certain ?elds within client records could be searched. This search identi?ed 1,062 unique cases of which 56% had a indicator", meaning that they had a disability award or pension for a medical diagnosis. The remainder would have had a disability award or pension for a physical health condition. Some of them also would have had mental and physical health conditions for which they did not have disability benefits. Among those for whom it could be determined they had died of suicide, their dates of death ranged from 1961 to 20134. From this sample frame we selected client cases to ensure representation from a variety of client characteristics (Table 1), which means the sample was not random. In the initial screening stage we tried to identify an equal number of cases of suicidal ideation, attempts and completed suicides. We attempted to oversample both CAF Veterans and completed suicides since these were the . client subpopulations of primary interest. It proved quite dif?cult to identify suicide cases owing to limitations of the administrative database. Suicides by still-serving personnel were not included since these cases would be reviewed by CAF. Some of these cases were looked at to get a general sense of VAC's involvement. This was a qualitative study, not quantitative, owing to limitations in the VAC administrative database and uncertainty in documentation. Low numbers in the tables therefore do not necessarily mean that the characteristic was not observed. were searched over the 13- year period ending 10 January 2014 and dates of death by suicide ranged from 1961 to 2013 (52 years). 3 There were 26,525 clients in CSDN with a indicator". This includes all client types with client le including War Service, CAF Service, RCMP, Survivors, Dependants, Merchant Marine, etc. Dates of death from all causes were present for 1,475 in the past 4 years. This included all clients, including RCMP. Of those deaths, 502 were CAF clients, serving and nonserving, Regular and Reserve Forces. Only 15 of those had one of 4 Medical Diagnosis Codes indicating suicide, however all these files would have to be hand?searched for evidence of suicidality. Several of these cases were in the ?le review. 4 As of January 14, 2014, there were 139 records and 97 unique people in CSDN where suicide death was identified using 4 medical diagnosis codes attributable to suicide. The dates of death ranged from 1961 to 2013 (52 years). Their service was 20 War Service (WWII or Korea), 57 CAF and 20 RCMPwas determined that the suicide was related to service. Of those, eight were related to Afghanistan service and all had a condition of which four were for PTSD. 8 I . . SuiCidality File Review 2014 (000063 Released under the Access to lnformation Acti Divulg?ls) en vertu cle la Loi sur l?acc?s l?information. - s.19(1) Table 1. Profiles of VAC clients with suicidalityHead 2 Front?: .. -.: ir- - - Office Line Review Review :7Tota't . i: "=30 - [1:505 n= 30 Suicide pathway at time of review Suicidal ideation . 15 Suicide attempt Completed suicide Client type* War Service Veteran (WW II and Korean War) CAF Regular Force Veteran CAF Reserve Force Veteran Family members of military Veterans Gender? Male 63 Female 16 Age* 35 35-54 55-65 65+ Disability Benefit Entitlement medical diagnosis 17 24 . 33 Physical health medical diagnosis 21 -- (21/30) Health Status Mental health problem 65 Physical health problem 67 Both a physical and a mental health problem (25/30) Addiction Life Stress Stressful life events/circumstances Degree of life stress burden 66 Low Medium 10 High 13 Disability Restricted in work, family or community 22 -- (22I30) Needed help with activity of daily living 21 -- (21130) Unstable health or social situation 23 -- (23130) . *Samples sizes do not sum to the total reviewed owing to incomplete documentation. 9 I . Suicidality File Review 2014 (000064 Reieased under the Access to information Act Divulg?(s) en vertu cle la Loi sur l?aoc?s l?information. Limitations Short Development Time Frame The design of the file review including sample selection, design of data abstraction tools and reviewer preparation was compressed to less than two work-weeks. Reliance on CSDN All the front line file reviewers used only CSDN to answer the questionnaires owing to the length of time that would have been required to obtain and ship paper files. Head office and regional paper files were used only by the two file reviewers at Head Of?ce for the same reason. Qualitative not Quantitative The findings can only be used to qualitatively understand suicidality in VAC clients. The sample is not statistically representative owing to limitations in the VAC administrative database. Since VAC only learns of client suicidality as required for business purposes, sampling was opportunistic not systematic. The numerator (numbers of clients with confirmed suicidality) is unknowable owing to the nature of the VAC administrative database. Even if every ?le was - hand-searched, it would not be possible to identify all clients who had suicidality. Clients probably had triggers, in?uencing factors or suicide prevention interventions that were not documented or easy to find. Findings: Triggers and Influencing Factors Life Stressors . The reviewers found evidence of significant stress burdens from a variety of stressors. Stresses related to physical or mental health conditions or addiction were the most common, as were social difficulties, particularly intimate and family relationships. Other stressors in the order in which they were documented included financial and legal dif?culties; dealing with and VAC forms and administrative processes; problems with housing and, especially for geriatric clients, housing transitions; employment and workplace difficulties; disability; difficulties accessing care; and dealing with deaths in colleagues. Unlike the 2010 review, this review included very old Second World War and Korean War Veterans with suicidality. The reviewers were struck by the different patterns in these elderly Veterans: social isolation, housing transitions, presence of multiple chronic physical health . problems and frailty, relatively less documentation of mental health problems, and relatively less documentation of collaboration among service and health care providers. Disorders Nearly all cases had mental health problems (documented in 28/30 cases in the head of?ce review and 37/50 in the front line review); and about half (17/30) had disability benefits for a diagnosis. Depression and PTSD were the most common. It is well known that suicidality is often associated with disorders. 10 I Suicidality File Review 2014 (000065 Released under the Access to information Acti Divulg?ls) en vertu cle la Lei sur l?acc?s Physical Health Nearly all cases had physical health problems (documented in 29/30 and 38/50), and 21/30 had disability benefits for physical health diagnoses. Although painful conditions, particularly musculoskeletal, were most commonly mentioned, there were a wide variety of disabling disorders involving different organ systems. Comorbidity of both and physical health conditions was very common, documented in 25/30 cases. Veterans come to VAC with chronic health problems, most commonly physical health conditions, so it is not surprising that the majority of these Veterans with suicidality had physical health problems. Physical health . conditions can be comorbid with disorders for three reasons: the condition was triggered or caused by living with a chronic physical health condition, or vice- versa, or the two simply occur in the same person without any significant causal relationship. Regardless of the mechanism, living with the co?occurrence of mental and physical health - conditions is particularly stressful for many people. Problems with cognition were noted in several cases, particularly the elderly. Addictions Addiction or substance misuse problems were documented in 6/30 and 12/50 cases and might have occurred in more. - Social Situation Difficulties with social circumstances were common, as were problems with family and intimate social interactions. Barriers to Effective Care Barriers to care were noted in several cases, including difficulties finding a physician to complete forms and loss of regular physicians owing to moves. In several cases the reviewers noted that clients were reluctant to disclose their mental health issues to staff or engage with treatment. The reviewers found little documentation of communication and collaboration with clients? primary care physicians. Barriers to care were detected less often in more recent cases than earlier cases. It is unclear whether thisreflects better access to care or lack of documentation of barriers. Effectiveness of care was beyond the scope of this review and would be hard to detect in VAC files because health care and rehabilitation is delivered outside VAC. The reviewers noted several cases of what appeared to be effective case management, in that clients seemed to feel supported and appreciative and were directed to appropriate care. While the reviewers were not able to objectiVely determine whether this case management close support translated into effective suicide prevention, they subjectively [felt this was likely in some cases. - Social and Occupational Integration Difficulties with social and occupatiOnal integration were noted to be factors in many cases. These difficulties included family and marital problems, social interaction problems, workplace discrimination for mental health problems, and social isolation. 11 Suicidality File Review 2014 (000066 Reieased under the Access to information Act Divulg?ts) en vertu cle la Loi sur l?acc?s l?information. Factors Predisposing to and Protecting Against Suicidality factors that predispose to suicidality (other than disorders) were identi?ed in 23/30 cases. This included problems with emotion regulation, personality factors, and cognitive problems affecting problem-solving. Although cognitive problems were noted in all age groups, they were prominent in several very elderly Veterans. On the other hand, in at least a few cases the client's own resources were noted to be factors likely keeping them from progressing along suicidal pathways. - Access to Lethal Means - 5-19(1) Most documented suicides pccurred in Veterans' homes. Documented means of suicide was not available in many cases but those found included: Imitation/Contagion Comments about media and social media influences were infrequently found in the files. One client reported that a social media group was helpful for them. Some of the front line revieWers said that they have seen cases outside the review where clients were adversely affected by media activity related to the highly publicized suicides in CAF personnel and Veterans that occurred during November 2013-February 2014. Findings: suicide Prevention Interventions Knowledge Exchange/Gatekeeper RoleIScreening, Assessment and Monitoring The reviewers noted significantly more suicidality documentation by front line?staff in the period following the 2010 ?le review and action plan. This observation suggests that the actions taken by VAC since 2010 have improved skills and con?dence among front line staff in dealing with suicidality. The reviewers also noted several cases where case managers' "best practice" actions might have led to improvements in clients' well-being through brokering services and so contributed to suicide prevention. On the other hand, the reviewers noted quite a few opportunities to identify suicidality and take appropriate actions. Although there were some examples of good communication and collaboration with clients' health care providers, there were few instances of communication and collaboration with clients' primary care physicians. Active screening made VAC staff aware of suicidality in several cases. There were a few "best practice" examples among the cases reviewed. On the other hand, the reviewers noted a number of what appeared to be missed opportunities to either screen for suicidality or to? monitor cases where someone else had identi?ed suicidality previously. The reviewers noted that client ?le documentation tools are not well suited to the "clinical" process of identifying passing on awareness of client's health and social problem lists including prior suicidality. The tools were developed more for administrative "business" purposes, so clinical information was scattered and often difficult to find even when the reviewers were looking for it. 12 I A Suicidality File Review 2014 (000067 Reieased uncier the Access to information Act Divulg?(s) en vertu cle la Loi sur l?acc?s l?information. Crisis Intervention The reviewers noted several instances where NCCN passed calls from potentially suicidal clients to front line staff. This ?nding seemed to signal a change from the 2010 review, when the practice seemed to be less common. There were cases where front line staff referred potentially suicidal clients to emergency health services or the client's own health care providers, however it was not clear in many cases how the referral occurred and what information was transmitted. Dealing with suicidal clients can be quite stressful for staff, and assessing suicidality requires considerable clinical skill. There were few cases where there was evidence that front line staff consulted clinical care managers, mental health of?cers and medical of?cers. Overcoming Barriers to Effective Care A wide variety of barriers to care were identified in less than half the cases, including lack of client engagement with interventions and/or stigma (the most common), lack of a regular primary care physician, and little evidence of collaboration among service providers. Waiting times or problems with referrals were rarely documented in the CSDN records. In several of the suicide cases, VAC was not aware of suicidality until after the death and very little information was available in the files to assess reasons, including barriers to care. In many cases, front line staff were brokering and VAC was paying for services to address factors that trigger and_ influence suicidality. There was little information about effectiveness of care in the record, in part - owing to the fact that health care is provided in provincial and private health services Settings. One barrier to care noted by several reviewers was missed opportunities to recognize prior suicidality in clients and arrange followup monitoring. This barrier was thought in part to be due to the business rather than clinical focus of VAC's recording systems. in health care settings different systems are used for recording problem lists, past history and progress notes to ensure that subsequent service providers are aware of what has happened in the past (continuity). Pharmacotherapy and The reviewed clients were usually under the care of health professionals providing pharmacotherapy and for mental health conditions, and treatment for physical health conditions. Since this occurred in provincial and private health care settings outside VAC, there was little information in the files about the nature and effectiveness of this treatment. Social Supports VAC case management and provision of social support from municipal and provincial agencies appeared to be effective at supporting suicidal Veterans. However, VAC case management was not always consistently applied, and referral to clinical care managers and mental health of?cers was not often noted by the reviewers. Care-giver fatigue was identified in some cases, particularly for care-givers who themselves were dealing with physical or mental health issues. Peer referral (OSISS) was infrequently documented and reasons for that were unclear. Follow up Care for Suicidal ldeation and Attempts Followup care for suicidality was not frequently clearly documented in the ?les, in part owing to the business rather than clinical focus of the documentation tools. There was evidence of "best 13 Suicidallty File Review 2014? (000068 Reieased under the Access to Information Acti Divulg?Is) en vertu cle la Loi sur I?acc?s a I?information. practice" attempts to followup suicidality in some cases. However, in several cases the reviewers found documentation of suicidality in the past and could not see where that was followed up in later months and years. In several cases, VAC staff only became aware of prior suicidality opportunistically when informed by the client themselves, by family, or by the client's health. care provider. VAC Benefits, Programs and Services The reviewers noted that in several cases case managers brokered a wide variety of resources for clients, addressing multiple determinants of health and well-being. In at least a couple of cases, however, this ability to keep suggesting new approaches might have hindered clients from becoming adapted to their chronic conditions and living well within them, which possibly could have contributed to ongoing instability and stress. In one case a Mental Health Of?cer was able to intervene in this type of situation. The reviewers noted cases where dealing with VAC, DND and CAF administration had contributed signi?cantly to life stress, at least in the client's perception. Multiaqencv Collaboration The reviewers found evidence that, as expected, other agencies were engaged with well-being support in several of the clients, for example health care providers, municipal social workers and other departments and various government levels. There was little systematic documented engagement with these agencies and providers except as related to VAC business; Restriction of Access to Lethal Means In a few cases, VAC staff documented interventions by themselves or others to limit access to firearms. Although not statistically valid, the numbersindicate that non-?rearm means such as hanging were more common than firearms in these Veterans. It is difficult to prevent suicides 3 from hanging, which was the most common means, and from drowning. Media and Social Media Influence The file review did not identify any interventions with respect to adverse media and social media influence on Veterans. Intervention can occur at two levels: when caring for an individual warning them about being in?uenced or ensuring they receive professional counseling about this) and at the macroscopic public health level by informing well-meaning persons to be careful about how they report and discuss Veteran suicides. Systematic Quality Improvement In no case was it documented that a formal review was conducted after suicide in Veteran clients after release from service. Recommendations 1. It is recommended that the findings inform an update to the 2010 Suicide Prevention and Intervention Action Plan. 2. A single template should be developed to conduct future suicidality reviews, rather than 14 I Suicidality File Review 2014 (000069 Appendix 1. Previous VAC and?CAF File Reviews the two different templates used in this review. VAC 2010 Suicide Case Review in 2010, VAC reviewed 12 Veteran suicides from 2007-2009 (not statistically representative and cannot rely on documentation to conclude characteristics not present). Key findings: disorders 12l12. Physical health conditions 12/12 0 Pain affected functioning Disability in activities of daily living Multiple life stressors present in 12l12: 0 Living with mental and physical health issues 12l12. 0 Significant Significant__maritallfamily Financia 2. 0 Housing I12. 0 Social/occupational integration: - Unemployed Feelings of isolation/exclusion: 11/12. 0 Feeling useless/burdensome 10/12. 0 Hopelessness 10/12. Location of suicide mostly at home. On days with contact with VAC none. s.19(1) The findings informed recommendations that formed the basis Of the 2010 VAC suicide prevention action plan. CAF 2011-12 Suicide Case Review' CAF reported on the first 38 suicides during 2011-12 that underwent their new technical review process (Collins et al. 2013). Key ?ndings: Documented history of mental illness: 47%. Significant precipitating factors: 0 Relationship failure: 45%. 0 Career issues: 21%. 0 Financial problems: 16%. Reieasecl under the Access to information Act! Divulg?ts) en vertu ale la Loi sur l?acc?s a 15 Suicidality File Review 2014 (000070 Released under the Access to information Act! Divulg?ls) en vertu de la Loi sur l?acc?s a l?information. 0 Chronic physical health problems: 13%. . 0 Legal or disciplinary: 11%. 0 Operational deployment history: 63%. 0 Deployment in support of: I Afghanistan mission: 50%. - Former Yugoslavia mission: 21%. 0 (There was no statistically signi?cant association between operational deployment and suicide.) The reviewers made recommendations for enhancing suicide prevention for serving personnel. 1 6 I I Suicidality File Review 2014 (000071 Reieased under the Access to information Acti Divulg?(s) en vertu cle la Loi sur l?acc?s a l?information. Appendix 2. Findings from the "head office" file review. Total numbers are provided for columns and rows, but readers are reminded that owing to large uncertainties in documentation and the way the sample was stratified then resulting proportions merely illustrate qualitatively and are not quantitatively representative. Table 1a. Free text answers. s.19(1) g} ESUiijaJ ldeation i Atteth a 15* - Sljiicidie Completed . . Suicide aj g?vTotal _n=3o*i I Client Type Veteran War Service Veteran CAF Regular Force Veteran CAF Reserve Force Family or Other type of client Age at Last contact 34 or less 35-54 55-64 65+ Age at Death 34 or less 35-54 55-64 65+ Years between service ending and suicid 2 or less - 3-5 6-10 10+ Male Female VAC Region West Ontario Quebec Atlantic Marital status Married Common Law Widowed, Separated, Divorced Single Never Married Rank at release Of?cer NCM Service Branch Army Navy - Air Force 17 Suicidality File Review 2014 (000072 Released under the Access to information Acti Divulg?(s) en vertu cle la Loi sur l?acc?s l?information. s.19(1) {Suicidal Suicide .Completed ideation Attempt 3 =n Toe.? Length of service 5 years 5-9 years 10-19 years 20-24 years 25 years+ Deployed Homeless Part 2. Where was the client on the suicide pathway? At what stage on the pathway did VAC ?rst engage for suicidality? Suicidal ideation Suicide attempt Completed suicide For completed suicide Means of death Site of death Client known to VAC to be suicidal prior to suicide . Duration of VA C?s contact with the client for suicidality None Days Weeks Months Years Part 3. Suicide Triggers and Influencing Factors Stressful life events 6-12 months prior to the suicide ideation", attempt or cOmpleted suicide Degree of life stress burden Low Medium High Health Mental health problems Physical health problems Co-morbidity of either or physical health conditions or co?occurrence of both a condition and a physical health condition 18 I - Suicidality File Review 2014 (000073 Released under the Access to information Acti Divulg?ls) en vertu cle la Loi sur l?acc?s a l?information. s.19(1) - 5"_ldeatipnl. Attempt [Suicide Total: - n; 1"1 Addiction or substance misuse Emotion regulation, personality and/or cognitive function factors potentially 13 23 predisposing to suicidality - Disability Restricted role or function in work, family or 12 22 community . Needed help with a basic or instrumental 2 21 activity of daily living Social factors Marital or family relationship problems 10 Workplace problems -. Social interaction problem 13 Appeared unstable in any dimension of 12 23 health, disability or social situation Evidence of media influence Evidence of social media influence Part 4. Suicide Prevention Interventions Suicidality screening and assessment, crisis management Was the client assessed for Suicidal . 11 Ideahon? . Was the client assessed for Suicide Attempt? Screening! assessment for suicide by service providers other than VAC staff VAC responded to clients who appeared to be at risk of suicide 14 Was there a referral to or consult with a health care provider? Check all that apply Ambulance, police, ED IDT MHO Clinical Care Manager Senior District Medical Of?cer or other physician nurse or social worker Barriers to Care Client engaged in interventions Stigma issues Had a regular'primary care physician Collaboration among health care providers Collaboration among an interdisciplinary mental health team issues accessing care, e.g. waiting times or problems with referral 19 I Suicidality File Review 2014 (000074 Reteased under the Access to information Act Divulg?ts) en vertu cle la Loi sur l?acc?s l?information. 549(1) ?gSuicidalf. Suicide Completed 5; ?il?deationi Attempt 7 . Suicide. .- Total . 1 pin . Pharmacotherap and for Mental Health Problems Treatment for mental health problems 24 Taking medications for mental health 18 conditions Referred to OSI clinic 11 In treatment at an OSI clinic Seeing a Seeing a or social worker or, nurse Couple or family counselling Other Treatment Treatment for physical health conditions Treatment for chronic pain Assessment and treatment at interdisciplinary pain clinic Addiction treatment Occupational Therapy and/or Physiotherapy assessment and treatment 10 Follow-up Care Follow up with clients for suicidal ideation or attempts Contact with family members when VAC concerned about client?s suicidality Follow up with survivors after suicide Social Supports Degree of VAC Case Manager involvement not only for suicidality Low Medium High Referred to or using a Clinical Care Manager Involved with OSISS Receiving assistance from CAF Assisting Of?cer Receiving social assistance from provincial or municipal sources - VAC Programs and Services i Disability benefit for a mental health condition Disability benefit for a physical health condition In the Rehabilitation Program For a physical health problem . For a mental health problem Receiving VAC Earnings Loss support Received disability pension/award posthumously 20 I A Suicidality File Review 2014 (000075 s.19(1) Totally and Permanently lncapacitated Suicidal ldeation -7 'n 15* - Suicide Mum-agency Collaboration I Collaboration specifically for suicide prevention Reduction of Access to Lethal Means Access to lethal means limited by some provider or agency one case the client was recorded as reporting that social media was protective. Released under the Access to lnformation Act! Divulg?ls) en vertu de la Loi sur l?acces a l?information. 21 Suicidality File Review 2014 (000076 Released under the Access to information Act! Divulg?ls) en vertu de la Loi sur l?acces a l?information. s.19(1) Table 1b. Free text answers. imagine "3115f: . a vNumberof?. - - - Cases'Where. DocLImented - Evidence that the manner of death was suicid I Means of Suicide Location of suicide Triggers and in?uencing factors (for ideations, attempts and suicides combined) VAC response to suicidality (for ideations, attempts and suicides combined) Administrative documentation client note) Verbal report from family or similar Death certificate or equivalent Firearm Hanging Home Mental health Physical health Social problems Housing Financial Administrative problem with DND, CAF, VAC Disability Access to physicians for care or forms Suicidality in relatives or friends Employment/workplace Legal problems Addiction/substance misuse Active case management including home visits More benefits and services Referral to clinicians Referral to VAC health professional, IDT Regular follow-ups Safety plan established Screening Actions that appeared to help identify suicidality (for ideations, attempts and suicides combined) Actions that appeared to work to decrease suicidality (for ideations, attempts and suicides combined) Awareness of findings by health care providers 15 Screening by VAC staff VAC monitoring and follow-up Client self-disclosure Family involvement Multidisciplinary collaboration Active VAC case management Family member's actions VAC followup and monitoring Collaboration/communication with health care providers Hospitalization Financial benefits 22 Suicidality File Review 2014 (000077 Reieased under the Access to lnformation Act! . Divulg?ts) en vertu de la Lei sur l?acces a l?informatien. s.19(1) Appendix 3. Findings from the "front. line" file review. Total numbers are provided for columns and rows, but readers are reminded that owing to large uncertainties in documentation and the way 'the sample was stratified then resulting proportions merely illustrate qualitatively and are not quantitatively representative. Table 2a. Yes/No answers. 7.39;} Suicide 23 7 PART I PROFILE Age at Last contact 34 or less 35-54 55-64 65+ Age at Death 34. or less 35?54 55?64 65+ Male Female Client Type: Veteran War Service Veteran CAF Regular Force Veteran CAF Reserve Force Family or Other type of client Is the client in receipt of VAC Disability Benefit? Was the client in the Rehabilitation Program? 'At what stage on the pathway did VAC ?rst engage for suicidality Suicidal ideation Suicide attempt Completed suicide 17 14 20 Duration of VA C?s contact with the client for suicidality: None Days Weeks Months Years 17 23 I Suicidality File Review 2014 (000078 Released under the Access to Information Act! Divulg?ls) en vertu de la Loi sur I?acces l?information. s.19(1) Suicid'e_ Completed Ideatign' i Attempt i' ?Suicide Total-f in n=18' an=5oi~? PART II - TRIGGERS AND INFLUENCING FACTORS Were there any stressful life events 6- - 12 months prior to the suicide 10 13 17 . 4O 7 ideation, attempt or completed suicide 4 According to your assessment, categorize the degree of life stress: Low Medium High Did the client have any diagnosed mental health problems or conditions? Disability benefit for a medical diagnosis - Did the client have any chronic physical health conditions Did the client have chronic pain Did the client have any addiction issues Was there suggestion of influence of media or social media suicide reporting? PART SUICIDE PREVENTION INTERVENTIONS Screening and Assessment Did the client have a transition interview? Was the client assessed for Suicidal Idea?on? Was the client assessed for Suicide Attempt? Was there follow-up care for suicide ideations or attempts by a VAC staff? Was there notice received that the client had been denied or received unsatisfactory disability bene?t for a condition? If so,_ was there follow up to assess coping and suicidaiity? Was an area counsellor client- centered assessment available? Was suicidality identified in the AC assessment? Was there a Case Manager involved in the caseSuicidality File Review 2014 (000079 Reieaseci uncier the Access to information Acti Divulg?ts) en vertu cle la Loi sur l?acc?s a l?information. s.19(1) Suicidal 1 . Suicide 3 Completed a. ideation"? . Attempt Suicide.- - _..7Total Did the client have a case plan? i 31 Was suicidality identified in the case 14 plan? Was a RRIT completed? 17 Was suicidality identified in the What was the case complexity: Low Medium High Was the VAC Suicide Awareness and Intervention Protocol applied? Was the client screened for substance use disorders? Was there ongoing screening for suicidality? 15 13 Treatment Interventions Was there a referral to or consult with a health care provider? Check all that apply: Ambulance, police or ED - IDT - MHO Clinical Care Manager Senior District Medical Officer or other physician . nurse or social worker 11 16 26 Was a safety plan developed with the client such as in the assist model? Was there follow-up for suicidality in those with ideation or attempts? Did the client have a regular . . 18 . Was the client being treated for 14 mental health problems? Was the client engaged with a 12 or Was the client being treated for 16 physical health problems? Was the client being treated for 12 chronic pain? Was the client being treated for addiction? Did the client accept referral and follow up with the health professional? Were service barriers present25 Suicidality File Review 2014 (000080 Released under the Access to information Acti Divulg?ls) en vertu cle la Lei sur i?acc?s i?infermatien. s.19(1) Suicidal? 'Suicide'fj Completed 7 Attempt a Suicide Total n'=18 n=23 ?rm-50 If service barriers were present, did the client receive help negotiating them? Was the client referred to or engaged with Was the family engaged as part of the 13 17 treatment plan? Were family services offered? 15 Was client engaged in the .l 27 interventions? 26 I Suicidality File Review 2014 (000081 Released under the Access to information Act I Divulg?ls) en vertu de la Loi sur l?acces a l?information. s.19(1) Table 2b. Free text answers. - of . 1-57 - 1.11: . - .1 iQuestions and 'anDocumented"; Evidence that the manner of death was suicide Administrative documentation client note) Verbal report from family Death certificate or equivalent 12 Means of suicide Hanging Firearm Drowning Overdose Location of suicide - Home Outside Home Triggers and in?uencing factors (for ideations, attempts and suicides combined) Physical health Mental health Social problems Intimate relationship problems Other family problems Addiction/substance misuse Financial Employment/workplace Housing Legal Administrative problem with DNDICAFNAC Deaths in relatives or friends Factors that appeared to help identify suicidality (for ideations, attempts and suicides combined) Client self-disclosure Information from health professionals Family involvement Screening by VAC staff 13 Factors that appeared to work to decrease suicidality (for ideations, attempts and suic combined) Active VAC case management Family member's actions Mental and other health care VAC followup and screening . Collaboration or communication among service and health care providers Various VAC benefits including rehab program, OSISS Hospitalization or admission to LTC *Multiple factors per case, not unique cases. 27] Suicidality File Review 2014 (000082