National guidance on action to address suicides at locations of concern
- Published
- 28 November 2022 (Latest release)
- Type
- Guidance
- Author
- Public Health Scotland
- Suicide
Where to get help
If you’re dealing with suicidal thoughts or thinking about self-harm, it’s important to know that you're not alone. Help is available when you’re feeling low – you do not have to hurt yourself or suffer in silence.
If you're struggling to cope, reach out to one of the services on NHS inform.
If it's an emergency, dial 999.
Overview
Purpose
This resource has been developed to:
- support community planning partnerships (CPPs) and local multi-agency steering groups to develop strategies to prevent suicides at identified locations of concern
- aid these, and other relevant agencies, to prevent the emergence of further locations of concern by incorporating suicide prevention measures into infrastructure development and maintenance
- support multi-agency collaboration, recognising that suicide prevention is a whole-community responsibility
What is a location of concern?
A location of concern can be broadly defined as a specific, usually public, site that is used as a location for suicide and that provides either means or opportunity for suicide.
One or more incidents of suicidal behaviour at a particular location suggests that action should be considered to address the site in question.
What is suicidal behaviour?
For this resource, suicidal behaviour is defined as the transition from feelings and thoughts about suicide towards acting on them.
Further information on the transition can be found in the Integrated Motivational Volitional Model.
Likely locations of concern sites in Scotland
The reasons why particular sites become locations of concern are complex. They can often be particularly scenic or iconic public structures or sites, around which there is a certain history, infamy or mythology. This may have been stimulated by media reporting that has linked the site in the public’s mind to acts of suicidal behaviour.
The following places have become locations of concern.
- Tall buildings, bridges, cliffs and other manufactured or natural structures that provide an opportunity for jumping from a height.
- Rural or secluded locations such as car parks, roadside lay-bys and woodlands. Methods of suicide at these locations commonly involve poisoning or hanging.
- Sections of railway lines and roads where bridges span the tracks. Sections of railway lines that allow for jumping or lying in front of a train can become locations of concern for several reasons. These include ease of access to the train lines, the proximity of mental health facilities and imitation or copycat acts.
- A particular stretch of railway track or road, even though incidents occurred at different points along the stretch of railway tracks or roads. Relevant authorities will need to draw on their own knowledge of local geography, as well as available data, to decide the boundaries of each site.
- Locations that provide access to water for drowning or submersion (for example open water, lakes, rivers and canals).
Water Safety Scotland (WSS), the Royal Society for the Prevention of Accidents, and the Scottish Fire and Rescue Service developed the drowning and incident review (DIR) process for accidental water-related fatalities in Scotland.
During the initial stages of the DIR process, the suspected outcome is classified into: Suspected accident, suspected suicide, suspected crime or unknown. If suicide is suspected, a DIR will not be triggered, and any available information will be provided to the lead agency of the suicide review process and the local suicide prevention representative that sits on the Partnership Approach to Water Safety/local water safety group.
If an unknown fatality triggers a DIR meeting, and it later becomes clear that suicide is suspected, the DIR will be adjourned, and information will be provided as above.
Further information relating to the DIR process is available from Water Safety Scotland.
How action will help to reduce suicides
Actions at locations of concern aim to interrupt the suicidal process. This is achieved primarily by restricting access to suicide means by enabling another party to intervene or by signposting to sources of support.
Restricting access to means can reduce suicide in three ways:
- increasing the difficulty of obtaining the opportunity for suicide may give individuals time to think through their options and reduce the likelihood that they will follow through with the suicidal act
- postponing the act by making it harder to obtain the necessary means or opportunity may allow time for other interventions, such as by mental health services or professional support, to take place
- restricting the means available may result in individuals choosing less lethal means and therefore result in fewer deaths
Actions at locations of concern that are designed to enable intervention by a third party aim to offer a suicidal person time and help to reconsider their possible action, and to link the suicidal person with support services and professional help.
A key consideration when adopting any third-party intervention is the provision of support should an intervention not be successful.
Process for managing a location of concern
Redirect
The five-step process
This resource promotes a five-step process for addressing an identified location of concern.
Step 1: multi-agency collaboration and management
Effective intervention at a location of concern will require leadership. This should be under the remit of the local area’s multi-agency steering group, which should have a standing group for addressing locations of concern. Subgroups may be required if dealing with multiple locations.
Collaboration and communication will be needed between the owner of the site, the manager of the site and any constructed infrastructure associated with it.
Step 2: data collection and analysis
Data on suicidal behaviour at sites strengthens the argument for action. It also gives a baseline against which the success of any action can be assessed as well as an ongoing picture of use.
This data can come from a range of sources. These can include national and local datasets as well as informal intelligence gathered from emergency services, helplines, local organisations, community groups and site owners or managers themselves.
Step 3: review options
Depending on the nature of the site and the resources available, there are several options to consider.
Physical barriers
Barriers, fences, screens, safety nets and natural barriers (for example dense shrubs) can delay or stop a suicidal act. This form of action, particularly barriers, has the most evidence of effectiveness.
Barriers can be costly to install and it may not be feasible to secure the entirety of a site (cost-wise or physically). However, where applicable, they should be considered as the most appropriate long-term solution to halting access to the means or opportunity at the identified site.
Engaging with communities may be required to reduce any resistance, especially at sites of community interest.
Signs and telephone helplines
Evidence suggests there is effectiveness in installing signs that encourage help-seeking and the use of helplines (which link a suicidal person or concerned third party to support or emergency personnel).
They provide the opportunity to link to existing services at both national and local levels as well as helping an individual to seek professional help and support in addressing their distress.
However, careful consideration must be given to the balance of introducing signage and telephones to prevent inadvertently advertising the location as providing the means or opportunity for suicide.
Surveillance measures
The use of CCTV and surveillance patrols show some evidence of effectiveness.
It can be expensive and there are personnel, privacy and legal considerations when implemented. These will need to be explored.
Restriction of pedestrian and vehicular access to the site
Actions such as road closure or restricting pedestrian access show some evidence of effectiveness. This can be a relatively low-cost option in the short term.
However, they may not be practical in the long term if the site in question is significantly used or deemed important by the local community.
Training for staff
Staff working at, or near, locations of concern or community lay persons in the vicinity can receive training. This is also known as gatekeeper training.
This involves training people who are not necessarily clinicians to be able to identify people experiencing suicidality and refer them to appropriate services.
Gatekeeper training is one of the most widely used suicide prevention strategies. It shows evidence of effectiveness and normally forms part of a series of actions undertaken (for example in conjunction with signage, CCTV or surveillance patrols).
Gatekeeper training shows promise in general suicide prevention as it increases awareness and confidence to intervene when someone is in distress.
Postvention support mechanisms are a key consideration when increasing the possibility of third-party intervention.
Improved response and rescue efforts
This is likely to be costly, but it may reduce the fatality of suicidal acts. However, it does not address access to the means or opportunity for suicide at a location.
Suicide risk management in planning and building standards
This offers a cost-effective suicide prevention measure, particularly in new constructions, as retrofitting effective prevention measures (like barriers on a bridge) can be costly.
Managing mainstream media
There is strong evidence that inappropriate media reporting of suicide can lead to copycat acts.
Evidence also shows that sensitive and measured reporting may help to de-link the suicidal act and the site in the mind of a vulnerable person and reduce the risk of further suicidal acts at the site.
Social media
The use of social media and online platforms by individuals, communities and organisations can hugely influence others by identifying a location of concern and highlighting the opportunity of a means of suicide presented by a specific location.
Summary
Some options have a stronger evidence base than others, particularly if physically restricting access to a means of suicide at a location can be achieved. This does not mean that the other intervention options listed should be discounted. See the rapid evidence review in the evidence and additional resources section of this guidance.
The purpose of undertaking action at a site is to save lives and ideally encourage the individual to seek professional help.
Step 4: planning considerations
Several factors will need to be considered.
Consultation and information management
This will be needed to overcome possible public resistance to actions, which is usually based on:
- aesthetic concerns
- a misconception that suicidal people will find a way to complete the suicidal act no matter what intervention is taken
- inconvenience, such as having to walk further because of barriers
- the cost and cost-effectiveness of the project
Proactive engagement with the media
This is needed to raise awareness of their role in preventing suicides at a location of concern.
Explore available options for funding
Funding will be required for the intervention(s) in the short, medium and long term
Infrastructure development
Suicide prevention measures can be integrated into infrastructure development, maintenance and planning cycles, based on an understanding of effective strategies and designs. This provides the opportunity to build in preventative measures from the start or to retrofit when maintenance is undertaken.
Step 5: monitor effectiveness
Monitoring should consider changes in the number of attempted and completed suicides across the location, the site and the local area in relation to any interventions put in place.
Ideally the use of a geographical information system (GIS) software application should be adopted to aid monitoring and surveillance – possible site substitution (displacement) and proximity of relevant locations where vulnerable population groups are concentrated, such as psychiatric hospitals, prisons and probation hostels.
This guidance provides a summary of available evidence and a more detailed indication of key steps in establishing actions at locations of concern. However, all action should be considered in the context of longer-term suicide prevention activity.
Case studies
A case study about the Erskine Bridge and its identification as a location of concern for suicides is available on NHS Health Scotland’s publication page.
The case study followed the five-step process recommended by this guide. Since the intervention was put in place at the location of concern there has been a year-on-year reduction in incidents of suicidal behaviour (data up to and including 2017).
As part of the cycle process proposed in the guidance, the longer-term impact and continual effectiveness of the intervention should be reviewed and examined.
This will ensure that actions undertaken continue to support the reduction in suicidal behaviour at an identified location.
Practical guidance: multi-agency collaboration and management
Overview
The agencies and individuals involved in managing a location of concern will vary depending on the nature of the site and the action required.
As a general principle, action taken at a location of concern will require a multi-agency group made up of individuals who can influence or ensure change happens. This may be part of a wider standing group in a local area’s multi-agency steering group or be set up to consider a specific location depending on size and impact.
The group should comprise individuals and agencies with the ability to influence and/or deliver change.
Core stakeholders/change agents
- Those with knowledge of suicide prevention evidence and intervention effectiveness.
- The designated owner of the site, for example local councils.
- The site manager and any infrastructure associated with it, such as tourism authorities, roads, transport authorities or railway service providers.
Additional change agents
- Community and private interest groups who access or overlook the site, including residents in a particular area.
- Community health agencies and services, such as general practitioners, counselling services and helpline providers.
- Emergency services such as police, transport police, fire and rescue and ambulance.
- Media liaison, to ensure reporting of activity at the site is carefully managed.
Leadership
The authority and ability to undertake action will vary from location to location. Effective action at a location of concern will require leadership and be under the remit of the local multi-agency steering group.
Leadership responsibilities include ensuring that:
- the necessary stakeholders, both national and local, are identified and involved
- there is adequate and facilitated communication between group members
- decision-making is based on available evidence on suicide prevention and intervention effectiveness at a location
- good practice protocols are adhered to
- actions align with relevant policies and guidelines, including those of the individual participating agencies
Meetings and documentation
An early meeting of core stakeholders can be used to map other parties that should be involved. It may also be useful to dedicate some time to the group’s workings to agree on goals and to define responsibilities.
If it’s a long-standing group, set a review date to assess whether these goals and responsibilities are still relevant and appropriate.
Terms of reference may be required to document the expectations and responsibilities of each group member, especially when agreeing on actions to be taken.
An example of a terms of reference document has been developed and added to the evidence and addition resources section of this guidance.
Practical guidance: data collection and analysis
Redirect
Overview
Data on suicidal behaviour at locations will strengthen the argument for actions at the site and will establish a baseline against which the success of any action can be assessed.
The first step is to establish what data is already being collected and by whom. This will prevent duplication.
Examples data sources
National data sources
- National and local data on all deaths by probable suicide is collected by the National Records of Scotland (NRS) as part of its annual national statistics release.
- More detailed information on the characteristics of deaths by probable suicide in Scotland has been collected via the Scottish suicide information database (ScotSID).
- Public Health Scotland supplies monthly data on probable suicides to nominated recipients in local areas.
- The Water Incident Database (WAID) from the National Water Safety Forum supplies data on suspected suicides by drowning.
Local knowledge of locations, as well as local sources of data, both formal and informal, will be important when identifying a particular site.
Using this local knowledge should also ensure that a location of concern is not treated in isolation, but rather that action is taken in support of other local activities and/or interventions at other locations of concern.
Local data sources
- Multi-agency suicide death reviews and other death reviews.
- Local emergency services liaison contacts.
- Local site owners or managers.
- Local helplines.
- Local organisations.
- Local community groups.
Assessing the risk
One or more incidents of suicidal behaviour at a particular site should give cause for concern. This is sufficient to prove that the site may hold an appeal for suicidal individuals and offers the means or opportunity for suicide.
Decisions on what action to take will depend on the number and nature of suicidal behaviour and the frequency with which they occur. Additionally, site-specific factors like topography or engineering considerations will need to be reviewed.
Who is involved in assessing risk
In practice, judgment is required around the assessment of risk and requires views to be obtained from:
- the agency or individual responsible for a particular site
- those who respond to attempted and completed suicides at the site
How to assess risk
Factors to consider when assessing a location of concern:
- number and frequency of suicides or suicide attempts at the site
- level of public and media concern
- level of stress in staff dealing with the aftermath
- risk of not undertaking action
- what action is appropriate in the short, medium and long term
High-risk locations
High-risk locations may vary in size. A single car park at a location may have been the venue for more than one incident of suicidal behaviour and would therefore be considered a location of concern. However, there may be several car parks in proximity that have each had one incident of suicidal behaviour.
In this case, it would be sensible to treat the area as a location of concern rather than individualising the car parks as separate locations of concern.
Similarly, a stretch of motorway or cliff might be designated a location of concern if there has been a number of incidents, even though these may have occurred at different points along the stretch or within different timeframes.
Summary
Local suicide prevention groups will need to exercise judgment and make their own decisions as to the size and boundaries of each site, based on the interpretation of local data, knowledge of local geography and the topography of the site.
Practical guidance: review options
Overview
Depending on the nature of the site, several actions may be needed at one specific location of concern.
At the start of the process, the multi-agency group should review actions that have been implemented at other similar locations of concern in Scotland. This will involve contacting local suicide prevention leads to discuss learning and the effectiveness of the response they put into action.
It is also worth considering the actions in terms of short-, medium- and long-term planning. This may help resource planning.
Pros and cons of possible actions
Table 1 summarises factors for and against possible actions based on available evidence or local experience.
| Action | Positives | Challenges | Evidence of effectiveness |
|---|---|---|---|
| Physically restrict access to means or opportunity: physical barriers | May delay or stop suicidal behaviour Recommended by people who survived attempts at suicides by jumping Reduces access for impulsive acts |
Likely to be costly to implement to existing structures and long stretches of railway track Engineering challenges to add barriers existing structures Public opposition based on cost, perceived futility and appearance Interventions at railway stations served by open track may not be as effective as those in locations where the station offers the only access to the track |
Robustly evaluated Strongest evidence of effectiveness Cost-effective in the short and medium term |
| Physically restrict access to means or opportunity: physical barriers | May delay or stop suicidal behaviour Restricts access yet avoids all arguments associated with barriers Reduces access for impulsive attempters Improves capacity for surveillance, e.g., when no pedestrians are permitted on the site |
Limits access rights of non-suicidal individuals May not be feasible as a medium to long-term strategy May not be feasible if site is a major access to route for pedestrians and/or vehicles or may not work if both are not restricted May cause inconvenience and therefore public annoyance |
Moderately evaluated Evidence of effectiveness |
| Increase help-seeking: signs and telephone hotlines | May delay or stop suicide act Shows that someone cares Relatively low cost Low maintenance Can be linked to existing services |
May alert others to idea of suicide or inadvertently advertise the site as a place for suicide Relies on individual contemplating suicide to make the call Relies on crisis line to respond appropriately |
Moderately evaluated Evidence of effectiveness |
| Increase intervention by third party: surveillance measures | May delay or stop suicide attempt Shows that someone cares Human contact is important in persuading not to attempt suicide Can buy time and alert relevant services to intervene |
Can be expensive Relies on patrol intervening efficiently and effectively Unsuccessful interventions traumatic for surveillance personnel Privacy and legal concerns with cameras Maintenance requirements |
Moderately evaluated Evidence of effectiveness |
| Increase intervention by third party: training of community, staff or ‘gatekeepers’ working at or near locations of concern | Relatively low cost Increased chance of appropriately alerting emergency services Human contact is important in persuading not to attempt suicide |
Likely low-cost effectiveness Likelihood of encountering suicidal individual is low (enhanced with surveillance measures) Possible negative effects depending on situation and outcome (postvention support needs to be provided and embedded) |
Moderately evaluated Evidence of effectiveness |
| Increase intervention by third party: improved rescue and response efforts | May prevent suicidal acts – such as enabling someone who is preparing to jump from a bridge to be talked down May reduce fatality of suicidal acts – for example by saving someone who survives a fall from a bridge but would otherwise have drowned |
Expensive Increased visibility of emergency call outs can increase community stress Does not respond to reducing access to means or opportunity of suicide |
No evaluations available |
Summary
Of all options, the most documented evidence of effectiveness relates to the construction of physical barriers that restrict access to the means of suicide at the site. However, other actions show promise and should be considered.
Any intervention strategy should always consider how the proposed actions align with broader local community education about suicide prevention and suicide prevention programmes.
Practical guidance: planning considerations
Redirect
Consultations
There may be organisational and/or public resistance to any proposed actions at locations of concern.
Reasons for this may include:
- visual or aesthetic disruption to an iconic natural or historical site
- lack of awareness about the effectiveness of the intervention – some people may hold the misconception that suicidal individuals will find a way to complete the suicidal act no matter what is done
- inconvenience to the public, in the case of restricted areas
- cost and cost-effectiveness
Overcoming resistance
Overcoming resistance may require some community consultation in addition to the process of engaging key stakeholders at the beginning of the development.
Public consultation should emphasise the need to promote actions at locations of concern based on a moral and ethical duty to prevent deaths, just as would happen at a dangerous road intersection.
Costs associated with preventative measures need to be weighed against the costs of search and rescue, body retrieval and public disruption due to access closure. The possible public trauma of witnessing a suicidal act and the personal costs for family and friends of those lost to suicide should also be considered.
Who should be involved in consultations
Local councils and third sector partners are often skilled at community consultation related to infrastructure and planning concerns.
Their role may be to:
- facilitate broad input into decisions on the type of response to be taken
- promote ownership and acceptability of the response
- build the capacity of the community to engage in the actions taken
It is likely specialist suicide prevention expertise will need to be sourced to participate in local council-led consultations.
As part of community consultation raising awareness of associated risks surrounding memorials at the site and social media should also be undertaken (see further information in social media and memorials sections of this guidance).
Media engagement
There is strong evidence of a relationship between media reporting of suicide and increases in subsequent suicidal acts.
Higher rates of suicide by a particular method have been found to follow media coverage of suicide by these methods.
Managing the media
As suicidal acts occurring at locations of concern tend to employ the same method, media professionals have been encouraged to exercise caution in reporting stories about these locations.
Even the implementation of suicide prevention strategies at locations of concern should be reported with care.
The multi-agency group managing action at a location of concern should proactively engage with the local media through the relevant channels at their disposal. Additionally, national media may need to be engaged depending on the profiles of the suicidal act and the site.
The media has a vital role to play in raising awareness of support, helping to de-stigmatise mental health and suicide, and ensuring the act of suicide and the site as access to means for suicide are not readily made available for public consumption.
Further information
Further information on the evidence of poorly managed media reporting can be viewed in the rapid evidence review available in the evidence and additional resources section of this guidance.
Samaritans, the National Union of Journalists (NUJ) and The suicide reporting toolkit have developed resources to help journalists and those educating journalists how to report on suicides in an appropriate, sensitive manner and help promote available support.
Other regulatory agencies include:
- the Independent Press Standards Organisation (IPSO)
- the Independent Monitor for the Press (IMPRESS)
- Ofcom, the broadcasting regulator
Advertising or promoting actions to prevent suicide at a location of concern can inadvertently publicise the site as a location for suicide. Therefore, it is recommended that actions taken at locations of concern are not advertised or promoted.
Social media
The use of social media and online platforms by communities and organisations can also have an influence in terms of spreading information on a location of concern.
However, social media can, and does, sometimes facilitate the spreading of information that is helpful, for example, through promoting helplines, sources of support and stories of hope and recovery.
The Samaritans has produced guidance for communities on how to safely talk about suicide online.
Memorials
As a mark of shared mourning, it is customary to leave tributes, such as flowers, scarves or teddy bears, and/or hold vigils at the site of sudden death. However, there is growing concern about doing so at the site of suicide. Extended vigils and collective grief can possibly trigger imitative acts, especially among young people.
Public memorial sites raise public awareness of the location as a place where a suicide has occurred. It can show vulnerable individuals that this is a location providing opportunities for suicide. They can also be a sign to the media that a potentially newsworthy death happened there.
Managing memorials
Local multi-agency steering groups should be encouraged to remove tributes as quickly and sensitively as possible to minimise potential harm.
These groups should:
- work with the family of the person who has died and bereavement support groups to suggest alternative forms of remembrance
- work with the media to encourage them to report in a sensitive, responsible manner and ensure the information on sources of support is promoted when reporting
- assign a team to remove tributes, with timescales and policies in place
Refer to Public Health Scotland’s guidance on Managing the risks of public memorials after a probable suicide for further information.
Contagion
Contagion is a situation where one person’s suicide, due to its circumstances and the publicity around it, triggers the risk of suicidal ideation, suicide attempts and/or deaths by suicide in others who are already vulnerable to suicidal thoughts or behaviours.
When contagion occurs, this can sometimes lead to suicide clusters.
For further information on suicide clusters, please refer to Public Health Scotland’s National guidance on identifying and responding to a suicide cluster.
Integrating suicide prevention measures into infrastructure development
Various infrastructure and design considerations will impact measures to restrict access to jumping sites.
New infrastructure developments must comply with relevant legislative and structural requirements, some of which may contribute to suicide prevention at locations of concern. However, there are no suicide prevention-specific statutory requirements for new infrastructure developments in Scotland.
International evidence, however, suggests several infrastructure interventions to reduce suicidal acts at sites that encourage jumping/falls.
Barriers at jumping sites should:
- be at least 230 cm or higher
- not offer toe/foot holds to assist with climbing
- be inwardly curved to increase the difficulty of climbing from the inside
- provide easier climbing from the outside should an individual wish to climb back to safety
- secure the whole of the site to increase the effectiveness
Tall buildings should have restrictions to:
- rooftop access
- window openings
- balcony access or the availability of jumping access from a balcony
It is important to keep in mind some changes to existing structures can be particularly difficult to implement (for example increasing parapet height). Ensuring town planners and structural engineers are considering preventative measures when developing buildings or bridges is strongly recommended.
Where changes to structures are unable to be made, consider adopting alternative preventative approaches, such as implementing signs or telephones in the area, surveillance and local community education on suicide prevention.
Practical guidance: monitoring effectiveness
Overview
It is important to monitor the interventions applied to the location to assess their effectiveness. The absence of robust and ongoing monitoring of applied intervention(s) limits opportunities to establish effectiveness and cross-agency learning.
Ongoing monitoring is necessary to determine whether the interventions introduced at a location have been successful.
The important work completed by the lead agent, or agencies, at step 2 of the process will prove vital in the ongoing provision of data.
The lead agency or agencies should ensure data for monitoring is fed back at regular intervals. For example, at quarterly intervals in the first year and no longer than annually in subsequent years.
Geographical information systems
Where feasible, systematic recording of the data through the adoption of a geographical information system application will aid in the continual monitoring of effectiveness of action. It will help determine if further action or actions are necessary to improve effectiveness.
Additionally, a geographical information system will assist in the monitoring of:
- possible site substitution (displacement)
- the proximity of relevant locations where vulnerable population groups are concentrated, such as psychiatric hospitals, prisons and probation hostels
- the proximity of possible locations of concern within their vicinity