MR1142 - Self Harm Monitoring Project - Mortality Following Self-Harm

NHS England has previously provided civil registration mortality and demographics data for use in the Derby Monitoring system of Self-harm and the Multicentre Study of Self-Harm in England.

In England and Wales there are at least 200,000 general hospital presentations for self-harm (intentional self-poisoning or self-injury) per year. Self-harm occurs in relation to a wide range of personal problems, emotional turmoil and psychiatric disorders. It carries a significant risk of premature death, particularly suicide and has major impacts on family members and friends. It also places pressure on busy emergency departments (EDs), wards and clinicians, as well as having major financial costs for the NHS. It is also associated with considerable healthcare costs. Self-harm has been highlighted as a priority area for research in the National Suicide Prevention Strategy for England.

Since 1989 the South Derbyshire Liaison team (formerly named the deliberate self-harm team and then the Mental Health Liaison Team) of Derbyshire Healthcare NHS Foundation Trust based at the Royal Derby Hospital (formerly the Derby Royal Infirmary and Derby City General) have monitored self-harm attendances (the team’s patient population) to the Emergency Department as part of everyday clinical practice.

The aim of the Derby monitoring system is to:

• Monitor local self-harm and suicide numbers

• Examine the association between self-harm, suicide and other causes of premature death

• Help inform service planning, policy development, local service provision, deliver training to clinical staff and local suicide prevention strategies.

In respect of the Derby monitoring system, the processing of identifiable and personal data is necessary for the monitoring of self-harm attendances to general hospitals and the linkage with mortality data. The processing of the data therefore leads to increased knowledge and understanding around risk of premature death and effective clinical management for people who self-harm, which is in the public interest (UK GDPR Article 6 (1) (e)) and for the prevention of suicide (UK GDPR Article 9 (2) (h)- Health and Social Care with a basis in law) as through analysis this will enable Derbyshire Healthcare NHS Foundation Trust to identify risk factors for premature death for people who self-harm and aspects of clinical management which are/could mitigate such risks.

In order to meet such aims, each person attending the Emergency Department at the Royal Derby Hospital due to self-harm is flagged with NHS England for mortality follow up. The main ethical issue facing this study is the appropriateness and feasibility of obtaining informed consent. This study does not seek to gain informed consent from patients to use their data and has approval under Section 251 of the NHS Act 2006 to process their confidential data without consent. However, the use of confidential data has been minimised and the researchers have taken actions to increase the likelihood of patients becoming aware of the study and of their right and the process to withdraw should they wish.

This study includes the processing of sensitive and identifiable data of individuals who have self-harmed and it is not practical to seek informed consent from each patient. Consequently, a risk to participants would be through inadvertent disclosure of their identifiable or personal data. Appropriate safeguards are in place to ensure confidentiality is maintained.

In reference to transparency, Derbyshire have information on a website, leaflets given to all patients seen by the Liaison team (main clinical team supporting people presenting with self-harm), speak about the study at events and meetings (e.g. suicide prevention strategy groups) with patient representatives (individuals and organisations) in attendance. Derbyshire are also planning to increase PPIE activity this year, and can explore ideas for further awareness raising of study/ opportunity to opt out, though it is a challenge given the sensitivity of the topic.

The Derby monitoring system of self-harm is a long running project. All people attending Derby’s Emergency Department with self-harm since 2000 had been (or will be, accounting for recent cases) flagged with NHS England for mortality follow up.

The Derby Monitoring system of self-harm is run solely by Derbyshire Healthcare NHS Foundation Trust, for service evaluation, development and research purposes.

The Multicentre Study of Self-harm in England is a collaboration between three separate self-harm monitoring projects based in different areas of England (University of Oxford, the University of Manchester, and Derbyshire Healthcare NHS Foundation Trust), that conducts studies on the epidemiology, causes, clinical management, outcome and prevention of self-harm. By combining data on self-harm from different areas, the Multicentre Study of Self-harm in England provides more representative and reliable data on self-harm in England than could be achieved by each site individually. The Multicentre Study contributes to the National Suicide Prevention Strategy for England (2002, 2012), and prevention and service initiatives, including NICE guidance on self-harm (National Collaborating Centre for Mental Health 2004, 2011). The programmes of research under the Multicentre Study is processed in the interests of the public (UK GDPR Article 6 (1) (e)) & 9 (2) (j)) as this will identify risk factors for premature death for people who self-harm and aspects of clinical management which are/could mitigate such risks.

Data for the study are collected in the three study sites (Oxford, Manchester, and Derby) in five general hospitals; one in Oxford, three in Manchester and one in Derby. Over 10 collaborating researchers from the three study sites are part of the research group. The project also has input from service users.

The Multicentre Study programme of research includes 4 broad areas:

- Epidemiology and trends in self-harm

- Clinical management of self-harm

- Outcome of self-harm, including repetition and mortality

- Pharmaco-epidemiology, including drug toxicology and impacts of changes in prescribing legislation and trends

With regards to the Derby monitoring system, Derbyshire Healthcare Foundation NHS Trust is the sole data controller of the detailed and identifiable mortality data. No other organisation determines the purposes for which the data is processed.

With regards to the Multicentre Study of Self-Harm in England, Derbyshire Healthcare Foundation NHS Trust is the sole data controller, who also process the copy of the pseudonymised multi-site data they receive from the University of Oxford. Derbyshire Healthcare Foundation NHS Trust is the sole data controller for the copies of pseudonymised data received from the other sites. Derbyshire Healthcare Foundation NHS Trust has full autonomy to determine the purposes for and the manner in which that data will be used without needing input or authorisation from the other sites. For example, a specific researcher at Derbyshire Healthcare Foundation NHS Trust will identify a purpose for analysing the data and will undertake the analysis. The findings may be shared with collaborators at other sites who may then have input into the writing of the paper for publication but at this point, the findings are aggregated and sufficiently derived from the data under this Agreement.

Each collaborator independently undertakes follow-up of individuals who present to hospital with self-harm in their respective areas. This involves receiving follow up data from NHS England under separate Data Sharing Agreements. These are Agreements ref: DARS-NIC-147916-DPQ3Q for University of Manchester and ref: DARS-NIC-147957-4444C for the University of Oxford. For the purpose of the Multicentre Study of Self-harm in England, pseudonymised copies of their respective datasets are transferred to the University of Oxford. Amalgamated copies of the pseudonymised data for all three locations are then transferred to each collaborating organisation. The organisations then have autonomy to independently determine what analyses will be undertaken using their copies of the data and for what purposes, in support of the aims of the programme above.

For avoidance of doubt, notwithstanding mention of hospitals in Leeds and a research group in Leeds being mentioned as part of the multicentre collaborative project in a protocol document produced in 2008, no hospitals or research groups in Leeds including from the University of Leeds are part of this project nor will they either control or process any data under this Agreement.

The Derby monitoring system of self-harm and the Multicentre Study of Self-harm in England (including data from the monitoring systems for self-harm at University of Manchester and University of Oxford) are ongoing projects. Outputs from these projects are multiple. The aims of this study are to identify risk factors for specific causes of death (including suicide) in persons who present to hospital after self-harm and to investigate how specific aspects of in-hospital care relate to mortality following self-harm. Specific outputs planned for the next 3 years include:

A. Periodic reports and presentations:

Periodic reports for the Department of Health and Social Care (the study funding body) and the National Suicide Prevention Strategy for England Advisory Group to communicate progress and key findings will be produced.

B. Papers will be submitted for publication in peer reviewed journals on an ongoing basis over the next three years and will focus upon areas including:

i. Young people - Ongoing monitoring of self-harm trends and characteristics; Clustering

ii. Women in midlife - Trends, characteristics, subsequent mortality from suicide and other causes

iii. Multiple repetition of self-harm - Types of people who repeat on multiple occasions, antecedents, clinical management, patterns of repetition, and association with suicide risk

iv. Physical illness - Trends, characteristics, mortality in people who self-harm, including those with physical illness at the time of hospital presentation

* Findings are published on the website of the Multicentre Study of Self Harm (https://www.psych.ox.ac.uk/research/csr/ahoj - currently being updated) and on the Manchester Self-harm Project Pages (https://www.research.manchester.ac.uk/portal/en/projects/manchester-selfharm-project(5e5f3c18-db80-41a4-9761-95feb90ac877).html ).

C. Other outputs include:

* Presentations of research findings at scientific meetings aimed at clinicians, researchers, patients and the public, and other stakeholders e.g. National Suicide Prevention Alliance national conferences

* Presentations at meetings with clinical staff involved in delivering care for individuals who self-harm e.g. NHS Clinical team meetings (Liaison Psychiatry services), Local Suicide Prevention Strategy Groups

* Meetings with policy making and regulatory bodies such as the National Institute for Health and Care Excellence (NICE), Medicines and Healthcare products Regulatory Agency (MHRA), National Suicide Prevention Strategy working group

Level of Data

Data will be presented in an aggregate format with all small numbers suppressed within all study outputs.

Dissemination and Communication

a) Dissemination of key findings

Study findings will be shared with stakeholders throughout the project. Dissemination will occur at scientific conferences and groups, but the main target audience are policy makers and healthcare providers. Key findings and messages will be shared through presentations, lay summaries, websites and social media pages, clinical team newsletters and day to day informal conversations with clinical colleagues in mental health and emergency department, suicide prevention strategy groups. Findings are frequently used to support the development of NICE guidelines for self-harm, as well as local and national suicide prevention strategies. Dissemination channels include: scientific journals, public reports, direct bilateral engagement using new and established relationships, newsletters, and co-hosted events.

b) Communication of results/outputs

Regular and active communication activities are undertaken with clinicians and policy makers to ensure the study findings improve the provision of care for people who self-harm and the development of effective suicide prevention approaches. Due to the long-standing nature of the project and reputational status of the study leads, key findings and recommendations are regularly fed back to key groups through strong, well established communication channels. Findings are also shared via more public forums, such as study websites, at National Suicide Prevention Alliance meetings and newsletters, and press releases.

c) Exploitation of results/outputs

The main aim of the study is monitoring self-harm rates over time, examining the link between self-harm and suicide, and the identification of high-risk groups and areas for intervention– to improve the understanding around, and therefore clinical care for, people who self-harm.

The study is funded by the Department of Health and Social Care. The DHSC play no role in conducting the research nor do they have access to the data.

Derbyshire Healthcare NHS Foundation Trust owns its’ data. A collaboration contract is in place detailing ownership of the data and knowledge generated from the Multicentre study.

All deliverables specified in previous Data Sharing Agreements have been realised. Annual reports have been made to the Department of Health and Social Care and papers have been published in/submitted to a number of peer reviewed journals on the areas of study previously specified:

1. Identifying overall risk factors for suicide and other specific causes of death following self-harm.

- Geulayov, G., Casey, D., Bale, L., Brand, F., Clements, C., Farooq, B., ... & Hawton, K. (2019). Suicide following presentation to hospital for non-fatal self-harm in the Multicentre Study of Self-harm: a long-term follow-up study. The Lancet Psychiatry, 6(12), 1021-1030.

- Clements, C., Farooq, B., Hawton, K., Geulayov, G., Casey, D., Waters, K., ... & Kapur, N. (2022). Self-harm in people experiencing homelessness: investigation of incidence, characteristics and outcomes using data from the Multicentre Study of Self-Harm in England. BJPsych Open, 8(2).

2. Identifying risk factors for suicide and non-suicidal premature mortality in children and adolescents

- Hawton, K., Bale, L., Brand, F., Townsend, E., Ness, J., Waters, K., ... & Geulayov, G. (2020). Mortality in children and adolescents following presentation to hospital after non-fatal self-harm in the Multicentre Study of Self-harm: a prospective observational cohort study. The Lancet Child & Adolescent Health, 4(2), 111-120.

- Geulayov, G., Casey, D., Bale, L., Brand, F., Townsend, E., Ness, J., ... & Hawton, K. (2022). Self-harm in children 12 years and younger: characteristics and outcomes based on the Multicentre Study of Self-harm in England. Social psychiatry and psychiatric epidemiology, 57(1), 139-148.

- Farooq, B., Clements, C., Hawton, K., Geulayov, G., Casey, D., Waters, K., ... & Kapur, N. (2021). Self-harm in children and adolescents by ethnic group: an observational cohort study from the Multicentre Study of Self-Harm in England. The Lancet Child & Adolescent Health, 5(11), 782-791

3. Specific method of self-harm as a risk for suicide and premature death

- Geulayov, G., Casey, D., Bale, E., Brand, F., Clements, C., Farooq, B., ... & Hawton, K. (2021). Risk of suicide in patients who present to hospital after self-cutting according to site of injury: findings from the Multicentre Study of Self-harm in England. Psychological medicine, 1-9.

4. Epidemiology of paracetamol poisoning and risk of death by suicide.

- Casey, D., Geulayov, G., Bale, E., Brand, F., Clements, C., Kapur, N., ... & Hawton, K. (2020). Paracetamol self-poisoning: epidemiological study of trends and patient characteristics from the multicentre study of self-harm in England. Journal of affective disorders, 276, 699-706.

• Derbyshire Healthcare’s Suicide Prevention Strategy and that of Derbyshire Suicide Prevention Partnership Forum includes a target to support high risk groups - particularly those who have self-harmed.

• Commissioning of a 24/7 Liaison Psychiatry service at the Royal Derby Hospital. Following the linkage and analysis of mortality data alongside the self-harm study data, Derbyshire have been able to demonstrate that people who self-harm are at significantly high risk of future suicide. The National Suicide Prevention Strategy, Derbyshire Healthcare’s Suicide Prevention Strategy and that of Derbyshire Suicide Prevention Partnership Forum (Public Health Led Suicide Prevention strategy) now include focused work areas and related funding streams to support people who self-harm.

• Contribution of data to the Multicentre Study of Self-harm, through which Derbyshire have conducted studies relevant to clinical services and policy on suicide prevention. Through data linkage (self-harm data from the hospital monitoring systems and mortality and cause of death data from NHS-Digital), Derbyshire have identified clinically important risk factors for suicide and premature mortality, following self-harm.

The linkage of mortality data with the study self-harm data, and subsequent analyses has enabled Derbyshire to demonstrate that the risk of suicide after self-harm is at its highest closer to the initial hospital visit. In fact, it is the first month which is especially risky. This finding has highlighted the importance of prompt and early intervention. The analysis of mortality data, has also demonstrated a particularly high risk of suicide, in people who have a history of multiple episodes of self-harm.

Such evidence supported the business case for the commissioning of a 24/7 Liaison Psychiatry service at the Royal Derby Hospital – which has a one hour target to start care provision for people who present to the Emergency Department with self-harm and to provide all people who present with self-harm a full psychosocial assessment. The protective effects of a psychosocial assessment following self-harm, against future self-harm and suicide is another finding produced as a result of the mortality data linkage with the self-harm study data.

Derbyshire have also found through the mortality data linkage, that amongst children and adolescents, the risk of future suicide is strongest in boys, in those with multiple episodes of previous self-harm and where certain methods of self-harm have been used. Such findings informed the business case for the commissioning of a psychiatric liaison team for under 18 year olds, with a core aim of providing tailored psychosocial assessments following self-harm related attendances to Emergency Department. Findings also inform local and national training packages on self-harm and suicide which ensure clinicians providing care for people who self-harm are aware of the increased risk associated with factors such as frequent repetition of self-harm and are therefore able to provide appropriate care and risk mitigation methods.

Derbyshire have also explored the relationship between clinical management of self-harm and subsequent suicide, enabling Derbyshire to demonstrate that the receipt of a psychosocial assessment whilst in hospital, significantly reduces the risk of further self-harm or suicide. This is a very important finding that now underpins national policy and strategy on suicide e.g. NICE Guidelines for the Management of Self-harm, and it is NICE guidance that forms the standard of care to which services must adhere.

A national Commissioning for Quality and Innovation (CQUIN) framework is currently underway to measure the proportion of adults receiving a psychosocial assessment following attendance at an Emergency Department following self-harm. The CQUIN framework supports improvements in the quality of services and the creation of new, improved patterns of care (https://www.england.nhs.uk/publication/combined-ccg-icb-and-pss-commissioning-for-quality-and-innovation-cquin-guidance/). This is as a result of the evidence base, to which Derbyshire have heavily contributed via this study, demonstrating that psychosocial assessment is a protective factor to repeat self-harm and suicide.

Study findings such as these form a significant part of the evidence base which has led to improvements in service provision and accessibility for people who self-harm or who are at risk of suicide e.g. the NHSE funding stream aiming to ensure all general hospitals have a 24/7 Liaison psychiatry service.

This Data Sharing Agreement permits Derbyshire Healthcare NHS Foundation Trust to securely store the data provided by NHS Digital under previous versions of this Agreement. Processing of the data other than for storage purposes is not permitted under this Agreement.

This restriction may be lifted under a subsequent version of this Agreement if Derbyshire Healthcare NHS Foundation Trust can evidence funding for the continuation of the study and section 251 support for the extension of the study beyond the end date of 31 March 2021 which is stipulated on the CAG Register.

NHS Digital has previously provided civil registration mortality and demographics data for use in the Derby Monitoring system of Self-harm and the Multicentre Study of Self-Harm in England.

In England and Wales there are at least 200,000 general hospital presentations for self-harm (intentional self-poisoning or self-injury) per year. Self-harm occurs in relation to a wide range of personal problems, emotional turmoil and psychiatric disorders. It carries a significant risk of premature death, particularly suicide and has major impacts on family members and friends. It also places pressure on busy emergency departments (EDs), wards and clinicians, as well as having major financial costs for the NHS.

Since 1989 the South Derbyshire Liaison team (formerly named the deliberate self-harm team and then the Mental Health Liaison Team) of Derbyshire Healthcare NHS Foundation Trust based at the Royal Derby Hospital (formerly the Derby Royal Infirmary and Derby City General) have monitored self-harm attendances (the team’s patient population) to the Emergency Department as part of everyday clinical practice.

The aim of the Derby monitoring system is to:

• Monitor local self-harm and suicide numbers

• Examine the association between self-harm, suicide and other causes of premature death

• Help inform service planning, policy development, local service provision, deliver training to clinical staff and local suicide prevention strategies.

In respect of the Derby monitoring system, the processing of identifiable and personal data is necessary for the monitoring of self-harm attendances to general hospitals and the linkage with mortality data. The processing of the data therefore leads to increased knowledge and understanding around risk of premature death and effective clinical management for people who self-harm, which is in the public interest (GDPR Article 6 (1) (e)) and for the prevention of suicide (GDPR Article 9 (2) (h)- Health and Social Care with a basis in law) as through analysis this will enable Derbyshire Healthcare NHS Foundation Trust to identify risk factors for premature death for people who self-harm and aspects of clinical management which are/could mitigate such risks.

In order to meet such aims, each person attending the Emergency Department at the Royal Derby Hospital due to self-harm is flagged with NHS Digital for mortality follow up. The main ethical issue facing this study is the appropriateness and feasibility of obtaining informed consent. This study does not seek to gain informed consent from patients to use their data and has approval under Section 251 of the NHS Act 2006 to process their confidential data without consent. However, the use of confidential data has been minimised and the researchers have taken actions to increase the likelihood of patients becoming aware of the study and of their right and the process to withdraw should they wish.

This study includes the processing of sensitive and identifiable data of individuals who have self-harmed and it is not practical to seek informed consent from each patient. Consequently, a risk to participants would be through inadvertent disclosure of their identifiable or personal data. Appropriate safeguards are in place to ensure confidentiality is maintained.

The Derby monitoring system of self-harm is a long running project. All people attending Derby’s Emergency Department with self-harm since 2000 (to 2016) had been flagged with NHS Digital for mortality follow up.

The Derby Monitoring system of self-harm is run solely by Derbyshire Healthcare NHS Foundation Trust for service evaluation and development purposes.

The Multicentre Study of Self-harm in England is a collaboration between three separate self-harm monitoring projects based in different areas of England (University of Oxford, the University of Manchester, and Derbyshire Healthcare NHS Foundation Trust), that conducts studies on the epidemiology, causes, clinical management, outcome and prevention of self-harm. By combining data on self-harm from different areas, the Multicentre Study of Self-harm in England provides more representative and reliable data on self-harm in England than could be achieved by each site individually. The Multicentre Study contributes to the National Suicide Prevention Strategy for England (2002, 2012), and prevention and service initiatives, including NICE guidance on self-harm (National Collaborating Centre for Mental Health 2004, 2011). The programmes of research under the Multicentre Study is processed in the interests of the public (GDPR Article 6 (1) (e)) & 9 (2) (j)) as this will identify risk factors for premature death for people who self-harm and aspects of clinical management which are/could mitigate such risks.

Data for the study are collected in the three study sites (Oxford, Manchester, and Derby) in five general hospitals; one in Oxford, three in Manchester and one in Derby. Over 10 collaborating researchers from the three study sites are part of the research group. The project also has input from service users.

The Multicentre Study programme of research includes 4 broad areas:

- Epidemiology and trends in self-harm

- Clinical management of self-harm

- Outcome of self-harm, including repetition and mortality

- Pharmaco-epidemiology, including drug toxicology and impacts of changes in prescribing legislation and trends

With regards to the Derby monitoring system, Derbyshire Healthcare Foundation NHS Trust is the sole data controller of the detailed and identifiable mortality data. No other organisation determines the purposes for which the data is processed.

With regards to the Multicentre Study of Self-Harm in England, Derbyshire Healthcare Foundation NHS Trust is the sole data controller, who also process the copy of the pseudonymised multi-site data they receive from the University of Oxford. Derbyshire Healthcare Foundation NHS Trust is the sole data controller for the copies of pseudonymised data received from the other sites. Derbyshire Healthcare Foundation NHS Trust has full autonomy to determine the purposes for and the manner in which that data will be used without needing input or authorisation from the other sites. For example, a specific researcher at Derbyshire Healthcare Foundation NHS Trust will identify a purpose for analysing the data and will undertake the analysis. The findings may be shared with collaborators at other sites who may then have input into the writing of the paper for publication but at this point, the findings are aggregated and sufficiently derived from the data under this Agreement.

Each collaborator independently undertakes follow-up of individuals who present to hospital with self-harm in their respective areas. This involves receiving follow up data from NHS Digital under separate Data Sharing Agreements. These are Agreements ref: DARS-NIC-147916-DPQ3Q for University of Manchester and ref: DARS-NIC-147957-4444C for the University of Oxford. For the purpose of the Multicentre Study of Self-harm in England, pseudonymised copies of their respective datasets are transferred to the University of Oxford. Amalgamated copies of the pseudonymised data for all three locations are then transferred to each collaborating organisation. The organisations then have autonomy to independently determine what analyses will be undertaken using their copies of the data and for what purposes, in support of the aims of the programme above.

For avoidance of doubt, notwithstanding mention of hospitals in Leeds and a research group in Leeds being mentioned as part of the multicentre collaborative project in a protocol document produced in 2008, no hospitals or research groups in Leeds including from the University of Leeds are part of this project nor will they either control or process any data under this Agreement.

The Derby monitoring system of self-harm and the Multicentre Study of Self-harm in England (including data from the monitoring systems for self-harm at University of Manchester and University of Oxford) are ongoing projects. Outputs from these projects are multiple. The aims of this study are to identify risk factors for specific causes of death (including suicide) in persons who present to hospital after self-harm and to investigate how specific aspects of in-hospital care relate to mortality following self-harm. Specific outputs planned for the next 18 months include:

* Identifying overall risk factors for suicide and other specific causes of death following self-harm.

* Identifying risk factors for suicide and non-suicidal premature mortality in children and adolescents

* Specific method of self-harm as a risk for suicide and premature death

* Epidemiology of paracetamol poisoning and risk of death by suicide.

* The findings from these studies will be published in peer-reviewed journals aimed at clinicians and researchers.

* Periodic reports for the Department of Health (the study funding body) and the National Suicide Prevention Strategy for England Advisory Group to communicate progress and key findings will be produced.

* Findings are published on the website of the Multicentre Study of Self Harm in England where information is summarized in layman's terms.

Other outputs include:

* Presentations of research findings at scientific meetings aimed at clinicians, researchers and stakeholders

* Presentations at meetings with clinical staff involved in delivering care for individuals who self-harm

* Meetings with policy making and regulatory bodies such as the National Institute for Health and Care Excellence (NICE), Medicines and Healthcare products Regulatory Agency (MHRA), National Suicide Prevention Strategy working group

In all the above, data will be presented in an aggregate format and individuals cannot be identified.

Summaries of projects undertaken are accessible on the Derbyshire Health NHS Foundation Trust website: http://www.derbyshirehealthcareft.nhs.uk/get-involved/research-and-development-home/sh-and-sp/research/

Details of publications by the Multicentre Study are published on the Multicentre Study website: http://cebmh.warne.ox.ac.uk/csr/mcm/index.html

Derbyshire Healthcare’s Suicide Prevention Strategy and that of Derbyshire Suicide Prevention Partnership Forum includes a target to support high risk groups - particularly those who have self-harmed.

Commissioning of a 24/7 Liaison Psychiatry service at the Royal Derby Hospital.

Data contributed to the Multicentre Study of Self-harm. Conducted studies which are relevant to clinical services and policy on suicide prevention. One example is how through linking episodes of self-harm with suicide as an outcome, researchers are able to identify clinically important risk factors for suicide following an episode of self-harm (non-fatal self-harm being the most important risk factor for suicide). For example, in children and adolescents is has been shown that risk of future suicide is strongest in boys, and in those with multiple episodes of previous self-harm and where certain specific methods of self-harm have been used. In adults it has been shown that a particularly high risk of subsequent suicide in people who have a history of multiple episodes of self-harm. Another example concerns the relationship between clinical management and subsequent suicide. Thus, the researchers have been able to investigate whether receipt of a psycho-social assessment while a person is in hospital following self-harm decreases the risk of future suicide.

Derbyshire Healthcare NHS Foundation Trust requires demographic and mortality data for use in the Derby Monitoring system of Self-harm and the Multicentre Study of Self-Harm in England.

In England and Wales there are at least 200,000 general hospital presentations for self-harm (intentional self-poisoning or self-injury) per year. Self-harm occurs in relation to a wide range of personal problems, emotional turmoil and psychiatric disorders. It carries a significant risk of premature death, particularly suicide and has major impacts on family members and friends. It also places pressure on busy emergency departments (EDs), wards and clinicians, as well as having major financial costs for the NHS.

Since 1989 the South Derbyshire Liaison team (formerly named the deliberate self-harm team and then the Mental Health Liaison Team) of Derbyshire Healthcare NHS Foundation Trust based at the Royal Derby Hospital (formerly the Derby Royal Infirmary and Derby City General) have monitored self-harm attendances (the team’s patient population) to the Emergency Department as part of everyday clinical practice.

The aim of the Derby monitoring system is to:

• Monitor local self-harm and suicide numbers

• Examine the association between self-harm, suicide and other causes of premature death

• Help inform service planning, policy development, local service provision, deliver training to clinical staff and local suicide prevention strategies.

In respect of the Derby monitoring system, the processing of identifiable and personal data is necessary for the monitoring of self-harm attendances to general hospitals and the linkage with mortality data. The processing of the data therefore leads to increased knowledge and understanding around risk of premature death and effective clinical management for people who self-harm, which is in the public interest (GDPR Article 6 (1) (e)) and for the prevention of suicide (GDPR Article 9 (2) (h)) as through analysis this will enable Derbyshire Healthcare NHS Foundation Trust to identify risk factors for premature death for people who self-harm and aspects of clinical management which are/could mitigate such risks.

In order to meet such aims, each person attending the Emergency Department at the Royal Derby Hospital due to self-harm is flagged with NHS Digital for mortality follow up. The main ethical issue facing this study is the appropriateness and feasibility of obtaining informed consent. This study does not seek to gain informed consent from patients to use their data and has approval under Section 251 of the NHS Act 2006 to process their confidential data without consent. However, the use of confidential data has been minimised and the researchers have taken actions to increase the likelihood of patients becoming aware of the study and of their right and the process to withdraw should they wish.

This study includes the processing of sensitive and identifiable data of individuals who have self-harmed and it is not practical to seek informed consent from each patient. Consequently, a risk to participants would be through inadvertent disclosure of their identifiable or personal data. Appropriate safeguards are in place to ensure confidentiality is maintained.

The Derby monitoring system of self-harm is a long running project. All people attending Derby’s Emergency Department with self-harm since 2000 (to 2016) had been flagged with NHS Digital for mortality follow up.

The Derby Monitoring system of self-harm is run solely by Derbyshire Healthcare NHS Foundation Trust for service evaluation and development purposes.

The Multicentre Study of Self-harm in England is a collaboration between three separate self-harm monitoring projects based in different areas of England (University of Oxford, the University of Manchester, and Derbyshire Healthcare NHS Foundation Trust), that conducts studies on the epidemiology, causes, clinical management, outcome and prevention of self-harm. By combining data on self-harm from different areas, the Multicentre Study of Self-harm in England provides more representative and reliable data on self-harm in England than could be achieved by each site individually. The Multicentre Study contributes to the National Suicide Prevention Strategy for England (2002, 2012), and prevention and service initiatives, including NICE guidance on self-harm (National Collaborating Centre for Mental Health 2004, 2011). The programmes of research under the Multicentre Study is processed in the interests of the public (GDPR Article 6 (1) (e)) & 9 (2) (j)) as this will identify risk factors for premature death for people who self-harm and aspects of clinical management which are/could mitigate such risks.

Data for the study are collected in the three study sites (Oxford, Manchester, and Derby) in five general hospitals; one in Oxford, three in Manchester and one in Derby. Over 10 collaborating researchers from the three study sites are part of the research group. The project also has input from service users.

The Multicentre Study programme of research includes 4 broad areas:

- Epidemiology and trends in self-harm

- Clinical management of self-harm

- Outcome of self-harm, including repetition and mortality

- Pharmaco-epidemiology, including drug toxicology and impacts of changes in prescribing legislation and trends

With regards to the Derby monitoring system, Derbyshire Healthcare Foundation NHS Trust is the sole data controller, who also process the data, of the detailed and identifiable mortality data. No other organisation determines the purposes for which the data is processed.

With regards to the Multicentre Study of Self-Harm in England, Derbyshire Healthcare Foundation NHS Trust is the sole data controller, who also process the copy of the pseudonymised multi-site data they receive from the University of Oxford. Derbyshire Healthcare Foundation NHS Trust is the sole data controller for the copies of pseudonymised data received from the other sites. Derbyshire Healthcare Foundation NHS Trust has full autonomy to determine the purposes for and the manner in which that data will be used without needing input or authorisation from the other sites. For example, a specific researcher at Derbyshire Healthcare Foundation NHS Trust will identify a purpose for analysing the data and will undertake the analysis. The findings may be shared with collaborators at other sites who may then have input into the writing of the paper for publication but at this point, the findings are aggregated and sufficiently derived from the data under this Agreement.

Each collaborator independently undertakes follow-up of individuals who present to hospital with self-harm in their respective areas. This involves receiving follow up data from NHS Digital under separate Data Sharing Agreements. These are Agreements ref: DARS-NIC-147916-DPQ3Q for University of Manchester and ref: DARS-NIC-147957-4444C for the University of Oxford. For the purpose of the Multicentre Study of Self-harm in England, pseudonymised copies of their respective datasets are transferred to the University of Oxford. Amalgamated copies of the pseudonymised data for all three locations are then transferred to each collaborating organisation. The organisations then have autonomy to independently determine what analyses will be undertaken using their copies of the data and for what purposes, in support of the aims of the programme above.

For avoidance of doubt, notwithstanding mention of hospitals in Leeds and a research group in Leeds being mentioned as part of the multicentre collaborative project in a protocol document produced in 2008, no hospitals or research groups in Leeds including from the University of Leeds are part of this project nor will they either control or process any data under this Agreement.

The Derby monitoring system of self-harm and the Multicentre Study of Self-harm in England (including data from the monitoring systems for self-harm at University of Manchester and University of Oxford) are ongoing projects. Outputs from these projects are multiple. The aims of this study are to identify risk factors for specific causes of death (including suicide) in persons who present to hospital after self-harm and to investigate how specific aspects of in-hospital care relate to mortality following self-harm. Specific outputs planned for the next 18 months include:

* Identifying overall risk factors for suicide and other specific causes of death following self-harm.

* Identifying risk factors for suicide and non-suicidal premature mortality in children and adolescents

* Specific method of self-harm as a risk for suicide and premature death

* Epidemiology of paracetamol poisoning and risk of death by suicide.

* The findings from these studies will be published in peer-reviewed journals aimed at clinicians and researchers.

* Periodic reports for the Department of Health (the study funding body) and the National Suicide Prevention Strategy for England Advisory Group to communicate progress and key findings will be produced.

* Findings are published on the website of the Multicentre Study of Self Harm in England where information is summarized in layman's terms.

Other outputs include:

* Presentations of research findings at scientific meetings aimed at clinicians, researchers and stakeholders

* Presentations at meetings with clinical staff involved in delivering care for individuals who self-harm

* Meetings with policy making and regulatory bodies such as the National Institute for Health and Care Excellence (NICE), Medicines and Healthcare products Regulatory Agency (MHRA), National Suicide Prevention Strategy working group

In all the above, data will be presented in an aggregate format and individuals cannot be identified.

Summaries of projects undertaken are accessible on the Derbyshire Health NHS Foundation Trust website: http://www.derbyshirehealthcareft.nhs.uk/get-involved/research-and-development-home/sh-and-sp/research/

Details of publications by the Multicentre Study are published on the Multicentre Study website: http://cebmh.warne.ox.ac.uk/csr/mcm/index.html

Derbyshire Healthcare’s Suicide Prevention Strategy and that of Derbyshire Suicide Prevention Partnership Forum includes a target to support high risk groups - particularly those who have self-harmed.

Commissioning of a 24/7 Liaison Psychiatry service at the Royal Derby Hospital.

Data contributed to the Multicentre Study of Self-harm. Conducted studies which are relevant to clinical services and policy on suicide prevention. One example is how through linking episodes of self-harm with suicide as an outcome, researchers are able to identify clinically important risk factors for suicide following an episode of self-harm (non-fatal self-harm being the most important risk factor for suicide). For example, in children and adolescents is has been shown that risk of future suicide is strongest in boys, and in those with multiple episodes of previous self-harm and where certain specific methods of self-harm have been used. In adults it has been shown that a particularly high risk of subsequent suicide in people who have a history of multiple episodes of self-harm. Another example concerns the relationship between clinical management and subsequent suicide. Thus, the researchers have been able to investigate whether receipt of a psycho-social assessment while a person is in hospital following self-harm decreases the risk of future suicide.

Derbyshire Healthcare NHS Foundation Trust requires demographic and mortality data for use in the Derby Monitoring system of Self-harm and the Multicentre Study of Self-Harm in England.

In England and Wales there are at least 200,000 general hospital presentations for self-harm (intentional self-poisoning or self-injury) per year. Self-harm occurs in relation to a wide range of personal problems, emotional turmoil and psychiatric disorders. It carries a significant risk of premature death, particularly suicide and has major impacts on family members and friends. It also places pressure on busy emergency departments (EDs), wards and clinicians, as well as having major financial costs for the NHS.

Since 1989 the South Derbyshire Liaison team (formerly named the deliberate self-harm team and then the Mental Health Liaison Team) of Derbyshire Healthcare NHS Foundation Trust based at the Royal Derby Hospital (formerly the Derby Royal Infirmary and Derby City General) have monitored self-harm attendances (the team’s patient population) to the Emergency Department as part of everyday clinical practice.

The aim of the Derby monitoring system is to:

• Monitor local self-harm and suicide numbers

• Examine the association between self-harm, suicide and other causes of premature death

• Help inform service planning, policy development, local service provision, deliver training to clinical staff and local suicide prevention strategies.

In respect of the Derby monitoring system, the processing of identifiable and personal data is necessary for the monitoring of self-harm attendances to general hospitals and the linkage with mortality data. The processing of the data therefore leads to increased knowledge and understanding around risk of premature death and effective clinical management for people who self-harm, which is in the public interest (GDPR Article 6 (1) (e)) and for the prevention of suicide (GDPR Article 9 (2) (h)) as through analysis this will enable Derbyshire Healthcare NHS Foundation Trust to identify risk factors for premature death for people who self-harm and aspects of clinical management which are/could mitigate such risks.

In order to meet such aims, each person attending the Emergency Department at the Royal Derby Hospital due to self-harm is flagged with NHS Digital for mortality follow up. The main ethical issue facing this study is the appropriateness and feasibility of obtaining informed consent. This study does not seek to gain informed consent from patients to use their data and has approval under Section 251 of the NHS Act 2006 to process their confidential data without consent. However, the use of confidential data has been minimised and the researchers have taken actions to increase the likelihood of patients becoming aware of the study and of their right and the process to withdraw should they wish.

This study includes the processing of sensitive and identifiable data of individuals who have self-harmed and it is not practical to seek informed consent from each patient. Consequently, a risk to participants would be through inadvertent disclosure of their identifiable or personal data. Appropriate safeguards are in place to ensure confidentiality is maintained.

The Derby monitoring system of self-harm is a long running project. All people attending Derby’s Emergency Department with self-harm since 2000 (to 2016) had been flagged with NHS Digital for mortality follow up.

The Derby Monitoring system of self-harm is run solely by Derbyshire Healthcare NHS Foundation Trust for service evaluation and development purposes.

The Multicentre Study of Self-harm in England is a collaboration between three separate self-harm monitoring projects based in different areas of England (University of Oxford, the University of Manchester, and Derbyshire Healthcare NHS Foundation Trust), that conducts studies on the epidemiology, causes, clinical management, outcome and prevention of self-harm. By combining data on self-harm from different areas, the Multicentre Study of Self-harm in England provides more representative and reliable data on self-harm in England than could be achieved by each site individually. The Multicentre Study contributes to the National Suicide Prevention Strategy for England (2002, 2012), and prevention and service initiatives, including NICE guidance on self-harm (National Collaborating Centre for Mental Health 2004, 2011). The programmes of research under the Multicentre Study is processed in the interests of the public (GDPR Article 6 (1) (e)) & 9 (2) (j)) as this will identify risk factors for premature death for people who self-harm and aspects of clinical management which are/could mitigate such risks.

Data for the study are collected in the three study sites (Oxford, Manchester, and Derby) in five general hospitals; one in Oxford, three in Manchester and one in Derby. Over 10 collaborating researchers from the three study sites are part of the research group. The project also has input from service users.

The Multicentre Study programme of research includes 4 broad areas:

- Epidemiology and trends in self-harm

- Clinical management of self-harm

- Outcome of self-harm, including repetition and mortality

- Pharmaco-epidemiology, including drug toxicology and impacts of changes in prescribing legislation and trends

With regards to the Derby monitoring system, Derbyshire Healthcare Foundation NHS Trust is the sole data controller, who also process the data, of the detailed and identifiable mortality data. No other organisation determines the purposes for which the data is processed.

With regards to the Multicentre Study of Self-Harm in England, Derbyshire Healthcare Foundation NHS Trust is the sole data controller, who also process the copy of the pseudonymised multi-site data they receive from the University of Oxford. Derbyshire Healthcare Foundation NHS Trust is the sole data controller for the copies of pseudonymised data received from the other sites. Derbyshire Healthcare Foundation NHS Trust has full autonomy to determine the purposes for and the manner in which that data will be used without needing input or authorisation from the other sites. For example, a specific researcher at Derbyshire Healthcare Foundation NHS Trust will identify a purpose for analysing the data and will undertake the analysis. The findings may be shared with collaborators at other sites who may then have input into the writing of the paper for publication but at this point, the findings are aggregated and sufficiently derived from the data under this Agreement.

Each collaborator independently undertakes follow-up of individuals who present to hospital with self-harm in their respective areas. This involves receiving follow up data from NHS Digital under separate Data Sharing Agreements. These are Agreements ref: DARS-NIC-147916-DPQ3Q for University of Manchester and ref: DARS-NIC-147957-4444C for the University of Oxford. For the purpose of the Multicentre Study of Self-harm in England, pseudonymised copies of their respective datasets are transferred to the University of Oxford. Amalgamated copies of the pseudonymised data for all three locations are then transferred to each collaborating organisation. The organisations then have autonomy to independently determine what analyses will be undertaken using their copies of the data and for what purposes, in support of the aims of the programme above.

For avoidance of doubt, notwithstanding mention of hospitals in Leeds and a research group in Leeds being mentioned as part of the multicentre collaborative project in a protocol document produced in 2008, no hospitals or research groups in Leeds including from the University of Leeds are part of this project nor will they either control or process any data under this Agreement.

The Derby monitoring system of self-harm and the Multicentre Study of Self-harm in England (including data from the monitoring systems for self-harm at University of Manchester and University of Oxford) are ongoing projects. Outputs from these projects are multiple. The aims of this study are to identify risk factors for specific causes of death (including suicide) in persons who present to hospital after self-harm and to investigate how specific aspects of in-hospital care relate to mortality following self-harm. Specific outputs planned for the next 18 months include:

* Identifying overall risk factors for suicide and other specific causes of death following self-harm.

* Identifying risk factors for suicide and non-suicidal premature mortality in children and adolescents

* Specific method of self-harm as a risk for suicide and premature death

* Epidemiology of paracetamol poisoning and risk of death by suicide.

* The findings from these studies will be published in peer-reviewed journals aimed at clinicians and researchers.

* Periodic reports for the Department of Health (the study funding body) and the National Suicide Prevention Strategy for England Advisory Group to communicate progress and key findings will be produced.

* Findings are published on the website of the Multicentre Study of Self Harm in England where information is summarized in layman's terms.

Other outputs include:

* Presentations of research findings at scientific meetings aimed at clinicians, researchers and stakeholders

* Presentations at meetings with clinical staff involved in delivering care for individuals who self-harm

* Meetings with policy making and regulatory bodies such as the National Institute for Health and Care Excellence (NICE), Medicines and Healthcare products Regulatory Agency (MHRA), National Suicide Prevention Strategy working group

In all the above, data will be presented in an aggregate format and individuals cannot be identified.

Summaries of projects undertaken are accessible on the Derbyshire Health NHS Foundation Trust website: http://www.derbyshirehealthcareft.nhs.uk/get-involved/research-and-development-home/sh-and-sp/research/

Details of publications by the Multicentre Study are published on the Multicentre Study website: http://cebmh.warne.ox.ac.uk/csr/mcm/index.html

Derbyshire Healthcare’s Suicide Prevention Strategy and that of Derbyshire Suicide Prevention Partnership Forum includes a target to support high risk groups - particularly those who have self-harmed.

Commissioning of a 24/7 Liaison Psychiatry service at the Royal Derby Hospital.

Data contributed to the Multicentre Study of Self-harm. Conducted studies which are relevant to clinical services and policy on suicide prevention. One example is how through linking episodes of self-harm with suicide as an outcome, researchers are able to identify clinically important risk factors for suicide following an episode of self-harm (non-fatal self-harm being the most important risk factor for suicide). For example, in children and adolescents is has been shown that risk of future suicide is strongest in boys, and in those with multiple episodes of previous self-harm and where certain specific methods of self-harm have been used. In adults it has been shown that a particularly high risk of subsequent suicide in people who have a history of multiple episodes of self-harm. Another example concerns the relationship between clinical management and subsequent suicide. Thus, the researchers have been able to investigate whether receipt of a psycho-social assessment while a person is in hospital following self-harm decreases the risk of future suicide.