Key points

CCOPMM recommend that tertiary mental health services review their risk assessment processes prior to discharge of children and young people with suicidal ideation. 

CCOPMM recommend that mental health services develop a practice standard around discharge processes involving high-risk adolescents that involves a warm handover in which the young person and family meet with their inpatient team and receiving outpatient team face to face or online. This warm handover would allow the young person and their carers/parents to meet the people who will be looking after them, as well as to ask questions of their care and follow-up.  This warm handover could include multidisciplinary case conferencing, a supported transition to the new service and clarity of information sharing and responsibility in handover.  It is anticipated that this comprehensive handover involving all relevant stakeholders while time consuming, would be justified as it could lead to lower readmission rates and use of Emergency Departments, higher outpatient follow-up rates and an overall reduction of self-harming behaviours. 

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    Aim

    The aim of this good practice point is to provide guidance on handover and information sharing between services for young people at high-risk of suicide being discharged from mental health services. 

    Background

    Suicide and self-inflicted injury continue to be a leading cause of morbidity and mortality for young people aged 15-17 years in Victoria (Safer Care Victoria, 2004). 

    CCOPMM case reviews of deaths by deliberate self-harm note cases in which children and young people had been discharged from tertiary mental health services to Headspace but died by suicide before being picked up by the service.  The immediate period following inpatient admission has been consistently identified as high-risk for both self-harm and suicide (Forte et al., 2019).  The seven-day post discharge contact is a statewide metric to benchmark appropriate clinical care across all the adolescent inpatient units. The 2022-23 statewide Victorian target percentage of inpatients who were contacted within seven days following discharge from a mental health inpatient service is 76% (CAMHS, 2025).

    References

    Child and Adolescent Mental Health Services (CAMHS), retrieved 26 August 2025, Victorian Agency for Health Information, available at https://vahi.vic.gov.au/mental-health/child-and-adolescent-mental-health-services

    Forte, A., Buscajoni, A., Fiorillo, A., Pompili, M. and Baldessarini, R.J., 2019. Suicidal risk following hospital discharge: a review. Harvard review of psychiatry, 27(4), pp.209-216.

    Safer Care Victoria, 2024. Victoria’s Mothers, Babies and Children 2022 Report. Department of Health, Victoria.

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