‘Zero Suicide Is the Goal’: Prevention Efforts Getting Boost From Local Fatality Review Team

Investigators looking for answers in a 2016 Arcata suicide. [Photo by Oliver Cory]

The Humboldt County Coroner’s Office has expanded the way it investigates suicides by using a consolidated risk assessment profile in hopes of learning how to prevent future deaths.

Created by an Oregon epidemiologist and her team, this checklist tracks near real-time trends to determine who in the community is most at risk of suicide and what system changes can be made to prevent future suicides.

Kimberly Repp, the chief epidemiologist for Washington County, Ore., who holds a Ph.D. in microbiology, created the checklist which includes basic questions about age, gender and cause of death and expands to an extensive list of questions about a variety of things, including evidence of addiction, financial or job problems and relationship stress. Humboldt started using the checklist at the beginning of the year.

Dana Murguia, a senior program manager with the Humboldt County Department of Health & Human Services (DHHS), said she and her staff first heard about Repp and her methods when they saw her present at a conference. In December, Repp came to Humboldt and provided two suicide fatality review trainings to DHHS staff and community partners.

The purpose of these reviews is to take a closer look at these deaths and make recommendations for system changes, legislation, policy, training and public education based on data to prevent future deaths by suicide in Humboldt County. Murguia says sometimes just asking someone if they’re contemplating suicide can be enough to make the person realize someone cares about them and to be willing to seek necessary services. “It’s hard to ask the question, but it’s critical,” she said.

Humboldt County Sheriff’s Sgt. Jamie Barney, an investigator at the Coroner’s Office, said, “We attended Dr. Repp’s presentation and it kind of opened our eyes. We realized the data that we can provide can point to people in the community who are at risk of suicide and provide people with suicide prevention training to help.”

In order to establish baseline data and identify what was missing from traditional reports, staff from DHHS Public Health’s Suicide Prevention

Program reviewed five years of reports.

“We still investigate the same way, but prior to the checklist we had to go through each report narrative to find answers to these questions. Now it’s consolidated to a yes, don’t know or no on the checklist,” Barney said.

In May, DHHS and Coroner’s Office staff gathered for the first quarterly Suicide Fatality Review Team meeting to review the checklists from three recent suicide deaths. With permission from the decedent’s families, the team spoke to their medical providers and other providers or agency representatives that had been in contact with the individual leading up to their death.

DHHS Mental Health Branch Quality Management Coordinator Kayleigh Emry who attends the meetings, said, “Mental Health’s Mortality and Morbidity review provides valuable, client-specific information and will allow us to participate as a member of the suicide fatality review team in a meaningful way.”

Rep. Jared Huffman, who represents California’s second district, said he thinks forming the suicide fatality review team is another step in the right direction.

“Suicide is a particularly difficult problem in the rural parts of my congressional district,” Rep. Huffman said. “My staff and I have met with the public health officials and coroners who are on the front lines of this issue, and it’s good to see them taking this important step toward helping our Humboldt County communities move toward zero suicide.”

Although the program is still in its infancy, Murguia said they are busy compiling and analyzing data. “As we collect more data, we’ll get more insight on specific places where we can intervene and implement actual prevention. Our objective is to be able to make recommendations for changes that will make an impact.”

Barney agrees. “It’s very positive for the community,” he said. “Zero suicide is the goal. To see a reduction in suicides in Humboldt County will be the first thing we can look at and say ‘this is having an effect.’”