Suicide Prevention and Child Death Review

To create a comprehensive set of suicide prevention strategies for young people, many different avenues of intervention need to be considered.

The Child Death and Serious Injury Review Committee carefully reviews all information available to it to determine if a young person has suicided. The Committee uses this information to build ‘life charts’. These charts help to identify common themes in the lives of young people who have suicided.

The Committee has determined that 49 young people have suicided since 2005; 3.4% of the total number of children who have died in South Australia since that time. Deaths in transport crashes and from illness or disease are the two most common causes of death among 15-17 year olds in South Australia. Suicide is the third most common cause of death in this age group.

The Committee has reviewed 41 deaths using the life chart methodology[1]. Four sub-groups of commonly occurring life chart themes have been identified and intervention and prevention strategies that are needed to address these themes developed.

The different kinds of prevention and intervention strategies needed to develop a comprehensive suicide prevention plan for young people are summarised here and discussed in further detail below.

Group 1
Intervention and prevention strategies need to begin early in life for young people who have disengaged from home, school, community and other forms of support.

Group 2
Youth-oriented mental health services are needed by young people who experience anxiety, depression and other emerging mental health issues in their teenage years.

Group 3
Readily available support and information services are needed by young people who have no identifiable risk factors, and are not involved with support services.

Group 4
The Committee does not have enough information about the three young people in Group 4 to determine common themes in their lives. More analysis may be possible in time, should further cases be added to this grouping.

[1] Fortune, S, Stewart, A, Yadav, K, and Hawton, K (2007), Suicide in adolescents: using life charts to understand the suicidal process. J of Aff Disorders, 100, 199-220.


Group 1

Intervention and prevention strategies recommended to address the themes identified in this sub-group should begin early in life and include:

  • Strengthening parenting capacity within families during the child’s very early years.
  • Addressing learning and behavioural problems, as they are identified in early childhood.
  • Ensuring that ongoing problems with learning and social skills are addressed, with every effort made to keep the young person engaged in education, especially in the transition to secondary school and throughout adolescence.
  • Promoting engagement through youth-specific programs in the community, with a focus on building resilience and restoring self-esteem.
  • Ensuring integrated service delivery – juvenile justice, drug and alcohol services, mental health services and alternative education options.

The intervention and prevention strategies for this sub-group can be missed by suicide prevention plans focused on risk factors, tipping points and imminent harm.

The Committee’s intervention and prevention strategies for this sub-group are based on findings regarding the similarities in the life circumstances of 13 young people which included:

  • Multiple and complex problems starting very early in life, including significant family upheaval often resulting in homelessness.
  • Learning and behavioural problems which often started at kindergarten.
  • Exacerbation of these problems in adolescence, including problems making and keeping friends – leading to social and educational disengagement.
  • Involvement of educational support services, child protection, juvenile justice, adolescent mental health, housing, and drug and alcohol services.

Group 2

Intervention and prevention strategies recommended to address the themes identified in this sub-group include:

  • Provision of youth-oriented mental health services with an emphasis on assertive outreach and follow-up, and the capacity to support the young person’s family.
  • Co-ordination between mental health services and school support services.
  • Youth-specific services with the capacity to explore issues relating to romantic and sexual relationships.

The Committee’s intervention and prevention strategies for this sub-group are based on findings regarding the similarities in the life circumstances of 20 young people which included:

  • The presence of a supportive family or family member.
  • Engagement with family, school and friends until the emergence of challenges to their mental health, eg depression and/or anxiety, which often occurred after their transition to secondary school.
  • Seeking help from adolescent mental health services (government or private), and requiring assertive outreach.
  • History of deliberate self-harm and/or previous suicide attempts.
  • Challenges in social, romantic or sexual relationships in the year/months proximal to their death.

Group 3

Intervention and prevention strategies recommended to address the themes identified in this sub-group include:

  • Readily available and accessible support and information sources – through school, workplace and/or community as well as ‘crisis’ support, especially access to help for young people during the critical hours when they appear to decide to suicide.
  • Population-based prevention programs that emphasise the role that friends/peers play in helping those who are contemplating suicide.

The Committee’s intervention and prevention strategies for this sub-group are based on findings regarding the similarities in the life circumstances of five young people which included:

  • Stability at home, in friendships and at school.
  • ‘Positive’ approaches to life.
  • Exposure to suicide through school connections.
  • No contact with support services.
  • Challenges in romantic/sexual or social relationships immediately proximal to their death.

More information about deaths attributed to suicide, and life chart review can be found in the Committee’s annual reports.