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Background and aims

Mental health and specialist services in Australia’s Gold Coast (GCMHSS) undertook work in 2015 to implement a systems approach to suicide prevention using the zero suicide framework (ZSF) (Turner et al, 2020). Prior to implementation, traditional approaches to safety and suicide prevention did not result in a substantial change to outcomes. Challenges included difficulty responding to those in crisis who did not have a mental health diagnosis, using ineffective suicide risk assessments, a lack of meaningful interventions, a lack of comprehensive staff training and concern of a blame approach to reviewing incidences.


Implementation of the ZSF involved cultural change, emphasis on leadership, change management and quality improvement (including innovation and evaluation).  In a series of practical steps this included the adoption of new practices, increased staff support (in line with a cultural shift), and the development of an evaluation framework. These changes resulted in:

  • Improved processes
  • Improved staff skills and confidence
  • Embedded positive cultural change (for example: a restorative just culture)
  • Improved innovations (including the use of machine learning for the identification of suicide presentations)
  • Reduced rate of repeated suicide attempts and deaths by suicide

One example of the improved processes discussed in relation to the implementation of the ZSF was the GCMHSS suicide prevention pathway; the elements of which are summarised below:

  • Screening using the UK mental health triage scale (embedded in the electronic medical record)
  • Assessment enhanced by use of the chronological assessment of suicide events (CASE approach)
  • Formulation of risk
  • Brief ‘universal’ interventions to help enhance safety as part of an individualised care plan (of particular use in emergency department settings):
    • Safety planning intervention
    • Counselling on restricting access to lethal means
    • Provision of crisis numbers
    • Brief patient and carer information
    • Rapid follow up
  • Structured follow up

A person would be placed on the suicide prevention pathway based on the following criteria:

  • Anyone presenting following a suicide attempt or with a recent suicide attempt
  • Anyone with a history of a suicide attempt and presenting with suicidal ideation
  • Anyone admitted to an inpatient unit due to suicide risk
  • At the treating clinician’s discretion

Outcomes and benefits

In response to its initial success, the ZSF has been implemented across numerous states in Australia and within services internationally. Consequently, there was a call for more evidence for its effectiveness. In response, an in depth analysis was conducted to examine effectiveness of the ZSF over time (Stapelberg et al., 2020).  Two prominent key findings of the study are as follows:

  • A 65 percent reduction of risk for a repeated suicides attempts
  • Extension of the time between repeated attempts

*This effect was similar across all patient groups studied

Overall, these studies demonstrate the effectiveness of implementing the ZSF in reducing the rates of repeated suicide attempts and the number of deaths by suicide.  


Turner, K. et al. (2020). Implementing a systems approach to suicide prevention in a mental health service using the Zero Suicide Framework. Australian & New Zealand Journal of Psychiatry, 1-13. Available at: (accessed 18/01/2021) 

Stapelberg, N. et al. (2020). Efficacy of the Zero Suicide framework in reducing recurrent suicide attempts: cross-sectional and time-to-recurrent-event analyses. The British Journal of Psychiatry. Cambridge University Press, 1-10. Available at: (accessed 18/01/2021)

The aim of the ZSA Case Studies is to introduce users to a range of examples of new and innovative practice, with the broad aim of working to support people with their mental health, bring awareness to and help prevent incidence of suicide. Please seek further information by contacting the ZSA and appropriate professional input prior to making a decision over its use.

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Content last updated: 08/03/2021

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