Risk Assessment Protocol

EPDS Q10 ≥1 indicates the need for an immediate risk assessment.

The higher the score the more serious the concern for risk.

Below are the main issues that are used to assess the severity of the mother’s risk of suicide. If you don’t feel qualified to conduct risk assessment, refer on to a qualified health professional.

•  Suicidal thoughts
“What exactly have you been thinking? How often? How compelling or powerful are these thoughts? Is it worse than previously? What triggers these thoughts?”
•  Planning
“What have you been thinking you might do?” Press for plan details
• Lethality
Is the specific method likely to be lethal?
• Means
“Have you been thinking about how you might do it? Do you have the means to carry out your plan using this method?” “Do you have access to (drugs, weapon etc)?
• Intention
“How likely do you think you are to follow through and act on your thoughts or plan? What stops you?”
• Protective factors
“What stops you from acting on these thoughts?” “Sounds like you’ve been feeling pretty awful, what’s kept you going?”


Actions to Take:

If Q10 >1 and further questions indicate reason for concern:

  1. Develop a safety and management plan (include risk assessment for infant and contacts for crisis services). If urgent contact CATT team and arrange for person to be picked up.
  2. Provide safety numbers (see below)
  1. Ensure the client is aware of the health professionals that need to be informed
  2. Document the results of this assessment and actions you have taken.

Safety numbers:

  1. Crisis Assessment & Treatment Team (CATT) – 9450 9090
  2. Lifeline – 131114
  3. Suicide Helpline – 1300 651 251
  4. Suicide call back – 1300 659 467
  5. Mental Health Advice Line – 1300 280 737
  6. Parentline (8am – 12am Mon-Fri & 10am-10pm on weekends) – 132289
  7. Panda – 1300 726 306

Permission to contact other health professionals involved