National Confidential Inquiry into Suicide and Homicide by People with Mental Illness

As the UK’s leading research programme in this field, the Inquiry produces a wide range of national reports, projects and papers – providing health professionals, policymakers, and service managers with the evidence and practical suggestions they need to effectively implement change.Healthcare Quality Improvement Partnership

The Mental Health Clinical Outcome Review Programme is commissioned by the Healthcare Quality Improvement Partnership (HQIP) on behalf of the NHS England, NHS Scotland, NHS Wales, the Northern Ireland Department of Health, Social Services and Public Health (DHSSPS) and the State of Jersey to undertake the Mental Health  Clinical Outcome Review Programme.

WHAT'S NEW - research update!

** NEW REPORT ** Suicide in primary care in England: 2002-2011

New findings published 26 March 2014: Suicide risk increased with increasing GP consultations, particularly in the 2 to 3 months prior to suicide. In those who attended more than 24 times in the previous year, risk was increased 12-fold. Non-attenders were also at increased risk (67% increase on those who did attend); this group were more likely to be younger and male. Other markers for risk included receiving multiple mental health drugs and specific drug combinations such as benzodiazepines with antidepressants. Mental illness in primary care was frequently unrecognised; only 8% of individuals that died had been referred to specialist services. Read the full report (PDF, 700KB) including key messages for suicide prevention in primary care. Press release (PDF, 108KB)


Please give us your feedback on our research and how we share our findings. Your views will be summarised and posted here later in the year.
Click here to participate.


**SURVEY NOW LIVE** In-patient suicide whilst under non-routine observation

In this study we are examining why suicide deaths occur on in-patient wards whilst individuals are under observation? We are seeking service user and clinicians' views and experience of observation to help inform our study of this important issue. This study will report in 2015. For more information and to participate click here.

Features of mental health organisations and suicide rates

This study aims to investigate the organisational characteristics of mental health service providers and establish which characteristics are associated with reduced suicide rates. A range of measures will be examined that will include staff and patient survey findings, serious untoward incident reporting, sickness and absence records and vacancy rates. This study will report later in 2014.


Patient suicide: the impact of service change. A UK wide study (November 2013) 
Report of the impact on suicide rate following implementation of key service recommendations. Specialist community services, implementation of NICE guidelines, information sharing with criminal justice agencies, ward safety and prevention of absconding and creating a learning culture all contribute positively.
Download report (PDF, 305KB)

Quality of risk assessment prior to suicide and homicide - A pilot study (June 2013)
Report describing the development of a framework for assessing the quality of risk assessment prior to suicide and homicide. In around one third of a sample of Inquiry suicide and homicides the quality of prior risk assessment was considered not satisfactory.
Download report (PDF, 397KB); download vignettes (PDF, 101KB)


The findings from our core research programme providing an in-depth analysis of the changing patterns and risk factors behind cases of suicide and homicide by people in contact with mental health services and of cases of sudden unexplained death amongst psychiatric in-patents.
Annual report 2013 (PDF, 6,763KB)

Report videos:


Our research papers focus on specific issues across a wide range of topics and discuss the clinical implications of our findings. See our publications section.


Our toolkits help health professionals and managers apply the Inquiry’s research findings as they improve service safety and reduce risk.

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