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.

WHAT'S NEW - Inquiry update

2015 Annual report out in July.

For details of the launch click here

In-patient Suicide Under Observation

We found 18 deaths by suicide per year in in-patients under observation across the UK during 2006-12. We found that half of deaths examined occurred when checks were carried out by less experienced staff or agency staff who were unfamiliar with the patient. A common feature was that staff did not follow the observation plan because the ward was busy or poorly designed. We found that the current observation approach is not working safely enough. New models need to be developed and evaluated. For a copy of the report click on the image (pdf, 670KB) Press release (pdf, 177KB)

Healthy services and safer patients

We examined whether suicide rates were related to the way NHS mental health services were organised based on staff and patient surveys and national databases. We found higher staff turnover and more patient complaints and patient safety incidents were associated with higher suicide rates. A full copy of the report is available here (pdf, 816KB)

Final report on National learning disabilities mortality review function

In August 2014 the Inquiry were commissioned by the Health Quality Improvement Partnership (HQIP) on behalf of NHS England to develop an options appraisal for the specification for a national mortality review function for people with learning disabilities. A full copy of this report is available here. (pdf 1.04MB) Presentation slides available here. (ppt 2.17MB)

Inquiry questionnaires - online data capture - FAQs

From September 2014 the Inquiry will begin collecting its suicide questionnaire data online via a secure web based database. More information about this development and responses to frequently asked questions about how the system has been built is available here.

National Confidential Inquiry Annual Report 2014 (16 July 2014)

Report videos:

Inquiry report publication schedule 2014-16

See also: Centre news

Stakeholder survey 2014

The survey will only takes a few minutes to complete and we value your opinion. Please give us your feedback on our research and how we share our findings.

Last year's survey findings: your views on our research

Current studies

Features of mental health organisations and suicide rates
This study will investigate a range of organisational characteristics of mental health service providers to establish which characteristics are associated with reduced suicide rates. This study will report in February 2015.

In-patient suicide whilst under non-routine observation
Thank you to all service users, consultants and nurses working in mental health that shared their experience in our online survey. In this study we are examining why suicide deaths occur on in-patient wards whilst individuals are under observation. This study will report in March 2015.

Reports on recent findings

Suicide in primary care in England: 2002-2011 (March 2014)
Suicide risk increased with increasing GP consultations; non-attenders were also at higher risk. Other markers for risk and messages for primary care services identified. Read summary and download full report. Professor Louis Appleby (Director) presents the main findings and implications from the research.

Report videos:

Patient suicide: the impact of service change. A UK wide study (November 2013) 
Report showing that the implementation of key service recommendations can reduce suicide rate within mental health services.

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.

National Confidential Inquiry Annual Report

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 2014 (PDF)

Report videos: (Links to new report videos)

  • Key findings 1
  • Key findings 2

Latest research papers

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.

  • Safer Services. A toolkit for patient safety review.

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