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

NCISH will be holding its 20th anniversary conference on 6th October 2016 at Manchester's Whitworth Hall. For details of the event click here

July 2016

7 July. New study: “Weekend effect”; incidence of patient suicides 12-15% lower at the weekend. Mental health services, suicide and 7-day working, press release

May 2016

***25th May, new Inquiry report published today***

We carried out an examination of suicides by people aged under 20 years who died between January 2014 and April 2015 in England. This is the first phase of a UK-wide investigation into suicides by people aged under 25. We collected data from a range of investigations by official bodies in England, including coroners, local authorities and health services, and identified relevant antecedents prior to suicide. There were 145 suicides and probable suicides by young people in England in the study period. The suicide rate at this age is low but escalates in the late teens. Our findings suggest that numerous experiences and stresses are likely to have contributed to suicide risk in children and young people. Many young people who die by suicide have not expressed recent suicidal ideas, but their absence cannot be assumed to show lack of risk. Improved services for self-harm and access to CAMHS is crucial, but the antecedents identified in this study show that schools, primary care, social services and youth justice also have an important role to play.

For a full copy of the report click here. (PDF, 600KB)
For a copy of the infographics sheet with key messages click here. (PDF, 644KB)
To see a video of Professor Louis Appleby presenting the key findings cilck on the following links: Key findings. What do our findings mean for prevention?
For a copy of the press release click here. (DOCX, 26KB)
For link to blog click here.

A linked academic paper ‘An investigation into suicide in children and young people in England: a consecutive case series’ has been published in The Lancet Psychiatry click here.    

April 2016

***Asking for your views on Personality Disorder***
NCISH launches new survey exploring the views of people with personality disorder and their experience of receiving care from mental health services. To find out more click here

July 2015

***22nd July, new Inquiry report published today***

For a copy of the report click here (pdf, 6.24mb)

For a copy of the press release click here (pdf, 79kb)

For a copy of our infographics sheet for key messages click here (pdf, 435kb)

For a copy of our service user information sheet click here (pdf,195kb)

For details of the report launch click here

For a copy of our report launch slides click here (ppt 2.63mb)


Our Annual Report 2015 report, which presents findings from 2003 to 2013, highlights areas of healthcare where safety should be strengthened.  Key messages include:

  • The rise in suicide among male mental health patients appears to be greater than in the general population - suicide prevention in middle aged males should be seen as a suicide prevention priority.
  • It is in the safety of crisis resolution/home treatment that current bed pressures are being felt – the safe use of these services should be monitored; providers and commissioners (England) should review their acute care services. 
  • Opiates are now the most common substance used in overdose – clinicians should be aware of the potential risks from opiate-containing painkillers and patients’ access to these drugs.
  • Families and carers are a vital but under-used resource in mental health care – with the agreement of service users, closer working with families would have safety benefits.
  • Good physical health care may help reduce risk in mental health patients – patients’ physical and mental health care needs should be addressed by mental health teams together with patients’ GPs.
  • Sudden death among younger in-patients continues to occur, with no fall – these deaths should always be investigated; physical health should be assessed on admission and polypharmacy avoided.

May 2015

Outstanding Benefit to Society Through Research:  NCISH, MASH and the Centre for Suicide Prevention highly commended for our work as part of the University of Manchester ‘Making a Difference’ awards. Click here for further information

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.

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)

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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