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
***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.
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
Last year's survey findings: your views on our research
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.
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
- Patients with mental illness as victims of homicide: a national consecutive case series (The Lancet, Psychiatry)
Key finding - Risk of mental health patients being homicide victims more than 2 times as high as for the general population.
- Safety of patients under crisis resolution home treatment services in England: a retrospective analysis of suicide trends from 2003 - 2011 (The Lancet, Psychiatry)
Key finding - Risk of suicide in home treatment care is higher than in in-patient services
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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