National Confidential Inquiry into Suicide and Safety in Mental Health
The National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH) is an internationally unique project.
Our study has collected in-depth information on all suicides in the UK since 1996. Our recommendations have improved patient safety in mental health settings and reduced patient suicide rates, contributing to an overall reduction in suicide in the UK. Our evidence is cited in national policies and clinical guidance and regulation in all UK countries.
July 2019: Suicide can now be concluded on “balance of probabilities”.
Read our new BMJ editorial.
Improving safety in mental health services
We have been collecting data for over 20 years. Based on our evidence from studies of mental health services, primary care and accident and emergency departments we have developed a list of 10 key elements for safer care for patients.
These recommendations have been shown to reduce suicide rates.
Services should review in-patient safety, and remove ligature points from wards. There should be measures in place to prevent patients from leaving the ward without staff agreement; this might be through better monitoring of ward entry and exit points, and by improving the in-patient experience through recreation, privacy and comfort. Observation policies should recognise that observation is a skilled intervention to be carried out by experienced staff.
Following NCISH recommendations, suicide using non-collapsible ligature points became an NHS ‘never event’ (a serious incident that is preventable) in 2009. This means that health services are required to monitor their incidence, and are provided with advice to reduce the risk.
Since then suicide by mental health in-patients continues to fall. However, the large fall in the 4 years after 2006 (31%) has become more modest, e.g. in the 4 years after 2012, the rate fell by 11%. On average, there are still 106 suicides by in-patients in the UK per year.
This recommendation was originally cited in the Department of Health report An Organisation with a Memory in 2000.
More recently, it is included in:
- HM Government’s 2017 Third Progress Report of the Suicide Prevention Strategy
- Northern Ireland’s draft strategy for suicide prevention
- The Welsh Government’s suicide and self-harm prevention strategy Talk To Me 2
Early follow-up on discharge
Patients discharged from psychiatric in-patient care should be followed up by the service within two to three days of discharge. A care plan should be in place at the time of discharge.
In England, there were 2,220 suicides within three months of discharge from in-patient care between 2006 and 2016. 16% of these post-discharge suicides occurred within the first weeks of leaving hospital, with the highest number occurring on the second (18%) and third (21%) day.
Department of Health Mental Health Performance Framework Guidance states that all patients discharged to their place of residence, care home, residential accommodation, or to non-psychiatric care must be followed up within seven days of discharge.
National clinical guidelines have been developed with reference to our findings on suicide following discharge from in-patient care. See the NICE guidance on transition between in-patient mental health settings and community or care home settings.
No out-of-area admissions
Very ill patients should be accommodated in a local in-patient unit. Being admitted locally means that patients stay close to home and the support of their friends and family, and are less likely to feel isolated or to experience delayed recovery. Local admission should also result in simpler discharge care planning.
In England, 199 patients (10%) died after being discharged from a non-local in-patient unit. This proportion was similar to those who died within two weeks of discharge (65, 12%). There has been a downward trend in the number of suicides by patients recently discharged from hospital in England and Scotland. In England, there were 177 post-discharge deaths in 2016 (26 in Scotland), down from 227 in 2011 (49 in Scotland).
Both the King’s Fund Under Pressure report and the Independent Commission on Acute Adult Psychiatric Care referenced this recommendation in 2015, calling for an end to acute admissions out of area.
24-hour crisis resolution/home treatment teams
Community mental health services should include a 24-hour crisis resolution/home treatment team (CRHT) with sufficiently experienced staff and staffing levels. CRHTs provide intensive support in the community to patients who are experiencing crisis, as an alternative to in-patient care. CRHT teams should be monitored to ensure that they are being used safely. Contact time within CRHTs should reflect the specialist and intensive nature of that role.
The main setting for suicide prevention is now the crisis team, following a fall in in-patient suicides and a rise in the use of CRHT as an alternative to admission in acute care, since 2004. In England, there are on average 191 suicides per year by CRHT patients – over two times as many as under in-patient services. The introduction of a 24-hour CRHT appears to add to the safety of a service overall, with a reduction in suicide rates in implementing mental health services. In our study of the assessment of clinical risk in mental health services, both patients and carers emphasised the need for clarity about what to do and who to contact in a crisis.
Both the King’s Fund Under Pressure report and the Independent Commission on Acute Adult Psychiatric Care referenced these recommendations in 2015, and emphasised the importance of CRHTs operating efficiently as intensive specialist community-based alternatives to in-patient care, and not simply as generic crisis teams.
Working more closely with families could improve suicide prevention. Services should consult with families from first contact, throughout the care pathway and when preparing plans for hospital discharge and crisis plans.
Staff should also make it easier for families to pass on concerns about suicide risk and be prepared to share their own concerns. This could help to ensure there is a better understanding of the patient’s history and what is important to them in terms of their recovery, and may support better compliance with treatment.
There should be a multi-disciplinary review following all suicide deaths, involving input from and sharing information with families.
Staff told us that greater involvement of the family by the service would have reduced suicide risk in 17% of patients.
One example of how services can improve contact with families is shown in how services respond when a patient does not attend an appointment. In only 22% of deaths by suicide the service contacted the family when the patient missed the final appointment before the suicide occurred. Policies for multidisciplinary review and information sharing with families were associated with a 24% fall in suicide rates in implementing NHS Trusts, indicative of a learning or training effect.
Patients tell us they want their families to have as much involvement as possible in their assessment of clinical risk, including sharing crisis/safety plans with them.
The Independent Commission on Acute Adult Psychiatric Care cite these recommendations, stating that families and carers are an underused resource.
Guidance on depression
Services that implemented NICE guidance for depression and self-harm guidelines had significant reductions in suicide rates of 26% and 23% respectively.
See the NICE Quality Standard for the Management of Self-harm.
The NICE guidelines on depression are currently in development.
Personalised risk management
All patients’ management plans should be based on the assessment of individual risk and not on the completion of a checklist. Patients should have the opportunity to discuss with their mental health team the signs that they will need additional support, such as specific stresses in their life. Families and carers should have as much involvement as possible in the assessment process, including the opportunity to express their views on potential risk. Consulting with the patient’s GP may also be helpful.
Risk assessment is one part of a whole system approach that should aim to strengthen the standards of care for everyone, ensuring that supervision, delegation and referral pathways are all managed safely.
Most risk assessment tools seek to predict future suicidal behaviour. Clinicians tell us that tools, if they are used, should be simple, accessible, and considered part of a wider assessment process. Treatment decisions should not be determined by a score. Risk tools and scales have a positive predictive value of less than 5%, meaning that they are wrong 95% of the time, and miss suicide deaths in the large ‘low risk’ group. In a sample of patient suicides, the quality of assessment of risks and management was considered by clinicians to be unsatisfactory in 36%.
Risk is often individual, suggesting risk management should be personalised.
See the NICE guidelines for the long-term management of self-harm.
Community mental health teams should include an outreach service that provides intensive support to patients who are difficult to engage or who may lose contact with traditional services. This might be patients who don’t regularly take their prescribed medication or who are missing their appointments.
Implementation of an assertive outreach policy was associated with lower suicide rates among patients who were non-adherent with medication or who had missed their last appointment with services, and with lower suicide rates overall in implementing Trusts.
The Independent Commission on Acute Adult Psychiatric Care includes recommendations for comprehensive and effective community mental health, including outreach teams.
Low staff turnover
Organisations with low turnover of non-medical staff had lower suicide rates than organisations where staff changed frequently. In addition, those services with low staff turnover saw a greater reduction in their suicide rates when they implemented NCISH recommendations than services with high staff turnover.
The King’s Fund cited this recommendation in their Under Pressure report in 2015.
Reducing alcohol and drug misuse
We recommend there are drug and alcohol services available that work closely with mental health services for patients with mental illness and alcohol and drug misuse.
Only a minority of patients who died by suicide between 2006 and 2016 were in contact with specialist substance misuse services, despite alcohol and drug misuse being a common antecedent of patient suicide in all UK countries. In England, there was a 25% fall in rates of suicide by patients in those NHS Trusts which had put in place a policy on the management of patients with co-morbid alcohol and drug misuse.
Our toolkit presents the 10 key elements as quality and safety statements about clinical and organisational aspects of care. It can be used by mental health care providers as a basis for self-assessment.
Download a Word version of our toolkit, which can be used to record progress.
Toolkit for self-harm
A toolkit for self-assessment based on the NICE Quality Standard for Self-Harm.
Information for practitioners
We produce a wide range of national and themed reports and research papers.
Every report we publish is accompanied by infographics and videos summarising the key findings and recommendations. These are designed to be shared with colleagues and used in staff training sessions.
Resources for practitioners
Resources include data slides and sample questionnaires. You are free to use these in local presentations and teaching, with NCISH acknowledged as the source.
We value your opinion on our research, how we share our findings and what improvements we could make. Our survey is short and confidential.
How we use your data
Visit our data security page to find out about our policies on information governance.
Service users and carers
We work closely with service users and carers in the design and development of our studies. It is important for us to listen to the experiences and opinions of patients, and their family members, friends or carers, who have been involved with mental health services.
Help our research now
Your experience and views on how care can be safer help inform our recommendations and help us develop new areas of work.
Share your views and experience on mental health care and your suggestions about how we can develop our work.
Your opinion matters
Some of our research projects ask for your opinions on specific aspects of patient care and service provision. Previously, we have asked about experiences of risk and safety assessment and your views on personality disorder and psychiatric in-patient services.
Join our Lived Experience Advisory Panel
Are you interested in helping us develop our research to understand how services can help prevent suicide and self-harm? Have you, or a family member, been affected by suicidal behaviour or self-harm? If you would like to share your thoughts on how we present our research findings, or give your opinion on adverts, information sheets and report drafts for research studies, please email firstname.lastname@example.org to express your interest. We have opportunities to contribute in person at our informal discussion groups, and to contribute virtually by email. No previous experience of research is required and you would be reimbursed for your time.
Future work seeking the experiences and views of patients of mental health services will be published on this website and also on our Twitter account.
View our latest reports, including related videos, infographics detailing what our findings mean for your care, and summaries.
Poems inspired by our work
As writer-in-residence for NHS North West R&D, Char March wrote a series of poems to help us understand the power of creativity in conveying our messages.
Help in a crisis
Sources of help and support can be found on our page for help in a crisis.
To report concerns about the care you, or someone else, has received, see the NHS Choices website.
For those bereaved or affected by suicide, support is available from Support After Suicide Partnership (SASP).