National Confidential Inquiry into Suicide and Safety in Mental Health

The University of Manchester


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.



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.

Safer wards
Bed iconServices 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.

Our evidence

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. There was a 40% fall in rates of in-patient suicides per 100,000 admissions in 2005-2015. However, on average, there are still 114 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:

Early follow-up on discharge
House iconPatients 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.

Our evidence

In England, there were 2,288 suicides within three months of discharge from in-patient care between 2005 and 2015. 16% of these post-discharge suicides occurred within the first weeks of leaving hospital, with the highest number (21%) occurring on day three.


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
Train iconVery 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.

Our evidence

In England, 212 patients (10%) died after being discharged from a non-local in-patient unit. This increased to 79 (13%) of those who died within two weeks of discharge. There has been a downward trend in the number of suicides by patients recently discharged from hospital in England and Scotland: there were 230 post-discharge deaths in 2015, down from 299 in 2011.


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
Call 24/7 iconCommunity 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.

Our evidence

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 2005. In England, there are on average 186 suicides per year by CRHT patients – around two to three 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.


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.

Family involvement
Family iconWorking 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.

Our evidence

Staff told us that greater involvement of the family by the service would have reduced suicide risk in 14% 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.


The Independent Commission on Acute Adult Psychiatric Care cite these recommendations, stating that families and carers are an underused resource.

Guidance on depression
Book iconThere should be a local NHS Trust/Health Board policy based on NICE (or equivalent) guidelines for depression and self-harm.

Our evidence

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
Medical record iconAll 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.

Our evidence

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.

Outreach teams
Chat iconCommunity 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.

Our evidence

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
Nurse iconThere should be a system in place to monitor and respond to non-medical staff turnover rates. Non-medical staff are all other health staff except doctors.

Our evidence

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.

Services for dual diagnosis
Clockwise arrows iconWe 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.

Our evidence

Only a minority of patients who died by suicide between 2005 and 2015 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.


See the NICE guidelines on coexisting severe mental illness and substance misuse.

Icons made by Freepik from is licensed by CC 3.0 BY

Our toolkit

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 our toolkit

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.

Our research

View 20 years of publications written by our researchers and associated colleagues and find out about the wide range of current and completed projects.

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.

Stakeholder survey

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.

Future studies

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.

Our reports

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.

Reporting concerns

To report concerns about the care you, or someone else, has received, see the NHS Choices website.

Bereavement support

For those bereaved or affected by suicide, support is available from Support After Suicide Partnership (SASP).