Frequently asked questions

Method

How do you define suicide and homicide?
General population suicides are defined as deaths by intentional self-harm and deaths of undetermined intent by individuals aged 10 and over. General population homicides are legally defined as convictions for murder, manslaughter (culpable homicide in Scotland), infanticide, and verdicts of not guilty by insanity and unfit to plead.
How do you define patient suicides?
Patients are those in contact with psychiatric, drug and alcohol, child and adolescent or learning disability services (if they are within mental health services) within 12 months of their death, with their care usually under a consultant psychiatrist. These include a range of patients, from those seen for one-off assessments to those who had been under the long term care of services. Patients who were seen for a one-off assessment in a liaison setting with no follow-up arranged would not meet NCISH criteria for a patient suicide.
How do you collect suicide data?

Stage 1

Obtain information on all general population suicides and deaths of undetermined intent from the Office for National Statistics (ONS) (England, Wales), National Records of Scotland (NRS) and the Northern Ireland Statistics and Research Agency (NISRA).

Stage 2

Identify contact of those individuals with mental health services in the 12 months prior to the incident through administrative contacts at healthcare organisations and if contact is confirmed.

Stage 3

Collect detailed clinical data via questionnaire from the consultant psychiatrist (or other senior professional) caring for the patient. NCISH has the following approvals:

  • Approval from the North-West Greater Manchester South Research Ethics Committee (ref: ERP/96/136).
  • Approval from the Health Research Authority Confidentiality Advisory Group (HRA-CAG). Section 251 approval permits us to access confidential and identifiable patient information in the interest of improving care. This approval is renewed on an annual basis (PIAG 4-08(d)/2003).
  • Approval from the Public Benefit and Privacy Panel for Health and Social Care (PBPP) (eDRIS ref: 1718-0171)

Individual R&D/R&I and Caldicott data sharing agreements with all NHS mental health services providing data.

How do you collect homicide data?

Stage 1

Obtain information on all homicide convictions from the Home Office Homicide Index (England and Wales) and the Management Information Analysis Team at the Scottish Courts and Tribunal Service (Scotland). We have historically obtained data from the Central Business Unit of Northern Ireland Courts and Tribunal Service (Northern Ireland).

Stage 2

Identify contact of those individuals with mental health services in the 12 months prior to the incident through administrative contacts at healthcare organisations – allowing us to record and report on the numbers of homicides by people in contact with mental health services.

How do you define homicide-followed by suicide and how do you collect these data?
Homicide followed by suicide is defined as when the offender died by suicide within three days of committing homicide. As there is no conviction for homicide, these cases are analysed separately. This data is collected in England and Wales only. We obtain information on homicides where the offender has died by suicide from the Home Office. We also contact police forces annually to request the completion of a pro forma which captures data about cases of homicide followed by suicide. This information is kept on file pending confirmation via national sources of suicide data that the offender’s death has been recorded as suicide.
How complete is the data you present?
Overall the data completeness for patient suicide is high, but the figures for more recent years in any given report will be less complete. This reflects the time taken to process the data and is, in part, because of delays in legal processes. Data on homicide convictions provided by the Home Office are also incomplete for more recent years and are likely to vary between police force areas. We calculate how complete our data are by examining data patterns from earlier years and estimating how much more data we are likely to receive and the number of questionnaires this would generate.
Why is there a delay in the receipt of data from national sources?
Some deaths must be referred for a coroner’s inquest into the cause of death, only then may the death be recorded as suicide or of undetermined cause on national registers. In England and Wales the inquest process can take several months creating a delay in death registration and subsequently the notification of the death to the NCISH on our national mortality data extracts. In Scotland delays in registration are minimal as deaths are required to be registered within eight days. Similarly, the legal process of bringing a homicide to court, the trial itself, and any subsequent appeal against conviction introduces a time lag from when the homicide was committed to the offender being convicted and this outcome being recorded on national databases and notified to us.
Do you only collect case series data?
No. NCISH is a large, national case series of suicide, homicide and SUD by mental health patients. However, we also use other methods to address specific research questions. We have:

  • carried out record linkage studies to identify patient suicides occurring in primary care;
  • interviewed GPs and nurses to identify barriers to accessing secondary services, and difficulties with observation in in-patient settings;
  • conducted case control studies to investigate in-patient suicide and suicide in the post-discharge period;
  • examined the association between local service delivery and changing suicide rates;
  • reviewed mental health care records to investigate the assessment and management of risk prior to suicide or homicide;
  • examined suicide in the general population using information from investigations by official bodies, mainly coroners.

Find out more about our projects.

How many of the questionnaires that you send out are returned
Response rates refer to the completion and return of NCISH questionnaires by clinicians and are expressed as a percentage. For example, 95 out of 100 questionnaires sent to clinicians within a trust/health board that are returned complete would equate to a 95% response rate. In 2017, response rates were 95% or better in almost all trusts.
What has been the effect of the ICD-10 coding changes to the recording of drug-related deaths?
Following an update to the International Classification of Diseases and Related Health Problems (ICD-10) in 2011, new rules for coding certain drug-related deaths were introduced. Some drug-related deaths previously coded as due to ‘mental and behavioural disorders due to psychoactive substance misuse’ are now coded as suicide or undetermined deaths. Both the Office for National Statistics (ONS) and the National Records of Scotland (NRS) have implemented these changes to coding practice. Analysis by ONS has shown these new coding rules have had no significant impact on the suicide figures in England. However, they have affected numbers in Scotland. More information on the change in coding rules can be found in the ONS statistical bulletin Suicides in the UK, 2011.
Why do you report homicide convictions?
We only include homicide offences that have resulted in a conviction for homicide to ensure that the individuals have been found guilty of committing a crime in a court of law.
Why are there differences between the rates of suicide you calculate and those calculated by other agencies?
Discrepancies may arise between national numbers and suicide rates presented in our annual reports and those presented by other agencies, like ONS, due to differences in measurement of suicide and how the rates of suicides are calculated. We:

  • Calculate the number of suicides based on the date of death.
  • Collect data on suicide from age 10 years and over.
  • Include a small number of deaths occurring outside the country and deaths of people who were not residents of the country. For example, for Wales we include all those deaths that occurred within Wales (residents and non-residents of Wales) and also the deaths of Wales residents who died in other countries.
  • Calculate the overall rate of suicide based upon the number in the general population aged 10 years and over.
  • Calculate crude suicide rates.

Other agencies sometimes report the rate of suicide:

  • Where the number of suicides reported are based on date of registration of death.
  • Using deaths from age 15 and over.
  • That have been standardised using the European Standard Population.

Obtaining data

Can I request data from the NCISH?

Yes. Individuals submitting data, audit teams and commissioners of services are able to access data through bespoke data requests. Currently, data requests must be initiated by the Medical Director of the healthcare organisation. Data requests provide individual trusts with benchmarking data for their trust in the context of the national data. Our annual reports provide some data on a regional basis, where appropriate. Annually, we provide a Safety Scorecard to the Medical Director of each mental health trust in England. This Scorecard provides benchmarking data to support quality improvement. All of our outputs and information about our work programme are available via our website – including PowerPoint data slides for download. We actively engage with clinical, commissioning and policy stakeholders through presentations at professional meetings and training days. We inform the public of our work through events, presentations, print and social media. However, we are bound by the conditions stated in the data sharing agreements we have with our data providers which are intended to safeguard the identifiable clinical information that they share with us and therefore it may not always be possible to respond to a request if it risks breaching these agreements. See our privacy notice for further information.

What happens to the information I provide?

We publish annual reports which include analysis of the most recent year of national data on patient suicides, as well as trends over time. In addition to annual reports, we publish project reports investigating specific patient sub-groups.

We recommend changes to clinical practice and policy to reduce the risk of suicide and improve the safety of mental health patients. We only publish aggregate figures, and we follow Office for National Statistics guidance about small numbers – we don’t publish low counts, and we never share information about an individual.

For more information on how we use the sensitive information that we collect in our research, and the rights you have if you think that we hold information about you as a data subject please refer to our privacy notice.

Involvement

How do you involve service users, carers and their representative organisations?
We recognise how important it is 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. We work closely with service users and carers in the design and development of our studies. Our independent advisory group also includes lay members with user and carer experience. Previously, we have asked about experiences of risk and safety assessment and have gathered views on personality disorder and psychiatric in-patient services (see our projects). Our work seeking the experiences and views of patients of mental health services is also published on our website and also on our Twitter account. We speak about our work to service user groups and other healthcare organisations and we attend public events (e.g. local markets and other community activities) with information about our findings.
Where can I obtain advice and support?
Sources of help and support can be found on our help in a crisis page. The Support After Suicide Partnership (SASP) has put together a library of support guides for those bereaved or affected by suicide for each country of the UK on their website.

Online data collection

All NHS Trusts in England, Health Boards in Scotland and Wales, and Health and Social Care trusts in Northern Ireland moved from the completion of paper NCISH questionnaires to an online system for the collection of questionnaire data by January 2018. The following FAQs provide more information about why this step was taken and how the online data collection site was built.

Why has an online data collection system been built using modern browser technology?
Our task was to build a secure, online method for the collection of NCISH questionnaire data. This was endorsed by our commissioners, the Healthcare Quality Improvement Partnership (HQIP) and our Independent Advisory Group (IAG). Although the online data collection system does not hold patient identifiable data we have built in the highest levels of security which may only be achieved using more recent browser software. When designing the system we took into account the following:

  • Use robust and secure technology that is suitable for the public internet because the system cannot be used in the N3 environment.
  • Use recommended software that could be supported long term, as the system is hosted on The University of Manchester’s servers.
  • Develop a system that is in a familiar format to the user and is easy to use.
  • Acknowledging that some NHS units are not as advanced in IT infrastructure upgrades; build in a simple secure solution to enable older systems to work with the online data collection system.
  • Ensure the system meets the requirements of the stakeholder and the governance bodies who nationally have to approve it.
  • Provide a solution that has no financial cost for relevant software to the end user.
Why hasn’t the use of older technology been taken into account?
When designing the system we looked at lots of different technologies and considered the very real problems of NHS staff being unable to upgrade or keep up with rapid technology change. One of our main criteria was to have a system that worked on supported software that is going to be maintained with security patching. Security patching support for Windows XP and older Internet Explorer browsers was withdrawn in April 2014. Designing for older systems was not therefore a sustainable option. Security was the primary consideration and the fact that the system had to be robust across the internet. Older solutions were considered, but would have compromised security and functionality, and would not have provided a sustainable system.
What if my organisation is unable to deploy new systems?
The online data collection system has been designed to work with modern browsers. These modern browsers are freely available and can be installed in addition to your existing browser without compromising any older systems you may have to run.
What if my firewall will not let me use the online data collection site?
The site does not use any protocols that should be blocked in a normal working environment. If you are using one of the recommended modern browsers then the only items that need allowing at firewall level are https://ncish-response.manchester.ac.uk. Your local IT administrators will be able to help you.
Why am I not receiving an email from the site to authenticate my registration email address?
Check your spam filters and junk mail. It may be that the software that filters out junk mail arriving in your email inbox has mistaken the application servers authentication message. Your local IT administrators will be able to help you.
Will the online data collection site hold any identifiable information?
The online data collection site does not hold any patient identifiable information. Each record is comprised of three unique identifiers representing (i) the service user; (ii) the consultant; (iii) the Trust or Health Board. It is not possible to identify an individual, a consultant, or the organisation in which a consultant is based from these identifiers. The key is held on the NCISH’s independent server which is not connected to The University of Manchester’s IT infrastructure.
What do I do if I have concerns about this online data collection site or am unable to use it?
The online data collection system is secure and will not pose any threat to your current applications or work. The system should have little or no impact on any other IT deployment and meets the standards required to protect patient information. You will be able to access the system via desktops, laptops or tablets however mobile phone devices are not recommended because of the screen size. For England and Wales the system has been approved by the Health Research Authority Confidentiality Advisory Group (HRA-CAG) and we have obtained 77% on the NHS Information Governance Toolkit. Our HRA-CAG reference number is: 8D594/Ecc0020. If you are experiencing difficulties accessing the online data collection system please email ncish@nhs.net.