Projects

Homicide and mental illness in England

Homicide by patients with mental illness is one of the most sensitive subjects in mental health and we recognise how much staff, friends and families are affected by these tragic incidents. We have been commissioned by the Healthcare Quality Improvement Partnership (HQIP) to resume the National Confidential Inquiry into Homicide in England, to reflect current public concerns regarding patient care.

Detailed data collection on homicides ended in 2018. We will restart data collection in 2025. Our aim is to obtain information to improve patient care and respond to any emerging concerns about patient safety.

The new study will include:

• closer working with the families of victims
• earlier data collection to reduce delays in reporting
• the collection of information from serious incident reports and independent investigations
• a focus on patients with schizophrenia and related psychoses
• resuming data collection on homicide followed by suicide

This study will run from July 2025 to June 2026, in the first instance.

Suicide during transition of care from child and adolescent to adult mental health services

The transition from child and adolescent mental health services (CAMHS) to adult mental health services (AMHS) can be a high-risk period for patients. To better understand this risk, we are conducting a mixed methods study of suicide during the transition of care from child and adolescent to adult mental health services. In this study, we will:

• use existing NCISH data for a five-year period (2018-2022) to estimate the number and proportion of mental health patients aged under 25 who had their care transitioned from CAMHS to AMHS, and died by suicide. In addition, we will identify sociodemographic and mental health characteristics that could be a focus of prevention in this group
• conduct semi-structured interviews with mental health professionals who have experienced the suicide of a patient whose care was transferred from CAMHS to AMHS to identify good practice and areas for improvement in the transition process that could help to reduce suicide risk
• develop online surveys (for people with lived experience, carers, and clinicians) to explore the differences in care and treatment between child and adolescent and adult mental health services, and how this may influence suicide risk. Our anonymous online surveys are available in three formats:
  • a survey for people with lived experience
  • a survey for carers
  • a survey for clinicians

Overall, this study aims to improve safety for young people during the transition of care from child and adolescent to adult mental health services. It has been commissioned by the Healthcare Quality Improvement Partnership (HQIP) and will report in February 2027.

More information

• information sheet for people with lived experience
• information sheet for carers
• information sheet for clinicians
• infographic for onward sharing for people with lived experience/carers
• infographic for onward sharing for clinicians

Implementing a personalised approach to risk

We are working with the National Collaborating Centre for Mental Health (NCCMH) to deliver one of four key interventions that aims to improve the culture of care on in-patient, learning disability and autism wards for patients and staff.

We are working alongside experts in neurodiversity, learning disability, equality, trauma, and quality improvement to support these wards to provide safe, equitable, trauma- and autism-informed care.

Our work will support mental health organisations to implement a personalised approach to suicide risk assessment. Initially, we will be working closely with ten organisations providing expert advice to support them to change their approach to assessing risk. This support will then be extended nationally.

We will bring together online resources related to a personalised approach to suicide risk assessment and management. These resources are available here.

This work is funded by NHS England and forms part of their Mental Health, Learning Disability and Autism Inpatient Quality Transformation Programme.

National real-time data collection of suspected suicide deaths under mental health care

We have established a national real-time data collection of suspected suicide deaths by people under the recent care of mental health services in England.

Our initial focus is on patients in closest contact with mental health services, specifically in-patients and post-discharge patients who died within 14 days of discharge.

Our overarching aim is to collect information that we need to know early to support suicide prevention efforts. This includes emerging novel methods, suicide related internet use, possible clusters, problems in care which may be systemic and particular problems that patients face.

We are taking a staged approach to establishing this real-time data collection:

1. Firstly, we piloted this RTS data collection in eight NHS Trusts in South East England.
2. In April 2024, we expanded this RTS data collection nationally to all mental health trusts across England that provide in-patient care.

We are asking clinicians for early notification of any suspected suicide death of an in-patient or a patient recently (within 14 days) discharged from in-patient care, where the death occurred from 1 January 2024, without waiting for the inquest or for a request from us. This is via our anonymous online questionnaire.

Further information can be found in our information sheet and FAQs. We have also produced an infographic for onward sharing. This study began in August 2023 and we will continue to report findings in our annual report.

Suicide in NHS staff: a national data collection to inform prevention

We have been commissioned by NHS England to establish a prospective data collection about suicide by NHS staff, with the aim of preventing future deaths. 

Some health service staff may be at an increased risk of suicide, and staff wellbeing is a priority in the context of sustained and growing pressures. 

We have taken a stepped approach to establishing this data collection: 

1. We worked with Greater Manchester NHS Integrated Care Board to engage with stakeholders and HR representatives across Greater Manchester as our trailblazer site to explore data availability for clinical staff. 
2. We expanded our engagement to the north-west region. NHS Trusts in Greater Manchester, Lancashire and South Cumbria, and Cheshire and Merseyside provided data on suicide deaths by NHS staff in clinical patient-facing roles over a five-year period (January 2019 to December 2023).  
3. We have now expanded this data collection nationally, to collect information about doctors, nurses and allied health professionals who die by suicide between January 2024 and April 2026. By learning from these tragic deaths, our aim is to improve safety and wellbeing for people working within the NHS. Data is being collected via our online questionnaire.  

Further information and resources can be found on our NHS Staff Suicide data collection webpage. This data collection will run from May 2023 to April 2026.

Completed projects