Real-time surveillance of mental health patient suicide

On this page:

• What we’re doing
• Our approach to data collection
• Numbers of suspected suicide deaths by mental health patients
• Clinical characteristics
• In-patient deaths
• Post-discharge patient deaths

What we’re doing

We are currently developing a national real-time surveillance (RTS) of suspected suicide deaths (i.e. unconfirmed by inquest) by patients under the recent care of mental health services in England.

Our initial focus is on in-patients and those who died within 2 weeks of discharge, i.e. patients in close proximity to services.

The aim is to collect information early to support suicide prevention efforts. This includes information about:

• emerging novel suicide methods
• suicide related internet use
• travelling to a specific location
• potential clusters
• systemic problems in care, and
• particular problems that patients face.

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Our approach to data collection

We are taking a staged approach to establishing this real-time data collection. First we piloted the data collection in eight NHS trusts in South East England. In April 2024 we expanded the data collection to all mental health trusts across England. We asked clinicians to notify us 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. Clinicians can complete an online questionnaire without waiting for the inquest or a request from us.

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Numbers of suspected suicide deaths by mental health patients

To date we have been notified of 67 suspected suicide deaths by patients under mental health care in England, the majority (44, 67%) by in-patients.

Between January 1 2024 and December 31 2024 we were notified of 42 suspected suicide deaths. Of these, around two-thirds (24, 65%) were men and most were aged between 25 and 44 (23, 55%) and 45-64 (10, 24%). The majority (28, 76%) were white.

The most common method of death was hanging/strangulation (21, 52%), followed by jumping/multiple injuries (7, 18%). Adverse experiences in the 3 months prior to death included isolation or loneliness (13, 31%) and workplace and/or financial problems (8, 19%)​.

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Clinical characteristics

Most patients we were told about were psychiatric in-patients (32, 76%) with the remaining 10 (24%) patients dying within 2 weeks of discharge from in-patient care. The most common diagnoses were schizophrenia and other delusional disorders (11, 26%) and affective disorder (10, 24%).

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In-patient deaths

6 patients (19%) waited up to 7 days in the community for an admission. Most patients (20, 65%) were admitted locally. At the time of death, over half (17, 55%) had been detained under Mental Health Act (MHA) powers and 14 (45%) had been admitted voluntarily. 15 (48%) patients self-harmed within a week prior to death. 12 (39%) patients died on the ward itself, and nearly half (15, 48%) were on agreed leave at the time of death. There was evidence of risk associated with internet use.

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Post-discharge patient deaths

For 6 (67%) patients who had been recently discharged, the last admission lasted less than a week. 4 patients had been detained under the MHA during this last admission. The majority (9, 89%) of patients had their first follow-up within 3 days of discharge; in most cases (6, 67%) this was face-to-face contact. 4 (40%) patients had experienced relationship problems following discharge.

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