In-patient suicide under observation

Date of publication: March 2015

This investigation by the National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH) examined suicides that had occurred in psychiatric in-patient care while the patient was under observation.

We looked at service-related factors related to the deaths, and asked patients and staff for their opinions on the effectiveness of and potential alternatives to observation.

Key messages

New models of observation are needed

The current observation approach (especially intermittent observation) is not working safely enough. There was on average of 18 suicides by in-patients under observation per year in the UK over a  seven year study period. 91% of deaths under observation occurred under level 2 (intermittent) observation. New models need to be developed and evaluated.

The figure shows between 2006 and 2012 there were 124 deaths in-patient suicides under observation, an average of 18 per year.

An opportunity for engagement

Icon showing people with speech bubblesThe observation component of a care plan should not be stand-alone; time with a patient is an opportunity for engagement within a comprehensive risk management plan.

Observation is an acute intervention

Observation should be seen as an acute intervention; there should be a record of breaches and the transition to general observation should be planned. A balance of observation and active engagement should be agreed with the patient where possible. As an acute intervention, observation is a skilled task for staff of appropriate seniority.

The figure shows half of deaths occurred when observation was carried out by a less experienced member of staff.

Proper implementation of protocols

Deaths under observation tended to occur when policies or procedures (including times between observations) were not followed. The observation component of a risk management plan should follow clear protocols – which should be adhered to, recorded, and monitored – including actions to take if the patient absconds.

The figure shows 35% of deaths occurred during busy periods on the ward, in 27% of deaths there were said to be problems with the ward design, and in 24% of deaths there were staff shortages.

Suicide under observation an NHS ‘never event’?

A red crossSuicide under observation (intermittent or constant) should be considered an NHS ‘never event’ in England and Wales (or as a serious adverse event in Northern Ireland and Scotland) and should be subject to independent investigation.


Breaches of protocol

All serious breaches of protocol in the care of patients under constant observation (for example, leading to self-harm and absconding, not only where there is a fatal outcome) should be investigated under NHS incident procedures.

The figure shows over half, 51%, of suicides by patients under constant observation occurred off the ward.

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