{"id":7919,"date":"2026-05-18T13:35:57","date_gmt":"2026-05-18T12:35:57","guid":{"rendered":"https:\/\/sites.manchester.ac.uk\/ncish\/?page_id=7919"},"modified":"2026-07-01T15:55:48","modified_gmt":"2026-07-01T14:55:48","slug":"10-ways-to-improve-safety","status":"publish","type":"page","link":"https:\/\/sites.manchester.ac.uk\/ncish\/resources\/10-ways-to-improve-safety\/","title":{"rendered":"10 ways to improve safety"},"content":{"rendered":"<p>[et_pb_section bb_built=&#8221;1&#8243; admin_label=&#8221;section&#8221; fullwidth=&#8221;on&#8221; next_background_color=&#8221;#000000&#8243; global_module=&#8221;322&#8243;][et_pb_fullwidth_menu global_parent=&#8221;322&#8243; _builder_version=&#8221;3.0.106&#8243; menu_id=&#8221;7&#8243; submenu_direction=&#8221;downwards&#8221; fullwidth_menu=&#8221;off&#8221; background_layout=&#8221;dark&#8221; module_class=&#8221;main-navigation&#8221; \/][\/et_pb_section][et_pb_section bb_built=&#8221;1&#8243; fullwidth=&#8221;off&#8221; specialty=&#8221;off&#8221; transparent_background=&#8221;off&#8221; allow_player_pause=&#8221;off&#8221; inner_shadow=&#8221;off&#8221; parallax=&#8221;off&#8221; parallax_method=&#8221;on&#8221; make_fullwidth=&#8221;off&#8221; use_custom_width=&#8221;off&#8221; width_unit=&#8221;on&#8221; make_equal=&#8221;off&#8221; use_custom_gutter=&#8221;off&#8221; custom_padding=&#8221;0px||0px|&#8221; custom_css_main_element=&#8221;padding-top:0px&#8221; module_class=&#8221;header-image-section&#8221; prev_background_color=&#8221;#ffffff&#8221; next_background_color=&#8221;#ffffff&#8221;][et_pb_row allow_player_pause=&#8221;off&#8221; parallax=&#8221;off&#8221; parallax_method=&#8221;on&#8221; parallax_1=&#8221;off&#8221; parallax_method_1=&#8221;off&#8221; make_fullwidth=&#8221;off&#8221; use_custom_width=&#8221;off&#8221; width_unit=&#8221;on&#8221; use_custom_gutter=&#8221;off&#8221; make_equal=&#8221;off&#8221; custom_margin=&#8221;||0px|&#8221; custom_padding=&#8221;||0px|&#8221; module_class=&#8221;header-image&#8221; background_position=&#8221;top_left&#8221; background_repeat=&#8221;repeat&#8221; background_size=&#8221;initial&#8221;][et_pb_column type=&#8221;4_4&#8243;][et_pb_image src=&#8221;https:\/\/sites.manchester.ac.uk\/ncish\/wp-content\/uploads\/sites\/31\/2018\/07\/recommendations-wide-2.jpg&#8221; show_in_lightbox=&#8221;off&#8221; url_new_window=&#8221;off&#8221; use_overlay=&#8221;off&#8221; align=&#8221;left&#8221; always_center_on_mobile=&#8221;on&#8221; use_border_color=&#8221;off&#8221; force_fullwidth=&#8221;off&#8221; custom_margin=&#8221;0px|||&#8221; animation_direction=&#8221;left&#8221; show_bottom_space=&#8221;off&#8221; border_color_all=&#8221;#ffffff&#8221; _builder_version=&#8221;3.17.6&#8243; \/][\/et_pb_column][\/et_pb_row][\/et_pb_section][et_pb_section bb_built=&#8221;1&#8243; fullwidth=&#8221;off&#8221; specialty=&#8221;off&#8221; transparent_background=&#8221;off&#8221; allow_player_pause=&#8221;off&#8221; inner_shadow=&#8221;off&#8221; parallax=&#8221;off&#8221; parallax_method=&#8221;on&#8221; make_fullwidth=&#8221;off&#8221; use_custom_width=&#8221;off&#8221; width_unit=&#8221;on&#8221; make_equal=&#8221;off&#8221; use_custom_gutter=&#8221;off&#8221; custom_padding=&#8221;||0px|&#8221; prev_background_color=&#8221;#ffffff&#8221; next_background_color=&#8221;#ffffff&#8221;][et_pb_row allow_player_pause=&#8221;off&#8221; parallax=&#8221;off&#8221; parallax_method=&#8221;on&#8221; parallax_1=&#8221;off&#8221; parallax_method_1=&#8221;off&#8221; make_fullwidth=&#8221;off&#8221; use_custom_width=&#8221;off&#8221; width_unit=&#8221;on&#8221; use_custom_gutter=&#8221;off&#8221; make_equal=&#8221;off&#8221; custom_margin=&#8221;||0px|&#8221; custom_padding=&#8221;||0px|&#8221; module_class=&#8221;breadcrumbs-row&#8221; background_position=&#8221;top_left&#8221; background_repeat=&#8221;repeat&#8221; background_size=&#8221;initial&#8221;][et_pb_column type=&#8221;4_4&#8243;][et_pb_text admin_label=&#8221;Breadcrumbs (do not remove)&#8221; background_layout=&#8221;light&#8221; text_orientation=&#8221;left&#8221; use_border_color=&#8221;off&#8221; border_color=&#8221;#ffffff&#8221; border_style=&#8221;solid&#8221; module_class=&#8221;breadcrumbs&#8221; custom_css_main_element=&#8221;border-bottom: 1px solid #ececed;&#8221; module_alignment=&#8221;left&#8221; background_position=&#8221;top_left&#8221; background_repeat=&#8221;repeat&#8221; background_size=&#8221;initial&#8221;]<\/p>\n<span><span><a href=\"https:\/\/sites.manchester.ac.uk\/ncish\/\">NCISH<\/a><\/span><\/span>\n<p>[\/et_pb_text][\/et_pb_column][\/et_pb_row][\/et_pb_section][et_pb_section bb_built=&#8221;1&#8243; fullwidth=&#8221;off&#8221; specialty=&#8221;on&#8221; transparent_background=&#8221;off&#8221; allow_player_pause=&#8221;off&#8221; inner_shadow=&#8221;off&#8221; parallax=&#8221;off&#8221; parallax_method=&#8221;on&#8221; parallax_1=&#8221;off&#8221; parallax_method_1=&#8221;off&#8221; parallax_2=&#8221;off&#8221; parallax_method_2=&#8221;off&#8221; make_fullwidth=&#8221;off&#8221; use_custom_width=&#8221;off&#8221; width_unit=&#8221;on&#8221; make_equal=&#8221;off&#8221; use_custom_gutter=&#8221;on&#8221; gutter_width=&#8221;2&#8243; prev_background_color=&#8221;#ffffff&#8221; next_background_color=&#8221;#1d1d1d&#8221;][et_pb_column type=&#8221;1_3&#8243;][et_pb_sidebar admin_label=&#8221;Left Nav Sidebar&#8221; area=&#8221;et_pb_widget_area_1&#8243; orientation=&#8221;left&#8221; remove_border=&#8221;on&#8221; background_layout=&#8221;light&#8221; module_id=&#8221;left-nav-menu&#8221; show_border=&#8221;off&#8221; \/][\/et_pb_column][et_pb_column type=&#8221;2_3&#8243; specialty_columns=&#8221;2&#8243;][et_pb_row_inner admin_label=&#8221;Row&#8221;][et_pb_column_inner type=&#8221;4_4&#8243; saved_specialty_column_type=&#8221;2_3&#8243;][et_pb_text admin_label=&#8221;Text: Intro and Safer wards&#8221; _builder_version=&#8221;3.17.6&#8243;]<\/p>\n<h1 id=\"top-link\">10 ways to improve safety<\/h1>\n<ul>\n<li><a href=\"#safer-wards\">Safer wards<\/a><\/li>\n<li><a href=\"#follow-up\">Early follow-up on discharge<\/a><\/li>\n<li><a href=\"#area\">No out-of-area admissions<\/a><\/li>\n<li><a href=\"#crisis\">24-hour crisis resolution\/home treatment teams<\/a><\/li>\n<li><a href=\"#family\">Family involvement<\/a><\/li>\n<li><a href=\"#guidance\">Guidance on depression<\/a><\/li>\n<li><a href=\"#risk\">Personalised approach to risk<\/a><\/li>\n<li><a href=\"#outreach\">Outreach teams<\/a><\/li>\n<li><a href=\"#staff\">Low staff turnover<\/a><\/li>\n<li><a href=\"#misuse\">Reducing alcohol and drug misuse<\/a><\/li>\n<\/ul>\n<p>\u00a0<\/p>\n<h2 id=\"safer-wards\">Safer wards<\/h2>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"size-full wp-image-2588 alignright\" src=\"https:\/\/sites.manchester.ac.uk\/ncish\/wp-content\/uploads\/sites\/31\/2018\/07\/Bed-100px.png\" alt=\"Bed icon\" width=\"100\" height=\"100\" \/>Services should review in-patient safety, and remove potential ligatures and 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 and should recognise that suicide risk is increased within the first week of admission.<\/p>\n<h3>Our evidence<\/h3>\n<p>Following <a href=\"http:\/\/documents.manchester.ac.uk\/display.aspx?DocID=37604\">NCISH recommendations<\/a>, suicide using non-collapsible ligature points became an NHS \u2018never event\u2019 (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. <span style=\"font-size: 16px\">Since then suicide by mental health in-patients has fallen by <\/span><a style=\"font-size: 16px\" href=\"https:\/\/www.cambridge.org\/core\/services\/aop-cambridge-core\/content\/view\/33C888CA2A2DB4D165085920BCAF6850\/S0033291723003628a.pdf\/div-class-title-psychiatric-in-patient-care-in-england-as-safe-as-it-can-be-an-examination-of-in-patient-suicide-between-2009-and-2020-div.pdf\">42%<\/a><span style=\"font-size: 16px\">, though figures have not decreased further in more recent years (2020-2023); there were an estimated\u00a0<\/span><a href=\"https:\/\/documents.manchester.ac.uk\/display.aspx?DocID=78594\">66<\/a><span style=\"font-size: 16px\">\u00a0suicides by in-patients in the UK and Jersey in 2023. Between 2013 and 2023, 41% of in-patient suicides took place on the ward. Half (49%) of in-patients who died by suicide were on agreed leave. The majority of\u00a0in-patient deaths on the ward are by hanging\/strangulation\/asphyxia. In our study of <\/span><a style=\"font-size: 16px\" href=\"https:\/\/bmcpsychiatry.biomedcentral.com\/articles\/10.1186\/s12888-019-2336-8\">clinicians&#8217; views of good quality practice in mental healthcare<\/a><span style=\"font-size: 16px\">, clinicians emphasised practices that improved safety in a ward environment such as observations conducted by trained staff.<\/span><\/p>\n<h3>Guidance<\/h3>\n<p>This recommendation was originally cited in <a href=\"http:\/\/webarchive.nationalarchives.gov.uk\/20130105105027\/http:\/www.dh.gov.uk\/en\/Publicationsandstatistics\/Publications\/PublicationsPolicyAndGuidance\/DH_4065083\">the Department of Health report An Organisation with a Memory<\/a> in 2000.\u00a0More recently, it is included in\u00a0<a title=\"HM Government's Suicide Prevention Strategy for England: 2023-2028\" href=\"https:\/\/www.gov.uk\/government\/publications\/suicide-prevention-strategy-for-england-2023-to-2028\">HM Government\u2019s\u00a0Suicide Prevention Strategy for England: 2023-2028<\/a>\u00a0and the\u00a0<a href=\"https:\/\/gov.wales\/sites\/default\/files\/publications\/2019-08\/talk-to-me-2-suicide-and-self-harm-prevention-strategy-for-wales-2015-2020.pdf\">Welsh Government\u2019s suicide and self-harm prevention strategy Talk To Me 2.<\/a> Based on our findings, the Health Services Safety Investigations Body (HSSIB) report <a href=\"https:\/\/www.hssib.org.uk\/patient-safety-investigations\/mental-health-inpatient-settings\/fourth-investigation-report\/\">Mental health inpatient settings: Creating conditions for learning from deaths in mental health inpatient services and when patients die within 30 days of discharge<\/a> recommends the development of guidance on how to reduce and respond to non-anchored ligature risks, whilst maintaining a therapeutic environment.<\/p>\n<p style=\"text-align: right\"><a href=\"#top-link\">&lt; Back to top<\/a><\/p>\n<p>[\/et_pb_text][et_pb_divider _builder_version=&#8221;3.17.6&#8243; \/][et_pb_text admin_label=&#8221;Text: Early follow-up on discharge&#8221; _builder_version=&#8221;3.17.6&#8243;]<\/p>\n<h2 id=\"follow-up\">Early follow-up on discharge<\/h2>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"size-full wp-image-2583 alignright\" src=\"https:\/\/sites.manchester.ac.uk\/ncish\/wp-content\/uploads\/sites\/31\/2018\/07\/House-100px.png\" alt=\"House icon\" width=\"100\" height=\"100\" \/>Patients discharged from psychiatric in-patient care should be followed up by the service within 72 hours of discharge. A comprehensive care plan should be in place at the time of discharge and during pre-discharge leave.<\/p>\n<h3>Our evidence<\/h3>\n<p>In the UK and Jersey, there were 2,250 suicides within three months of discharge from in-patient care between <a href=\"https:\/\/documents.manchester.ac.uk\/display.aspx?DocID=78594\">2013 and 2023<\/a>. 13% of these post-discharge suicides occurred within the first weeks of leaving hospital, with the highest number occurring on days 4 and 3 after leaving hospital (day 1 = day of discharge).<\/p>\n<h3>Guidance<\/h3>\n<p>We have recommended all patients are <a href=\"https:\/\/documents.manchester.ac.uk\/display.aspx?DocID=66829\">followed up within 72 hours of discharge<\/a> from in-patient care. The <a href=\"https:\/\/www.nice.org.uk\/guidance\/ng53\/evidence\/full-guideline-pdf-2606951917\">NICE guidance<\/a> of following up all discharged patients within 7 days was formally reviewed as part of the <a href=\"https:\/\/www.england.nhs.uk\/wp-content\/uploads\/2019\/03\/CQUIN-Guidance-1920-080319.pdf\">NHS Commissioning for Quality and Innovation (CQUIN) 2019\/20 scheme<\/a>. Based on our findings, the time frame has since been reduced to 72 hours. NHS England has included 72 hour follow-up in the <a href=\"https:\/\/www.england.nhs.uk\/publication\/full-length-nhs-standard-contract-2023-24-particulars-service-conditions-general-conditions\/\">NHS Standard Contract 2023\/24<\/a>.<\/p>\n<p>The 72-hour follow-up standard is also cited in HM Government&#8217;s <a href=\"https:\/\/www.gov.uk\/government\/publications\/suicide-prevention-strategy-for-england-2023-to-2028\">Suicide prevention strategy for England: 2023-2028<\/a>\u00a0and the Parliamentary and Health Service Ombudsman\u2019s report <a href=\"https:\/\/www.ombudsman.org.uk\/publications\/discharge-mental-health-care-making-it-safe-and-patient-centred\">Discharge from mental health care: making it safe and patient-centred<\/a>.\u00a0The importance of timely follow-up is referenced in the Department of Health &amp; Social Care\u2019s statutory guidance <a href=\"https:\/\/www.gov.uk\/government\/publications\/discharge-from-mental-health-inpatient-settings\/discharge-from-mental-health-inpatient-settings\">Discharge from mental health inpatient settings<\/a>.<\/p>\n<p>National clinical guidelines have been developed with reference to our findings on suicide following discharge from in-patient care. See the NICE guidance on <a href=\"https:\/\/www.nice.org.uk\/guidance\/ng53\">transition between in-patient mental health settings and community or care settings<\/a>.<\/p>\n<p>In <a href=\"https:\/\/www.gov.uk\/government\/news\/7billion-for-nhs-and-social-care-for-covid-19-response-and-recovery\">2021\/2022<\/a> NHS England will continue the 2020\/2021 winter funding programme to improve the care of post-discharge patients in England.<\/p>\n<p style=\"text-align: right\"><a href=\"#top-link\">&lt; Back to top<\/a><\/p>\n<p>[\/et_pb_text][et_pb_divider _builder_version=&#8221;3.17.6&#8243; \/][et_pb_text admin_label=&#8221;Text: No out-of-area admissions&#8221; _builder_version=&#8221;3.17.6&#8243;]<\/p>\n<h2 id=\"area\">No out-of-area admissions<\/h2>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"size-full wp-image-2586 alignright\" src=\"https:\/\/sites.manchester.ac.uk\/ncish\/wp-content\/uploads\/sites\/31\/2018\/07\/Train-100px.png\" alt=\"Train icon\" width=\"100\" height=\"100\" \/>Very 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.<\/p>\n<h3>Our evidence<\/h3>\n<p>In the UK and Jersey, 247 patients (12% of post-discharge deaths) died after being discharged from an\u00a0<a href=\"https:\/\/documents.manchester.ac.uk\/display.aspx?DocID=78594\">in-patient unit that was out of their local area<\/a>. In <a href=\"https:\/\/documents.manchester.ac.uk\/display.aspx?DocID=71818\">2021<\/a> there were 19 suicides after discharge from an in-patient unit that was out of the patient&#8217;s local area. The number of suicides by patients recently discharged from hospital in the UK fell in 2013-2017 <a href=\"https:\/\/documents.manchester.ac.uk\/display.aspx?DocID=78594\">but have since risen<\/a>. There were an estimated 205 post-discharge deaths in 2023, down from a peak of <a href=\"https:\/\/documents.manchester.ac.uk\/display.aspx?DocID=71818\">299 in 2011<\/a>.<\/p>\n<h3>Guidance<\/h3>\n<p>Both the King\u2019s Fund <a href=\"https:\/\/www.kingsfund.org.uk\/sites\/default\/files\/field\/field_publication_file\/mental-health-under-pressure-nov15_0.pdf\">Under Pressure<\/a> report and the <a href=\"https:\/\/s16878.pcdn.co\/wp-content\/uploads\/2016\/02\/0e662e_6f7ebeffbf5e45dbbefacd0f0dcffb71.pdf\">Independent Commission on Acute Adult Psychiatric Care<\/a> referenced this recommendation in 2015, calling for an end to acute admissions out of area.<\/p>\n<p>National clinical guidelines have been developed with reference to our findings on suicide following discharge from in-patient care. See the NICE guidance on <a href=\"https:\/\/www.nice.org.uk\/guidance\/ng53\">transition between in-patient mental health settings and community or care settings<\/a>.<\/p>\n<p style=\"text-align: right\"><a href=\"#top-link\">&lt; Back to top<\/a><\/p>\n<p>[\/et_pb_text][et_pb_divider _builder_version=&#8221;3.17.6&#8243; \/][et_pb_text admin_label=&#8221;Text: 24-hour crisis resolution\/home treatment teams&#8221; _builder_version=&#8221;3.17.6&#8243;]<\/p>\n<h2 id=\"crisis\">24-hour crisis resolution\/home treatment teams<\/h2>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"size-full wp-image-2590 alignright\" src=\"https:\/\/sites.manchester.ac.uk\/ncish\/wp-content\/uploads\/sites\/31\/2018\/07\/Call-100px.png\" alt=\"Call 24\/7 icon\" width=\"100\" height=\"100\" \/>Community 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.<\/p>\n<h3>Our evidence<\/h3>\n<p>The setting where suicide prevention can have the greatest impact is the crisis team; the main location where patients with acute illness are now seen. In England, there are on average <a href=\"https:\/\/documents.manchester.ac.uk\/display.aspx?DocID=78384\">189<\/a>\u00a0suicides per year by CRHT patients \u2013 over two 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 <a href=\"https:\/\/www.sciencedirect.com\/science\/article\/pii\/S0140673611617121\">reduction in suicide rates<\/a> in implementing mental health services. In our study of <a href=\"http:\/\/documents.manchester.ac.uk\/display.aspx?DocID=38466\">the assessment of clinical risk in mental health services<\/a>, both patients and carers emphasised the need for clarity about what to do and who to contact in a crisis.<\/p>\n<h3>Guidance<\/h3>\n<p>Both the King\u2019s Fund <a href=\"https:\/\/assets.kingsfund.org.uk\/f\/256914\/x\/78db101b90\/mental_health_under_pressure_2015.pdf\">Under Pressure<\/a> report and the <a href=\"https:\/\/www.rcpsych.ac.uk\/docs\/default-source\/improving-care\/better-mh-policy\/policy\/policy-old-problems-new-solutions-caapc-report-england.pdf?sfvrsn=7563102e_2\">Independent Commission on Acute Adult Psychiatric Care<\/a> 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<\/p>\n<p>Actions to improve crisis support are outlined in the <a href=\"https:\/\/www.longtermplan.nhs.uk\/\">NHS Long-Term Plan<\/a> and the <a href=\"https:\/\/www.gov.uk\/government\/publications\/suicide-prevention-strategy-for-england-2023-to-2028\">Suicide prevention strategy for England: 2023-2028<\/a>, including expanding all-age mental health crisis services across NHS trusts, in partnership with wider partners such as voluntary, community and social enterprise (VSCE) organisations, to support current demand.<\/p>\n<p style=\"text-align: right\"><a href=\"#top-link\">&lt; Back to top<\/a><\/p>\n<p>[\/et_pb_text][et_pb_divider _builder_version=&#8221;3.17.6&#8243; \/][et_pb_text admin_label=&#8221;Text: Family involvement&#8221; _builder_version=&#8221;3.17.6&#8243;]<\/p>\n<h2 id=\"family\">Family involvement<\/h2>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"size-full wp-image-2592 alignright\" src=\"https:\/\/sites.manchester.ac.uk\/ncish\/wp-content\/uploads\/sites\/31\/2018\/07\/Family-100px.png\" alt=\"Family icon\" width=\"100\" height=\"100\" \/>Working 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.<\/p>\n<p>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\u2019s history and what is important to them in terms of their recovery, and may support better compliance with treatment.<\/p>\n<p>There should be a multi-disciplinary review following all suicide deaths, involving input from and sharing information with families.<\/p>\n<h3>Our evidence<\/h3>\n<p>Staff told us that greater involvement of the family by the service would have reduced suicide risk in <a href=\"http:\/\/documents.manchester.ac.uk\/display.aspx?DocID=46558\">18% <\/a>of patients.<\/p>\n<p>One example of <a href=\"https:\/\/bmcpsychiatry.biomedcentral.com\/track\/pdf\/10.1186\/s12888-019-2336-8\">clinicians think<\/a> services can improve contact with families is by informing them when a patient does not attend an appointment. In only <a href=\"https:\/\/www.manchester.ac.uk\/ncish\/resources\/requests-for-information\/\">27% of deaths<\/a>\u00a0by 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 <a href=\"http:\/\/documents.manchester.ac.uk\/display.aspx?DocID=37575\">24% fall in suicide rates<\/a>\u00a0in implementing NHS Trusts, indicative of a learning or training effect.<\/p>\n<p><a href=\"http:\/\/documents.manchester.ac.uk\/display.aspx?DocID=38466\">Patients tell us<\/a> they want their families to have as much involvement as possible in their assessment of clinical risk, including sharing crisis\/safety plans with them. <a href=\"https:\/\/bmcpsychiatry.biomedcentral.com\/articles\/10.1186\/s12888-019-2336-8\">Clinicians tell us<\/a> family involvement is vital to enhancing patient safety in mental healthcare settings.<\/p>\n<h3>Guidance<\/h3>\n<p>The <a href=\"https:\/\/s16878.pcdn.co\/wp-content\/uploads\/2016\/02\/0e662e_6f7ebeffbf5e45dbbefacd0f0dcffb71.pdf\">Independent Commission on Acute Adult Psychiatric Care<\/a> cite these recommendations, stating that families and carers are an underused resource.<\/p>\n<p>An in-depth thematic review of claims made after an individual has attempted to take their life by <a href=\"https:\/\/resolution.nhs.uk\/wp-content\/uploads\/2018\/09\/NHS-Resolution_learing_from_suicide_claims_148pp_ONLINE1.pdf\">NHS Resolution<\/a> recommends family members and carers are included in all serious incident investigations following a suicide death.<\/p>\n<p>The <a href=\"https:\/\/www.nice.org.uk\/guidance\/qs189\">NICE Quality Statement on suicide prevention<\/a>\u00a0and the <a href=\"https:\/\/www.nice.org.uk\/guidance\/ng225\">NICE guideline on self-harm<\/a> state individuals presenting with suicidal thoughts or plans, or individuals who have self-harmed, should have the opportunity to discuss whether they would like their family, carers or friends involved in their care.<\/p>\n<p style=\"text-align: right\"><a href=\"#top-link\">&lt; Back to top<\/a><\/p>\n<p>[\/et_pb_text][et_pb_divider _builder_version=&#8221;3.17.6&#8243; \/][et_pb_text admin_label=&#8221;Text: Guidance on depression&#8221; _builder_version=&#8221;3.17.6&#8243;]<\/p>\n<h2 id=\"guidance\">Guidance on depression<\/h2>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"size-full wp-image-2589 alignright\" src=\"https:\/\/sites.manchester.ac.uk\/ncish\/wp-content\/uploads\/sites\/31\/2018\/07\/Book-100px.png\" alt=\"Book icon\" width=\"100\" height=\"100\" \/>There should be a local NHS Trust\/Health Board policy based on NICE (or equivalent) guidelines for depression and self-harm.<\/p>\n<h3>Our evidence<\/h3>\n<p>Across the UK and Jersey, suicide by patients with depressive illness has generally been falling since 2016 with an average of 509 deaths per year between <a href=\"https:\/\/documents.manchester.ac.uk\/display.aspx?DocID=78594\">2013 and 2023<\/a>, though estimated figures show a rise in 2021-2023. Services that implemented NICE guidance for depression and self-harm guidelines had <a href=\"http:\/\/documents.manchester.ac.uk\/display.aspx?DocID=37575\">significant reductions in suicide rates<\/a>\u00a0of 26% and 23% respectively.<\/p>\n<h3>Guidance<\/h3>\n<p>See the NICE <a href=\"https:\/\/www.nice.org.uk\/guidance\/qs34\">Quality Standard for the Management of Self-harm<\/a>\u00a0and the NICE guideline on <a href=\"https:\/\/www.nice.org.uk\/guidance\/ng225\">self-harm: assessment, management and preventing recurrence<\/a>.<\/p>\n<p>See the NICE guidelines on the<a href=\"https:\/\/www.nice.org.uk\/guidance\/ng134\"> identification and management of depression in children and young people<\/a>\u00a0and the NICE guidelines on<a href=\"https:\/\/www.nice.org.uk\/guidance\/ng222\"> depression in adults: treatment and management<\/a>.<\/p>\n<p style=\"text-align: right\"><a href=\"#top-link\">&lt; Back to top<\/a><\/p>\n<p>[\/et_pb_text][et_pb_divider _builder_version=&#8221;3.17.6&#8243; \/][et_pb_text admin_label=&#8221;Text: Personalised approach to risk&#8221; _builder_version=&#8221;3.17.6&#8243;]<\/p>\n<h2 id=\"risk\"><a href=\"https:\/\/sites.manchester.ac.uk\/ncish\/resources\/10-ways-to-improve-safety\/#risk\">Personalised approach to risk<\/a><\/h2>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"size-full wp-image-2582 alignright\" src=\"https:\/\/sites.manchester.ac.uk\/ncish\/wp-content\/uploads\/sites\/31\/2018\/07\/File-100px.png\" alt=\"Medical record icon\" width=\"100\" height=\"100\" \/>All patients\u2019 management plans should be based on a personalised approach to 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 (e.g. economic adversity, experience or threat of domestic violence), anniversaries and dates that are important to them and online experience. Families and carers should have as much involvement as possible in the assessment process, including the opportunity to express their views on potential risk. Consulting with the patient&#8217;s GP may also be helpful.<\/p>\n<p>Risk assessment is one part of a whole system approach that should aim to strengthen the standards of care for everyone, ensuring that supervision, delegation and referral pathways are all managed safely.<\/p>\n<h3>Our evidence<\/h3>\n<p><a href=\"http:\/\/documents.manchester.ac.uk\/display.aspx?DocID=38466\">Most risk assessment tools<\/a> seek to predict future suicidal behaviour. Clinicians tell us that tools, if they are used, should be simple, accessible, and considered part of a wider assessment process. Treatment decisions should not be determined by a score. Risk tools and scales have a <a href=\"http:\/\/bmjopen.bmj.com\/content\/6\/2\/e009297\">positive predictive value of less than 5%<\/a>, meaning that they are wrong 95% of the time, and miss suicide deaths in the large \u2018low risk\u2019 group. In a sample of patient suicides, the quality of assessment of risks and management was considered by clinicians to be <a href=\"http:\/\/documents.manchester.ac.uk\/display.aspx?DocID=37576\">unsatisfactory in 36%<\/a>.<\/p>\n<p>In our study of <a href=\"https:\/\/www.thelancet.com\/journals\/lanpsy\/article\/PIIS2215-0366(20)30381-3\/fulltext\">suicide risk assessment in UK mental health services<\/a>, we found risk is often individual, suggesting the management of risk should be personal and individualised.<\/p>\n<h3>Guidance<\/h3>\n<p><a href=\"https:\/\/www.england.nhs.uk\/long-read\/staying-safe-from-suicide\/#resources\">NHS England guidance on suicide risk assessment<\/a> promotes a shift towards a more personal and collaborative approach, not checklists and risk prediction. NICE guidelines on the <a href=\"https:\/\/www.nice.org.uk\/guidance\/ng225\">assessment, management and preventing recurrence of self-harm<\/a>\u00a0state that risk assessment tools should not be used to predict future suicide or repetition of self-harm, or to determine who should or should not be offered treatment. The guidelines suggest risk assessment should focus on the person&#8217;s needs and how to support their immediate and long-term psychological and physical safety. These guidelines are also referred to in the <a href=\"https:\/\/www.gov.uk\/government\/publications\/suicide-prevention-strategy-for-england-2023-to-2028\">Suicide prevention strategy for England: 2023-2028<\/a>.<\/p>\n<p>The use of risk assessment tools in mental health services has been <a href=\"https:\/\/hansard.parliament.uk\/commons\/2019-09-04\/debates\/01c19a13-b5be-45c9-a1a5-2fa94e8e860a\/suicideriskassessmenttoolsinthenhs\">debated in Parliament<\/a>.\u00a0The Health Services Safety Investigations Body (HSSIB) reports <a href=\"https:\/\/www.hssib.org.uk\/patient-safety-investigations\/mental-health-inpatient-settings\/fourth-investigation-report\/\">Mental health inpatient settings: Creating conditions for learning from deaths in mental health inpatient services and when patients die within 30 days of discharge<\/a> and <a href=\"https:\/\/www.hssib.org.uk\/patient-safety-investigations\/mental-health-inpatient-settings\/interim-report\/\">Creating conditions for learning from deaths and near misses in inpatient and community mental health services<\/a> refer to our recommendations on personalised risk assessment and on families and carers having as much involvement as possible in the assessment process.<\/p>\n<p style=\"text-align: right\"><a href=\"#top-link\">&lt; Back to top<\/a><\/p>\n<p>[\/et_pb_text][et_pb_divider _builder_version=&#8221;3.17.6&#8243; \/][et_pb_text admin_label=&#8221;Text: Outreach teams&#8221; _builder_version=&#8221;3.17.6&#8243;]<\/p>\n<h2 id=\"outreach\">Outreach teams<\/h2>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"size-full wp-image-2591 alignright\" src=\"https:\/\/sites.manchester.ac.uk\/ncish\/wp-content\/uploads\/sites\/31\/2018\/07\/Chat-100px.png\" alt=\"Chat icon\" width=\"100\" height=\"100\" \/>Community 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\u2019t regularly take their prescribed medication or who are missing their appointments.<\/p>\n<h3>Our evidence<\/h3>\n<p>Implementation of an assertive outreach policy was associated with <a href=\"http:\/\/documents.manchester.ac.uk\/display.aspx?DocID=37575\">lower suicide rates<\/a>\u00a0among 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.<\/p>\n<p>In our study of <a href=\"https:\/\/bmcpsychiatry.biomedcentral.com\/articles\/10.1186\/s12888-019-2336-8\">clinicians&#8217; views of good quality practice in mental healthcare,<\/a> clinicians emphasised dedicated outreach services that provide intensive support to enhance patient engagement.<\/p>\n<h3>Guidance<\/h3>\n<p>The<a href=\"https:\/\/s16878.pcdn.co\/wp-content\/uploads\/2016\/02\/0e662e_6f7ebeffbf5e45dbbefacd0f0dcffb71.pdf\"> Independent Commission on Acute Adult Psychiatric Care<\/a> includes recommendations for comprehensive and effective community mental health, including outreach teams. The <a href=\"https:\/\/www.health-ni.gov.uk\/sites\/default\/files\/publications\/health\/pl-strategy.PDF\">Northern Ireland strategy for preventing suicide and self-harm<\/a> cites this recommendation.<\/p>\n<p style=\"text-align: right\"><a href=\"#top-link\">&lt; Back to top<\/a><\/p>\n<p>&nbsp;<\/p>\n<p>[\/et_pb_text][et_pb_divider _builder_version=&#8221;3.17.6&#8243; \/][et_pb_text admin_label=&#8221;Text: Low staff turnover&#8221; _builder_version=&#8221;3.17.6&#8243;]<\/p>\n<h2 id=\"staff\">Low staff turnover<\/h2>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"size-full wp-image-2585 alignright\" src=\"https:\/\/sites.manchester.ac.uk\/ncish\/wp-content\/uploads\/sites\/31\/2018\/07\/Nurse-100px.png\" alt=\"Nurse icon\" width=\"100\" height=\"100\" \/>There 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.<\/p>\n<h3>Our evidence<\/h3>\n<p>Organisations with low turnover of non-medical staff had <a href=\"http:\/\/documents.manchester.ac.uk\/display.aspx?DocID=37573\">lower suicide rates<\/a>\u00a0than 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.<\/p>\n<h3>Guidance<\/h3>\n<p>The King\u2019s Fund cited this recommendation in their <a href=\"https:\/\/www.kingsfund.org.uk\/sites\/default\/files\/field\/field_publication_file\/mental-health-under-pressure-nov15_0.pdf\">Under Pressure<\/a> report in 2015.<\/p>\n<p style=\"text-align: right\"><a href=\"#top-link\">&lt; Back to top<\/a><\/p>\n<p>[\/et_pb_text][et_pb_divider _builder_version=&#8221;3.17.6&#8243; \/][et_pb_text admin_label=&#8221;Text: Reducing alcohol and drug misuse&#8221; _builder_version=&#8221;3.17.6&#8243;]<\/p>\n<h2 id=\"misuse\">Reducing alcohol and drug misuse<\/h2>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"size-full wp-image-2587 alignright\" src=\"https:\/\/sites.manchester.ac.uk\/ncish\/wp-content\/uploads\/sites\/31\/2018\/07\/Arrows-100px.png\" alt=\"Clockwise arrows icon\" width=\"100\" height=\"100\" \/>We recommend there are local drug and alcohol services available that work jointly with mental health services for patients with mental illness and alcohol and drug misuse.<\/p>\n<p>Other clinical measures that could reduce suicide risk in this group are substance misuse assessment skills in frontline staff and specialist substance misuse clinicians within mental health services.\u00a0People in contact with both drug and alcohol and mental health services have multiple complex needs. Engaging these people with both mental health and substance misuse interventions is important to suicide prevention.<\/p>\n<h3>Our evidence<\/h3>\n<p>Across the UK and Jersey, alcohol and drug misuse is common among patients who die by suicide (<a href=\"https:\/\/documents.manchester.ac.uk\/display.aspx?DocID=78594\">46% and 38%<\/a> of all patient suicides UK-wide, respectively, higher in <a href=\"https:\/\/documents.manchester.ac.uk\/display.aspx?DocID=78386\">Scotland <\/a>and <a href=\"https:\/\/documents.manchester.ac.uk\/display.aspx?DocID=78385\">Northern Ireland<\/a>). However, only a <a href=\"https:\/\/documents.manchester.ac.uk\/display.aspx?DocID=66829\">minority<\/a> of patients who died by suicide were in contact with specialist alcohol and drug misuse services.\u00a0Between <a href=\"https:\/\/documents.manchester.ac.uk\/display.aspx?DocID=71822\">October 2021 and September 2022<\/a>, 428 people in England and Wales died by suicide within 12 months of contact with drug and alcohol services, 8% of all suicide deaths registered in this period.<\/p>\n<p>In England, there was a <a href=\"http:\/\/documents.manchester.ac.uk\/display.aspx?DocID=37575\">25% fall in rates of suicide<\/a>\u00a0by patients in those NHS Trusts which had put in place a policy on the management of patients with co-morbid alcohol and drug misuse.<\/p>\n<h3>Guidance<\/h3>\n<p>See the NICE <a href=\"https:\/\/www.nice.org.uk\/guidance\/ng58\">guidelines on coexisting severe mental illness and substance misuse<\/a>.<\/p>\n<p>Embedding suicide prevention in drug and alcohol policy and services is an action in the <a href=\"https:\/\/www.health-ni.gov.uk\/sites\/default\/files\/publications\/health\/pl-strategy.PDF\">strategy for preventing suicide and self-harm in Northern Ireland.<\/a><\/p>\n<p>The <a href=\"https:\/\/www.gov.uk\/government\/publications\/suicide-prevention-strategy-for-england-2023-to-2028\">Suicide prevention strategy for England: 2023-2028<\/a> also highlights plans to identify actions to improve mental health treatment for people with mental health conditions who also misuse alcohol and drugs. This will include improving access to mental health treatment and promoting better links between mental health services and substance misuse treatment services.<\/p>\n<p style=\"text-align: right\"><a href=\"#top-link\">&lt; Back to top<\/a><\/p>\n<p>&nbsp;<\/p>\n<p>[\/et_pb_text][\/et_pb_column_inner][\/et_pb_row_inner][\/et_pb_column][\/et_pb_section][et_pb_section bb_built=&#8221;1&#8243; admin_label=&#8221;Connect Title&#8221; module_class=&#8221;footer-section&#8221; _builder_version=&#8221;3.0.90&#8243; background_color=&#8221;#1d1d1d&#8221; custom_padding=&#8221;0px||0px|&#8221; prev_background_color=&#8221;#ffffff&#8221; global_module=&#8221;380&#8243;][et_pb_row admin_label=&#8221;row&#8221; global_parent=&#8221;380&#8243; parallax_method_1=&#8221;off&#8221; parallax_method_2=&#8221;off&#8221; parallax_method_3=&#8221;off&#8221; module_id=&#8221;footer-row&#8221; _builder_version=&#8221;3.0.89&#8243; locked=&#8221;off&#8221;][et_pb_column type=&#8221;1_3&#8243;][et_pb_text admin_label=&#8221;Contact Us Title&#8221; 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There should be measures in place to prevent patients from leaving the [&hellip;]<\/p>\n","protected":false},"author":11,"featured_media":0,"parent":1741,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_et_pb_use_builder":"on","_et_pb_old_content":"","_et_gb_content_width":"","_exactmetrics_skip_tracking":false,"footnotes":""},"class_list":["post-7919","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/sites.manchester.ac.uk\/ncish\/wp-json\/wp\/v2\/pages\/7919","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/sites.manchester.ac.uk\/ncish\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/sites.manchester.ac.uk\/ncish\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/sites.manchester.ac.uk\/ncish\/wp-json\/wp\/v2\/users\/11"}],"replies":[{"embeddable":true,"href":"https:\/\/sites.manchester.ac.uk\/ncish\/wp-json\/wp\/v2\/comments?post=7919"}],"version-history":[{"count":10,"href":"https:\/\/sites.manchester.ac.uk\/ncish\/wp-json\/wp\/v2\/pages\/7919\/revisions"}],"predecessor-version":[{"id":7929,"href":"https:\/\/sites.manchester.ac.uk\/ncish\/wp-json\/wp\/v2\/pages\/7919\/revisions\/7929"}],"up":[{"embeddable":true,"href":"https:\/\/sites.manchester.ac.uk\/ncish\/wp-json\/wp\/v2\/pages\/1741"}],"wp:attachment":[{"href":"https:\/\/sites.manchester.ac.uk\/ncish\/wp-json\/wp\/v2\/media?parent=7919"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}