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National Confidential Inquiry Report Published

Important recommendations

Mental health patients at highest risk of suicide in first two weeks after leaving hospital:

Researchers call for suicides soon after discharge and deaths following restraint to be ‘never events’ in NHS Mental health patients are at their highest risk of dying by suicide in the first two weeks after leaving hospital - a report out today shows.

Around 3,225 patients died by suicide in the UK within the first three months of their discharge from hospital – 18% of all patient suicides, between 2002-2012.

The University of Manchester's National Confidential Inquiry into Suicide and Homicide by People with Mental Illness found that 526 patients died within the first week, the peak time of risk in England, Northern Ireland and Scotland; it is the first
two weeks in Wales.

The Inquiry data, commissioned by the Healthcare Quality Improvement Partnership (HQIP) on behalf of NHS England, the Health Department of the Scottish Government, the Welsh Government, DHSSPS Northern Ireland and Jersey, was being presented to healthcare professionals and service users at a launch event in Manchester today.

Professor Louis Appleby, Director of the National Confidential Inquiry, who led the study said: “Our latest data shows the first three months after discharge remain the time of highest risk but especially in the first 1-2 weeks. This increased risk has been linked to short admissions and to life events so our recommendations are that careful and effective care planning is needed including for patients before they are discharged and for those who self-discharge.

"Early follow-up appointments should be strengthened and reducing the length of in-patient stay to ease pressure on beds should not be an aim in itself. Instead health
professionals should ensure the adverse events that preceded the admission have been addressed."

The report also highlights 24 deaths in England and Wales in patients who had been restrained by ward staff in the previous 24 hours. 5 of these deaths occurred in 2012.