National Confidential Inquiry into Suicide and Homicide by People with Mental Illness

As the UK’s leading research programme in this field, the Inquiry produces a wide range of national reports, projects and papers – providing health professionals, policymakers, and service managers with the evidence and practical suggestions they need to effectively implement change.

WHAT'S NEW - Inquiry update


NCISH will be holding its annual report launch conference on 10th October 2017 at MANDEC. For details of the event and to book a place click here

July 2017

***13th July, NEW Inquiry report on suicide by children and young people published ***

For a full copy of the report click here (pdf, 1mb)

For a copy of the infographics sheet with key messages click here (pdf, 1mb)

For a copy of the press release click here (pdf, 89kb)

To watch videos of Professor Louis Appleby presenting the key findings and recommendations click here

We carried out a study of suicide by children and young people aged under 25 in England and Wales during 2014 and 2015. We wanted to find the common themes in the lives of young people who die by suicide, identify possible sources of stress and examine the role of support services. This report covers the second phase of a national investigation into suicide in children and young people. Findings from the first year of data collection (on people aged under 20, in England only) were published in May 2016. We collected antecedent information on 391 people aged under 25. The information came from investigations by official bodies, mainly from coroners, who take evidence from families and professionals. We confirmed in this second, larger study our previous findings of 10 common themes in suicide in children and young people. Our findings also highlight groups where specific actions are needed: support for young people who are bereaved, especially by suicide; greater priority for mental health in colleges and universities; housing and mental health care for looked after children; and mental health support for LGBT young people.

February 2017

*** Updated version of our toolkit ‘Safer Services: A Toolkit for Specialist Mental Health Services and Primary Care’ ***

In this updated version of our toolkit for specialist mental health services we have formulated the key elements of safer care in mental health services and in the wider health system – which are based on evidence from 20 years of research on patient safety – into quality and safety statements regarding clinical, organisational and training aspects of care.

To download the toolkit click here

October 2016

***6th October, new Inquiry report published today***

For a copy of the report click here (pdf, 5mb)

For a copy of our infographics sheet for key messages click here (pdf, 899kb)

For a copy of our service user information sheet click here (pdf, 113kb)

Making Mental Health Care Safer: Annual Report Key Findings video click here

Making Mental Health Care Safer: 20-year Review video click here


Report presentation slides

Professor Louis Appleby, Annual report and 20 year review click here

Professor Nav Kapur, 20 years of suicide research click here

Professor Jenny Shaw, 20 years of homicide research click here


Our Annual Report and 20-year Review 2016 presents findings from 2004 to 2014, and reviews 20 years of data collection. It provides the latest figures on suicide, homicide and sudden unexplained deaths and highlights the priorities for safer services. Key messages include:

  • There are now around 3 times as many suicides by CHRT patients as in in-patients. The crisis team is now the main setting for suicide prevention in mental health
  • Many people who died by suicide had a history of drug or alcohol misuse, but few were in contact with specialist substance misuse services. Access to these specialist services should be more widely available, and they should work closely with mental health services
  • More patients who died by suicide were reported as having economic problems, including homelessness, unemployment and debt
  • There has been a rise in the number of suicides by recent UK residents: those who had been in the UK for less than 5 years, including those who were seeking permission to stay
  • There are a number of ways in which mental health care is safer for patients, and we now know what services can do to reduce suicide risk:
    • Safer wards
    • Early follow-up on discharge
    • No out-of-area admissions
    • 24 hour crisis teams
    • Outreach teams
    • Dual diagnosis service
    • Family involvement in ‘learning lessons’
    • Guidance on depression
    • Personalised risk management
    • Low staff turnover
  • In England the number of homicides by people with schizophrenia appears to have risen since 2009, though the numbers are small
  • Most patients who committed homicide had a history of alcohol and drug misuse. This was found in all UK countries but was more common in Scotland and Northern Ireland

Stakeholder survey

The survey will only takes a few minutes to complete and we value your opinion. Please give us your feedback on our research and how we share our findings.

Last year's survey findings: your views on our research

Current studies

A national investigation of suicide in children and young people

We are conducting the first national investigation in suicide by children and young people both in the general population and among patients of mental health services, in order to identify possible sources of stress and to examine the role of support services. Two reports are currently planned to be published from this study. The first, published in May 2016, examined suicides by people aged under 20 in England. The second, to be published in July 2017, extended data collection to people aged up to 24, in England and Wales.

The assessment of risk and safety in mental health services

This study will be examining which risk assessment tools are currently being used in mental health services, with a focus on how effectively they are being used prior to suicide. We will be looking at the views of mental health professionals, service users and carers on the use of risk assessment tools and safety planning in mental health services and how their use may be improved. This study will report March in 2018.

Reports on recent findings

Suicide by children and young people in England (PDF, 600KB)

We carried out an examination of suicides by people aged under 20 years who died between January 2014 and April 2015 in England. This is the first phase of a UK-wide investigation into suicides by people aged under 25. We collected data from a range of investigations by official bodies in England, including coroners, local authorities and health services, and identified relevant antecedents prior to suicide. There were 145 suicides and probable suicides by young people in England in the study period. The suicide rate at this age is low but escalates in the late teens. Our findings suggest that numerous experiences and stresses are likely to have contributed to suicide risk in children and young people. Many young people who die by suicide have not expressed recent suicidal ideas, but their absence cannot be assumed to show lack of risk. Improved services for self-harm and access to CAMHS is crucial, but the antecedents identified in this study show that schools, primary care, social services and youth justice also have an important role to play.

In-patient suicide under observation (PDF, 670KB)

We examined the details of all suicides in the UK over 7 years under observation and also conducted an on-line survey for patients and staff to report their experience of observation. We found that half of deaths examined occurred when checks were carried out by less experienced staff or agency staff who were unfamiliar with the patient. Deaths occurred when staff were distracted by ward disruptions, during busy periods, or when the ward was poorly designed.

National Confidential Inquiry Annual Report

The findings from our core research programme providing an in-depth analysis of the changing patterns and risk factors behind cases of suicide and homicide by people in contact with mental health services and of cases of sudden unexplained death amongst psychiatric in-patents.
Annual Report 2016 (PDF)

Latest research papers

Our research papers focus on specific issues across a wide range of topics and discuss the clinical implications of our findings. See our publications section.


Our toolkits help health professionals and managers apply the Inquiry’s research findings as they improve service safety and reduce risk.

  • Safer Services. A Toolkit for Specialist Mental Health Services and Primary Care.

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