1. Louis Appleby Professor of Psychiatry University of Manchester Chair, National Suicide Prevention Advisory Group Department of Health

2. National Suicide Prevention Strategy: Six actions Reduce risk in high risk groups Tailor approaches to improve mental health in specific groups Reduce access to the means of suicide Provide better information and support to those bereaved or affected by suicide Support media in delivering sensitive approaches to suicide Support research, data collection and monitoring

3. Suicide rates, England 1994-2012 Age standardised death rate per 100,000 population Source: ONS 3-year average

4. Suicide rates by age and gender, England 2012 Source: ONS

5. Suicide in young men Age standardised death rate per 100,000 population Males 20-34 Persons, All Ages Three-year average rate, plotted against final year of average Males 35-49 Source: ONS 2010

6. UK (1996-2012) England (1996-2012) Wales (1996-2012) Scotland (1997-2012) N. Ireland (1997-2012) NNNNN General population 100,32978,1705,47513,2353,449 In contact with services 26,216 (26%) 20,300 (26%) 1,260 (23%) 3,705 (28%) 951 (28%) National Confidential Inquiry: suicides

7. Patient suicides: age and gender profile ENGLAND_SUICIDE (2002-2012) © National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. All rights reserved. Not to be reproduced in whole or part without the permission of the copyright holder.

8. Patient suicide - England ENGLAND_SUICIDE (2002-2012) © National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. All rights reserved. Not to be reproduced in whole or part without the permission of the copyright holder.

9. ENGLAND_SUICIDE (2002-2012) © National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. All rights reserved. Not to be reproduced in whole or part without the permission of the copyright holder. Patient suicide method - England

10. Patient suicides: primary diagnosis by gender ENGLAND_SUICIDE (2002-2012) © National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. All rights reserved. Not to be reproduced in whole or part without the permission of the copyright holder.

11. Living circumstances: patient suicides ENGLAND_SUICIDE (2002-2012) © National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. All rights reserved. Not to be reproduced in whole or part without the permission of the copyright holder.

12. Timing of last contact: patient suicides ENGLAND_SUICIDE (2002-2012) © National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. All rights reserved. Not to be reproduced in whole or part without the permission of the copyright holder.

13. Mental health teams’ estimation of suicide risk at last contact: patient suicides ENGLAND_SUICIDE (2002-2012) © National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. All rights reserved. Not to be reproduced in whole or part without the permission of the copyright holder.

14. UK (1996-2012) N England (1996-2012) N Wales (1996-2012) N Scotland (1997-2012) N N. Ireland (1997-2012) N General population 10,9748,9594161,329270 In contact with services 1,133 (10%) 866 (10%) 44 (11%) 191 (14%) 32 (12%) Homicide convictions UK_HOMICIDE © National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. All rights reserved. Not to be reproduced in whole or part without the permission of the copyright holder.

15. Primary diagnosis of patient homicides (based on Inquiry questionnaire data) ENGLAND_HOMICIDE (2002-2012) © National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. All rights reserved. Not to be reproduced in whole or part without the permission of the copyright holder.

16. Secondary diagnosis of patient homicides (based on Inquiry questionnaire data) ENGLAND_HOMICIDE (2002-2012) © National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. All rights reserved. Not to be reproduced in whole or part without the permission of the copyright holder.

17. Mental health teams’ estimation of risk of violence at last contact: patient homicides ENGLAND_HOMICIDE (2002-2012) © National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. All rights reserved. Not to be reproduced in whole or part without the permission of the copyright holder.

18. ENGLAND_HOMICIDE (2002-2012) © National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. All rights reserved. Not to be reproduced in whole or part without the permission of the copyright holder. Patient homicide - England

19. Study of “low risk paradox” Case note review of 81 patient suicides/homicides Conclusion: risk management should be individual to patient

20. Patient suicide: number of mental health in-patients; number who died by hanging/strangulation on the ward ENGLAND_SUICIDE (2002-2012) © National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. All rights reserved. Not to be reproduced in whole or part without the permission of the copyright holder.

21. In-patient suicides – care factors less likely to be detained under MHA (OR=0.43) more likely to be off ward without agreement (OR=13.07) Source: Hunt et al, Psych Med, 2007

22. Suicide under CR/HT and in-patient care - England ENGLAND_SUICIDE (2002-2012) © National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. All rights reserved. Not to be reproduced in whole or part without the permission of the copyright holder.

23. Suicide under crisis resolution/home treatment teams 140 suicides per year (England 2003-11) Rate higher than among in-patients (14.6 per 10,000 CR/HT episodes vs. 8.8 per 10,000 admissions) Increase from 80 per year (2003-04) to 163 (2010-11) Rate has fallen 44% lived alone; 49% adverse life events; 34% died <3 months discharge SOURCE: NCI data, Lancet Psychiatry (2014)

24. Suicides per week following discharge, England ENGLAND_SUICIDE (2002-2012) © National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. All rights reserved. Not to be reproduced in whole or part without the permission of the copyright holder.

25. Suicide within two weeks of hospital discharge Case-control study 100 post-discharge suicides and 100 living controls (England 2004-06) Independent risk factors: self-harm male gender aged ≥ 40 last admission <7 days adverse life events co-morbid psychiatric illness Under CPA protective SOURCE: NCI data, Psychiatric Services (2013)

26. Mental health teams contact with relatives after suicide: patient suicides ENGLAND_SUICIDE (2002-2012) © National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. All rights reserved. Not to be reproduced in whole or part without the permission of the copyright holder.

27. Patients as victims of homicide 1,496 victims (England & Wales, 2003-05) 90 (6%) patient victims 29/90 killed by fellow patient (7 with schizophrenia) 21/29 both victim and offender at the same NHS Trust Alcohol/drug misuse and previous violence common among patient victims and perpetrators SOURCE: NCI data, Lancet Psychiatry (2014)

28. Key service recommendations Removal of ligature points Assertive outreach 24-hour crisis team 7-day follow-up Non-compliance Dual diagnosis Criminal justice sharing Multi-disciplinary review Training in suicide risk management Safety First, 2001 12 Steps to a Safer Service

29. Do safety measures reduce suicide rates? Patient suicide rate per 10,000 * * = significant difference p<0.05 Source: National Confidential Inquiry, Lancet, 2012

30. Suicide rates in target groups Recommendation Target group % fall in suicide Ligature points In-patients 24% Assertive outreach ‘Non-compliant’ community patients 32% Assertive outreach ‘Missed appointment’ community patients 11% 24-hour crisis team In-patients 29% 7-day follow-up Patients within 3 months of discharge 21% Non-compliance ‘Non-compliant’ policy community patients 25% Source: National Confidential Inquiry, Lancet, 2012

31. Patient suicide: the impact of service changes

32. Safety priorities for MH care Support for patients facing financial problems Review use of crisis resolution/home treatment Care plan & early follow-up post-hospital discharge Continue focus on ward environment Maintain specialised community teams: AO, dual diagnosis Multidisciplinary review after incidents

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