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

Our annual report is the point in each year when we assess progress on safety in mental health care across the UK. It provides the latest figures on tragic events – suicides, homicides and sudden deaths – and highlights the priorities for safer services. We aim to reflect the concerns of patients, families and staff; this year’s report highlights acute care, economic adversity and recent migrants.

This year we are also looking back on 20 years of data collection, drawing on previous reports and journal papers. What have we learned? How has the challenge of managing risk changed? From our studies of mental health services, primary care and accident and emergency departments, we present the essential evidence-based elements of safer care.

In publishing this report we need to thank the clinical staff who have responded to our requests for information; their cooperation has been crucial. We also want to acknowledge the thousands of lost lives and devastated families that lie behind our statistics. This 20 year report, aiming to improve future prevention,
is dedicated to them.

The highest priority of health services should be the safety of patients in their care. Users of our mental health services are entitled to expect the protection they need, and all patients and service users should be protected from avoidable harm. Often risks are challenging to assess, as is the effectiveness of different interventions. Safe practice can only be achieved by adopting a rigorous learning culture. That is why the work of the National Confidential Inquiry over the last 20 years has been so valuable; it offers the objective evidence which can help in identifying what works and what needs to be fixed, both in mental health and across healthcare generally. Therefore its continuing work in this field, marked by this report, deserves our enthusiastic support, and even more importantly, our attention to the lessons it offers.

Service users deserve safe care. Findings from the National Confidential Inquiry over the last 20 years have helped to protect patients, and should be incorporated into the routine care provided to all people seen by mental health services.