National Confidential Inquiry into Suicide and Safety in Mental Health Annual Report 2025: UK patient and general population data 2012-2022 (February 2025)

Summary

This annual report from the National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH) provides information relating to people aged 10 and above who died by suicide between 2012 and 2022 across the UK and Jersey. It also presents findings on the number of people under mental health care who have been convicted of homicide, and those in the general population in the UK.

Content

Key findings

Patient suicide numbers and rates

• Over 2012-2022, there were 18,670 suicides by patients in the UK and Jersey, an average of 1,697 deaths per year, 26% of all general population suicides.
• The number of patient suicides increased in 2018 following a change in the standard of proof for suicide at inquest. In England and Wales, an increase in suicides registered in 2023, suggesting a possible rise in suicides occurring in 2022, has been reported by the Office for National Statistics. It is too early to say if this rise will be evident in our 2022 patient suicide figures.

Social and clinical characteristics

• A high proportion of patients who died by suicide showed evidence of isolation and social adversity; nearly half (47%) lived alone, and a sixth (17%) had recently experienced serious financial problems (see details on page 12). Suicide-related internet use was reported in 8% of patients.
• A history of alcohol (47%) or drug (38%) misuse was common. Over half (55%) had a comorbid mental health diagnosis. The majority (62%) of patients who died had a history of self-harm. The proportion who had recently (<3 months) self-harmed (31%) has increased over the report period.

Clinical care

• There were 4,718 (27%) patients who died by suicide in acute care settings, including in-patients (5%), and post-discharge care (13%) or crisis resolution/home treatment (13%) (with overlap between these latter two groups), an average of 429 deaths per year.
• There were an estimated 72 suicides by mental health in-patients in 2022, around 4% of all patient suicides in that year. Of all in-patients, 40% died on the ward, 50% were off the ward on agreed leave, and 10% had left the ward without staff agreement or left with agreement but failed to return. The proportion of inpatients who died on the ward has increased by 31% between 2012-2015 and 2019-2022.
• There were an estimated 198 deaths by suicide in the 3 months after discharge from mental health in-patient care in 2022, 11% of all patient suicides. The number and rate of post-discharge suicide has risen since 2017. Of all patients who died in the first week after discharge, the highest number occurred on day 3 (63 patients, 20%) post-discharge (taking day 1 as the day of discharge). However, in 2019-2022 the highest number occurred on day 6 (20 patients, 22%).

Real-time surveillance study

• NCISH is establishing an additional method of patient suicide data collection through real-time surveillance (RTS) in England and asking all trusts to notify it of suspected suicides by inpatients or those recently discharged, without waiting for inquest.
• To date we have been notified of 67 suspected suicide deaths, the majority (44, 67%) by in-patients. Early themes include high proportions of in-patients being detained under the Mental Health Act (55%) and being admitted to wards outside of the patient’s local area (35%).

Suicide and bipolar disorder

• In 2012-2022, there were 1,491 suicides by patients with bipolar disorder, 8% of all patient suicides, an average of 136 deaths per year. The average number in 2019-2022 increased by 19% compared to the average number in 2015-2018.
• Patients with bipolar disorder were more often female (47%), living alone (52%) and older, with more aged 45-64 (50%), than other patients who died by suicide.
• Overall, a minority (39%) were receiving lithium treatment and only 12% were receiving psychological treatment.
• More patients with bipolar disorder were non-adherent with medication (15%) and had experienced drug side effects (12%).

Suicide and missed contact and/or non-adherence with medication

• In 2012-2022, there were 3,817 suicides by patients who missed their last contact with mental health services, 22% of all patient suicides, an average of 347 deaths per year. There were 1,998 suicides by patients who were nonadherent with drug treatment, 12% of all patient suicides, an average of 182 deaths per year. Our estimates for 2022 show an increase in the proportion of patients with missed contact but a fall in those non-adherent with medication.
• Missed contact was often accompanied by clinical morbidity (for example, additional psychiatric diagnoses, self-harm, alcohol and/or drug misuse), and socioeconomic adversity (for example, unemployment, financial problems, living alone). Services had made contact with the patient’s family in 28% of those who had missed their last appointment.
• The majority (63%) of non-adherent patients had severe mental illness. Half (47%) were prescribed oral antipsychotics. Reasons for non-adherence were reported to be the patient’s impaired insight into their illness (31%), side effects (15%) and lack of effectiveness (13%).

Suicide and recent bereavement

• In 2012-2022, there were 1,312 suicides by patients who had been recently (<3 months) bereaved, 8% of all patient suicides, an average of 119 deaths per year. The number increased over two-fold in 2016-2022 compared to in 2012-2015, presumably due to better recognition by clinicians.
• Patients bereaved were more often female (40%) than other patients who had not recently been bereaved and they were more likely to be older, widowed (20%) and living alone (54%). A third (34%) had a primary diagnosis of depression. More died on or near the date of a family member or friend’s death anniversary compared to other patients (7% v. 1%). In 2020-2022, half (51% v. 35%) had reported suffering from insomnia and a third (35% v. 30%) had recently misused alcohol.