The assessment of risk in patients who go on to die by suicide or commit homicide is often poor, a new study has found.

A report by The University of Manchester’s National Confidential Inquiry (NCI) into Suicide and Homicide by People with Mental Illness out today has raised concerns about the way that risk is assessed and led to criticism of the tick-box approach to clinical practice.

Researchers looked at a sample of 81 cases where risk had been judged to be low, but seven days or less after the assessment the patient died by suicide or committed homicide, to retrospectively address the quality of the assessments. They found that in about a third of the cases (36% of the patient suicides and 41% or the patient homicides) the overall quality of risk assessment was unsatisfactory. In the majority of cases, however, risk assessment and management were satisfactory, even though they were followed within seven days by a fatal incident.

Professor Louis Appleby, commissioned by the Healthcare Quality Improvement Partnership (HQIP) on behalf of the NHS England, NHSSPS Northern Ireland, the Scottish Government, the Welsh Government and the Channel Islands, said: “The results suggest there is a need for risk management to be individually tailored, or personalised, to each patient rather than following a “tick-box” approach.

“In the majority of the 81 sample cases studied risk assessment and management were satisfactory, but in a significant minority of cases we studied we found clinical risk assessment and management may not have been adequate. This is an uncomfortable conclusion for clinicians but one that should lead to improvements.

“In a small but significant number of cases, even when risk was recognised, appropriate management did not follow, for example patients were granted unescorted leave within a few hours of detention for acute psychosis. This could be the consequence of a “tick-box” approach to risk assessment, something that has been widely criticised by clinicians.”

Professor Appleby, from the University’s Centre for Behaviour and Mental Health who is also part of Manchester Mental Health and Social Care Trust, said the risk factors associated with suicide and serious violence in mental illness were well documented. Previous studies show one in four people who die by suicide have a history of recent contact with mental health services and one in 10 who commit homicide.

The researchers developed a framework for evaluating the quality of risk assessment and management in mental health patients based on existing best practice guidelines which included taking into account the patient’s history, mental state and current circumstances, an overall judgment of the risk factors, a management plan, communication of the management plan and overall quality of assessment.

Unsatisfactory assessments before a homicide were often associated with a diagnosis of personality disorder or alcohol misuse.

The report authors hope that services will now use the framework and key principles set out in the report to examine their own processes, in particular that of individual risk assessment formulation followed by personalised risk management.  Further studies should focus on assessment of patients with personality disorder, look at more cases using the framework, Professor Appleby added.

-ENDS-

Notes for editors

The National Confidential Inquiry (NCI) into Suicide and Homicide by People with Mental Illness is a longitudinal national case series of all homicides in the UK, with particular focus on perpetrators with mental illness.

To view the full report, click here and scroll down to Latest News.

To request an interview with Professor Appleby or one of the team, please contact:
Alison Barbuti, Media Relations Officer, Faculty of Medical and Human Sciences |The University of Manchester
Tel. +44 (0)161 275 8383 Mobile 07887 561 318 Email: .(JavaScript must be enabled to view this email address)

The University of Manchester
The University of Manchester, a member of the Russell Group, is one of the largest and most popular universities in the UK. It has 20 academic schools and hundreds of specialist research groups undertaking pioneering multi-disciplinary teaching and research of worldwide significance. According to the results of the 2008 Research Assessment Exercise, The University of Manchester is one of the country’s major research institutions, rated third in the UK in terms of ‘research power’. The University has an annual income of £807 million and is ranked 40th in the world and fifth in the UK for the quality of its teaching and impact of its research.

The Healthcare Quality Improvement Partnership (HQIP)

The Healthcare Quality Improvement Partnership (HQIP) is led by a consortium of the Academy of Medical Royal Colleges, the Royal College of Nursing and National Voices. Its aim is to promote quality improvement, and in particular to increase the impact that clinical audit has on healthcare quality in England and Wales. HQIP hosts the contract to manage and develop the National Clinical Audit and Patient Outcomes Programme (NCAPOP). Their purpose is to engage clinicians across England and Wales in systematic evaluation of their clinical practice against standards and to support and encourage improvement in the quality of treatment and care. The programme comprises more than 30 clinical audits that cover care provided to people with a wide range of medical, surgical and mental health conditions.