Suicides after mental health patients have been discharged should be considered ‘never events’ in the NHS.
Researchers from the University of Manchester also said that death following restraint should be a never event.
In the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness, researchers found that the first two weeks following discharge have the highest risk of death by suicide for mental health patients.
Around 3,225 patients died by suicide in the UK within the first three months of their discharge from hospital – 18% of all patient suicides, between 2002-2012.
There had also been 24 deaths in patients who had been restrained by ward staff in the previous 24 hours. Five of the deaths were in 2012.
Professor Louis Appleby, director of the National Confidential Inquiry, who led the study said: “The first three months after discharge remain the time of highest risk, but especially in the first 1-2 weeks.
“This increased risk and been linked to short admissions and to life events, so out recommendations are that careful and effective care planning is needed, including for patients before they are discharged and for those who self-discharge.
“Early follow-up appointments should be strengthened and reducing the length of in-patient stay to east pressure on beds should not be an aim in itself. Instead, health professionals should ensure the adverse events that preceded the admission have been addressed.”