Psychiatric in-patients have a greatly elevated risk of suicide. We aimed to examine trends in in-patient suicide rates and determine if characteristics of in-patients who died by suicide have changed over time.

We identified all in-patients in England who died by suicide between 2009 and 2020 from the National Confidential Inquiry into Suicide and Safety in Mental Health. Suicide rates were calculated using data from Hospital Episodes Statistics.

The rate of in-patient suicide per 100 000 bed days fell by 41.9% between 2009–2011 and 2018–2020. However, since 2016 the rate has remained static with no significant fall. Rates fell in men, those aged 30–59, and those with schizophrenia and other delusional disorders or personality disorder. Rates also fell for suicide by hanging (including hanging on the ward) and jumping. No falls were seen in suicide rates among women, younger and older age groups, and those with affective disorder. There was no indication of a transfer of risk to the post-discharge period or to home treatment/crisis care. More in-patients in the latter part of the study were aged under 25, were on authorised leave, and had psychiatric comorbidity.

In-patient suicide has significantly fallen since 2009, suggesting patient safety may have improved. The recent slowdown in the fall in rates, however, highlights that renewed preventative efforts are needed. These should include a greater focus on women, younger and older patients, and those with affective disorder. Careful reviews prior to granting leave are important to ensure a safe transition into the community.

Community treatment orders (CTOs) enable patients to be treated in the community rather than under detention in hospital. Population-based studies of suicide among patients subject to a CTO are scarce.

To compare suicide rates among patients subject to a CTO with all discharged psychiatric patients and those detained for treatment but not subject to a CTO at discharge (‘CTO-eligible’ patients).

From a national case series of patients who died by suicide within 12 months of contact with mental health services in England during 2009–2018, we estimated average annual suicide rates for all discharged patients, those on a CTO at the time of suicide, those ever treated under a CTO and CTO-eligible patients.

Suicide rates for patients on a CTO at the time of suicide (191.3 per 100 000 patients) were lower than all discharged patients (482.3 per 100 000 discharges). Suicide rates were similar in those ever treated under a CTO (350.1 per 100 000 CTOs issued) and in CTO-eligible patients (382.9 per 100 000 discharges). Suicide rates within 12 months of discharge were higher in persons ever under a CTO (205.1 per 100 000 CTOs issued) than CTO-eligible patients (161.5 per 100 000 discharges), but this difference was reversed for rates after 12 months of discharge (153.2 per 100 000 CTOs issued v. 223.4 per 100 000 discharges).

CTOs may be effective in reducing suicide risk. The relative benefits of CTOs and intensive aftercare may be time-dependent, with the benefit of a CTO being less before 12 months after discharge but greater thereafter. CTO utilisation requires a careful balancing of patient safety versus autonomy.

Homelessness in England and Wales is on the rise together with the mortality rate among homeless people. Many homeless people have a mental illness, which is a risk factor for suicide.

This study used data from the National Confidential Inquiry into Suicide and Safety in Mental Health to examine demographic and clinical characteristics of homeless people who died by suicide and were in recent contact with mental health services.

We have compared 514 patients (2% of the total sample) who died by suicide and who were reported as being homeless or having no fixed abode by their clinicians with patients in stable accommodation between 2000 and 2016 to identify differences in sociodemographic characteristics and clinical care.

Our analysis suggests that homeless patients who died by suicide had more acute (alcohol: 47% v. 25%, P < 0.01, drug: 39% v. 15%, P < 0.01) and chronic (alcohol: 72% v. 44%, P > 0.01, drug: 64% v. 31%) substance misuse issues than patients in stable accommodation. Homeless patients were also more likely to die as in-patients (21% v. 10%, P < 0.01) or within 3 months of discharge (32% v. 19%, P < 0.01).

Homeless patients who died by suicide more often had known risk factors for suicide than patients in stable accommodation. As a result of the higher percentages of post-discharge and in-patient suicides in homeless patients as well as the high prevalence of substance misuse, this study recommends closer integration of services as well as awareness of risks during in-patient admission and in the weeks immediately after discharge.

Worldwide suicide is commonest in young people and in many countries, including the UK, suicide rates in young people are rising.

To investigate the stresses young people face before they take their lives, their contact with services that could be preventative and whether these differ in girls and boys.

We identified a 3-year UK national consecutive case series of deaths by suicide in people aged 10–19, based on national mortality data. We extracted information on the antecedents of suicide from official investigations, primarily inquests.

Between 2014 and 2016, there were 595 suicides by young people, almost 200 per year; 71% were male (n = 425). Suicide rates increased from the mid-teens, most deaths occurred in those aged 17–19 (443, 74%). We obtained data about the antecedents of suicide for 544 (91%). A number of previous and recent stresses were reported including witnessing domestic violence, bullying, self-harm, bereavement (including by suicide) and academic pressures. These experiences were generally more common in girls than boys, whereas drug misuse (odds ratio (OR) = 0.54, 95% CI 0.35–0.83, P = 0.006) and workplace problems (OR 0.52, 95% CI 0.28–0.96, P = 0.04) were less common in girls. A total of 329 (60%) had been in contact with specialist children's services, and this was more common in girls (OR 1.86, 95% CI 1.19–2.94, P = 0.007).

There are several antecedents to suicide in young people, particularly girls, which are important in a multiagency approach to prevention incorporating education, social care, health services and the third sector. Some of these may also have contributed to the recent rise.

Patients admitted to hospital at the weekend appear to be at increased risk of death compared with those admitted at other times. However, a ‘weekend effect’ has rarely been explored in mental health and there may also be other times of year when patients are vulnerable.

To investigate the timing of suicide in high-risk mental health patients.

We compared the incidence of suicide at the weekend v. during the week, and also in August (the month of junior doctor changeover) v. other months in in-patients, patients within 3 months of discharge and patients under the care of crisis resolution home treatment (CRHT) teams (2001–2013).

The incidence of suicide was lower at the weekends for each group (incidence rate ratio (IRR) = 0.88 (95% CI 0.79–0.99) for in-patients, IRR = 0.85 (95% CI 0.78–0.92) for post-discharge patients, IRR = 0.87 (95% CI 0.78–0.97) for CRHT patients). Patients who died by suicide were also less likely to have been admitted at weekends than during the week (IRR = 0.52 (95% CI 0.45–0.60)). The incidence of suicide in August was not significantly different from other months.

We found evidence of a weekend effect for suicide risk among high-risk mental health patients, but with a 12–15% lower incidence at weekends. Our study does not support the claim that safety is compromised at weekends, at least in mental health services.

Suicide prevention is a health service priority. Suicide risk may be greatest during psychiatric in-patient admission and following discharge.

To describe the social and clinical characteristics of a comprehensive sample of in-patient and post-discharge cases of suicide.

A national clinical survey based on a 4-year (1996–2000) sample of cases of suicide in England and Wales who had been in recent contact with mental health services (n=4859).

There were 754 (16%) current in-patients and a further 1100 (23%) had been discharged from psychiatric in-patient care less than 3 months before death. Nearly a quarter of the in-patient deaths occurred within the first 7 days of admission; 236 (31%) occurred on the ward, the majority by hanging. Post-discharge suicide was most frequent in the first 2 weeks after leaving hospital; the highest number occurred on the first day.

Suicide might be prevented among in-patients by improving ward design and removing fixtures that can be used in hanging. Prevention of suicide after discharge requires early community follow-up and closer supervision of high-risk patients.