Intended for healthcare professionals


Doctors are failing to identify patients most at risk of killing, report says

BMJ 2006; 333 doi: (Published 07 December 2006) Cite this as: BMJ 2006;333:1188
  1. Andrew Cole
  1. 1London

    Clinicians are too often failing to identify the mentally ill patients most at risk of killing either themselves or someone else, a national inquiry into suicide and homicide has concluded.

    The report looked at suicides in England and Wales between 2000 and 2004 and homicides between 1999 and 2003. It found that mental health patients were responsible for 9% of homicides and made up 27% of all suicides.

    Half of the mental health patients who committed suicide and nearly a third of such patients who killed someone else had been in touch with mental health services within the previous week; yet 86% of those who killed themselves and 88% of those who committed a homicide had been assessed as low or no risk.

    There was a danger that staff were becoming desensitised to the real risks of some of their patients' behaviour, said the inquiry's director, Professor Louis Appleby, who is also the national director for mental health.

    The report proposes a more rigorous approach to risk assessment. “It is quite easy at times to look at how someone is on a particular day and feel there isn't much risk,” said Professor Appleby. “But if you take a step back and look at the history of that person's illness you realise their risk is never going to be low.”

    The report found that the number of inpatient suicides fell by a quarter between 1997 and 2004. Deaths by hanging on wards halved from 53 to 26 a year, and suicides after refusal to take treatment also fell.

    But 27% of suicides among mental health patients occurred after a patient had absconded from the ward, and one in five inpatient suicides happened when the patient was supposed to be under observation by nursing staff.

    “We have got used to the fact that people often leave our wards without permission,” said Professor Appleby. “The families and carers never get used to it. It is a shocking finding.”

    Staff needed to be more aware of the triggers for this sort of behaviour, which often followed an incident or disturbance on the ward. There was also a case for using technology such as closed circuit television or swipe cards to control ward exits and entrances more effectively.

    Clinicians assessed only 19% of the suicides and 21% of the homicides as preventable. But this “culture of inevitability” had to be challenged, said Professor Appleby.

    The report shows that about 5% of all homicides each year are committed by people with schizophrenia, 9% by current or recent mental health patients, and 30% by people who are subsequently adjudged to have a lifetime mental disorder.

    Mental health patients are less likely to be involved in homicides where they do not know the victim. “The evidence suggests that the risk to the general public of being a victim of a random attack by a mentally ill person hasn't increased during the period community care has been national policy,” said Professor Appleby.


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