In 2017 our charity, Suicide Crisis, started a research project into deaths by suicide which involved attending every inquest which was a possible suicide in our county of Gloucestershire.

We also spoke to some of the families of the individuals who died.

At our Suicide Crisis Centre we are fortunate and immensely grateful that no client has died in the period that they have been under our care.

However, we were still hearing of deaths in our area, and this was distressing to us. We wanted to learn what more could be done to prevent them.

Here are some interesting findings from the first six months of our research, during which time the coroner found that twenty five individuals had died by suicide in Gloucestershire.

By flagging these findings Suicide Crisis is not seeking to put the blame anywhere but to open up a conversation about suicide risk.

1. Families flagging up risks to services

We believe that we need to take more notice of the concerns of loved ones. In five of twenty five deaths by suicide it appears that families flagged risk to services without it being acted upon. It appears that families were explicit in warning services about the potential risk of suicide.

We believe that it is vital that we listen to input from families and carers, particularly with regard to risks.

2. Assessing risk “in the moment”

Assessing suicide risk 'in the moment' appears not to take into account recent history, risk factors and future events likely to impact upon risk. We identified this in 24% of the deaths.

In some cases, individuals were assessed as being at low risk of suicide a few days before they died, despite the person having made a suicide attempt in the hours before assessment and despite the apparent presence of other significant risk factors.

In our view, assessing 'in the moment' does not take into account the person’s history which may include past traumas, psychiatric diagnoses, use of substances, suicide attempts and recent relevant events. Known future events, such as an impending court case, may also impact upon risk.

3. People with a diagnosis of personality disorders expected to manage their own crisis

We could see no evidence that mental health services had prepared people living with personality disorders to take responsibility for managing their own mental health crisis. 

For example, there was no evidence that they had been given therapies quoted in the NICE guidelines for Borderline Personality Disorder which might have helped them to do this – including therapies such as Dialectical Behaviour Therapy which NICE indicates can help in managing self-harm.

 4. Risk of serious mental illness and suicide in carers 

We believe that we need to take more notice of the risk of the particular demands of being a carer impacting upon a person’s mental health.  To such an extent that they may start to experience symptoms indicating possible serious mental illness (of which they had no previous history).

In one case, the person started to hear voices and in another, they started to develop paranoid thoughts.

 5. Appearing brighter in mood at the last clinical appointment before death

It appears that it was not always recognised that a sudden change in mood, and becoming brighter may indicate heightened risk.

In some cases, there was evidence documented either by families or GPs that the person had appeared brighter in mood shortly before their death. There were three cases where the person had presented in this way at their last appointment with their GP before their death.

Feeling or seeming brighter after a period of depression can be significant for the following reasons:-

  • When the person’s mood starts to improve a little, they may gain the energy needed to end their life, which was lacking while deeply depressed
  • A brighter mood can be an indication that a person has made a decision to end their life. Some people may appear bright (or even elated) once they have made the decision

 6. Apparently casual remarks about suicide signifying genuine intent

In the days before they died, some individuals made apparently casual remarks about ending their life.

It can be difficult for a person to disclose suicidal intent and that may be why they may express it in an apparently casual way

7. Statistics can be misleading

Six people (24%) were under mental health services at the time of their death. However, if we factor in the number who were trying to access mental health care in the days and weeks before they died, and those who were not referred after a suicide attempt or action indicating suicidal intent, the number would more likely have been fifteen (60%).

There were examples of people having made a suicide attempt but being provided with no ongoing care.

Our hopes 

In identifying learning points, we do not wish in any way to diminish the excellent work which is being done by our NHS services and others.

One of the consequences of attending full inquests is that you learn about the individuals who died. You get to know them, from talking to their families. You see the impact upon families. 

We hope that other counties will undertake this level of research, and focus upon all the detail which emerges at inquests.

We would like CCG mental health commissioners and Public Health commissioners to attend some inquests. As well as providing learning about how services may need to adapt and change in order to prevent more deaths.

We believe that the experience would make them even more determined that other people do not die in similar circumstances.     

Professionals wishing to access the full report of the research are welcome to email us at