Patient safety concerns relating to the continued use of risk stratification were identified during the Health Services Safety Investigation Body (HSSIB) investigations on the theme of 'Mental health inpatient settings'.
In September 2024, HSSIB released an interim report titled: “Creating conditions for learning from deaths and near misses in inpatient and community mental health services: Assessment of suicide risk and safety planning”.
This interim report, which is part of the Secretary of State directed mental health investigations, aims to highlight the importance of staff in mental health inpatient units and community mental health services, taking a person-centred approach to patient safety assessment and safety planning. The findings of this report may also be relevant to other services that care for and support people with mental health problems.
In this blog we share the key findings that can support improvements in taking a person-centred approach to patient safety risk assessment and safety planning for patients, families, and staff, and link to some useful resources for further reading.
The report focuses on the importance of:
- taking a person-centred approach to biopsychosocial assessments
- safety planning for patients in mental health inpatient units and community mental health teams
- stopping the use of risk assessment tools that stratify an individual’s risk of suicide or self-harm as low, medium, or high.
Background: The NICE guidance on self-harm
NICE guidance (NG225) on the assessment and management of self-harm was updated in 2022. This change in guidance marks a significant shift in the approach to risk assessment and management, and recommends against the use of risk assessment tools, scales, and risk stratification levels (such as “low”, “medium”, or “high” risk) for:
- predicting suicide or self-harm repetition, and
- making decisions about treatment or discharge.
Despite our best efforts and intentions evidence has consistently revealed the inherent limitations of trying to predict suicide, either with or without tools. Put simply, we can’t predict who will end their life or repeat self-harm. The not-so-good news for stratified risk levels, scales, and tools is positive news for person-centred holistic assessment and management for self-harm and suicide prevention.
This guidance also aligns with the Suicide Prevention Strategy for England 2023-28. All services have been urged to adopt an individualised approach to risk assessment and management.
The report says;
“National guidance and safety recommendations have stated to stop using risk assessment tools that stratify an individual’s risk of suicide or self-harm as high, medium, or low risk. This is because traditional risk prediction measures have been shown repeatedly, in studies, to be ineffective. Instead, biopsychosocial assessments have been identified to provide a more effective basis on which to understand risk factors to inform a patient’s care. This is achieved by taking a holistic approach to understanding why someone has attempted to harm themselves and developing a safety plan with the patient (a practical plan to help the patient cope with distress, thoughts of suicide or self-harm).”
The key findings of the report include;
- The use of risk assessment tools that provide a high, medium, or low risk score is no longer acceptable but continue to be used contrary to national guidelines for self-harm assessment.
- Patients who had expressed suicidal thinking, and their families and carers, said that they were not listened to when sharing their safety needs and their perceptions of risk were disregarded.
- Staff described a fear of being blamed if a risk assessment, including risk stratification, is not completed and a patient later comes to harm.
- Some digital patient record systems still require staff to categorise risk assessments as high, medium or low risk.
- Successful implementation of person-centred approaches to patient safety assessment and safety planning is dependent on many different factors including an organisations’ leadership culture, the people that work within organisations and the emphasis on involving the patient and their families and carers, in the assessment and planning processes.
- Organisations have involved ‘digital experts’ in their electronic patient record system improvement projects. Examples of changes made include the removal of automated predictive elements of risk stratification, free-text boxes with an increased character limit for improved narrative, and added space for family/carer views.
Further reading and supportive materials
NICE Guidance
Read the NICE Guideline [NG225] - Self-harm: assessment, management and preventing recurrence
Interim report by the HSSIB
Read the full interim report by the Health Services Safety Investigation Body (HSSIB)
“Interim Report - Creating conditions for learning from deaths and near misses in inpatient and community mental health services: Assessment of suicide risk and safety planning”
Resource by Storm Skills Training CIC
There’s a lot of information and evidence out there but sifting through it takes time and not all of it is accessible or practically oriented. Storm Skills Training has done the work for you with the resource ‘Moving Towards Individualised Risk Management’. It was created to support you and your team to meet the NICE Clinical Guidance (NG225) on the assessment and management of self-harm, updated in 2022.
Webinar by the National Suicide Prevention Alliance
In May, the National Suicide Prevention Alliance held a webinar on Best Practice in the Assessment of Suicide Risk.
This insightful session explored good practice in the use of risk assessments when supporting people who may be vulnerable to suicide.
Presenters included:
- Philip Pirie, bereaved father campaigning for suicide risk assessment reform
- Our very own CEO, Bianca Romanyk
- Andy Willis, NSPA Lived Experience Influencer
Bianca presented on the evidence-based elements of a person-centered approach to assessment. If you have any follow-up questions about her presentation, please reach out. We'd love to hear from you and continue the conversation.
Reflections
The shift towards a more individualised and compassionate model signals a positive change that is long overdue. This shift isn’t just about changing processes; it’s about developing a culture of empathy – one that focuses less on predicting risk and more on promoting safety and meeting individual needs. One that values the importance of human connection and uses a psychosocial perspective to explore the whole person - being guided by the person, not the template, form, or paperwork.
At Storm Skills Training, we're empowering frontline teams to do just that with our evidence-based self-harm and suicide prevention training. Our approach is rooted in the latest research, best practices, and lived experience evidence, and it is designed for professionals who regularly interact with individuals in distress or at risk of self-harm and suicide. We collaborate with teams and individuals to enhance their skills in effectively engaging with someone in distress using a person-centered approach. This includes engagement, holistic assessment, formulation, and personalised safety planning. Through our high-quality, evidence-based training, we help to build knowledge, skills, and confidence among professionals, to help them provide compassionate and effective support, ensuring that every interaction and decision truly centers on the individual's needs. If you'd like to learn more about our training, visit the training page on our website, or send us an email. We'd love to hear from you.
Let's work together to ensure fewer lives are lost to suicide and self-harm.
