Suicide prevention continues to be a key national priority for public health and mental health services. People with mental health problems are a particularly high-risk group and it is vital that mental health services continue to strengthen clinical practice if suicides are to be prevented.

In December 2006, the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (NCISH) published Avoidable Deaths: five year report of the national confidential inquiry into suicide and homicide by people with mental illness.1 This report outlined a number of positive findings and reflected the continuing fall in inpatient suicides. However, this report also highlighted continuing concerns in a number of areas including: (i) inpatients dying by suicide whilst being off the ward without permission; (ii) the transition from inpatient to community care; (iii) the management of risk and risk assessment.

These concerns were also reflected in the more recent annual report of NCISH, published in July 2009. This reported a fall in patient suicides overall but highlighted a number of areas for improvement.

The National Patient Safety Agency (NPSA) has updated this toolkit to take account of the lessons we have learnt since the original toolkit was published in 2003. It also reflects the changes in mental healthcare that have happened since that time. The toolkit continues to provide a simple method by which mental health services can measure the extent to which they are addressing the standards outlined in the toolkit.