Active intent and a plan with access to means: ensure a safe environment, do not leave the person alone, and get a senior mental health assessment before any discharge. Asking directly about suicide does not increase risk.
Assess (ask directly)
- Current thoughts, intent, a plan, and access to means
- The index act: method, lethality, precautions against discovery, regret about surviving
- Previous self-harm or attempts (a strong risk factor)
- Mental illness, substance use, psychosis or command hallucinations
NICE position
- Do not use risk-stratification tools or scales to predict suicide or to decide who gets care
- Use a psychosocial assessment of needs and risk formulation instead
- Consider static and dynamic factors (recent loss, hopelessness, agitation, insomnia, intoxication)
- Protective factors do not neutralise significant risk
Lower immediate concern
- No current intent or plan
- Safety plan and support
- Do not rely on risk scores
Significant distress
- Active thoughts, some protective factors
- Urgent mental health referral
- Means restriction, involve carers
High concern / imminent
- Clear intent, plan or recent attempt
- Do not leave alone
- Ensure safety, urgent assessment
Management
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1. Assess holistically
Undertake a psychosocial assessment of needs, not just a checklist. Treat any medical consequences of self-harm first.
Undertake a psychosocial assessment of needs, not just a checklist. Treat any medical consequences of self-harm first.
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2. Immediate safety
Remove access to means, ensure a safe environment and one-to-one support if needed, and involve the crisis or liaison psychiatry team. Consider admission or the Mental Health Act if the person cannot be kept safe.
Remove access to means, ensure a safe environment and one-to-one support if needed, and involve the crisis or liaison psychiatry team. Consider admission or the Mental Health Act if the person cannot be kept safe.
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3. Safety plan
Collaborative safety plan: warning signs, coping strategies, people and crisis lines to contact, and reducing access to means.
Collaborative safety plan: warning signs, coping strategies, people and crisis lines to contact, and reducing access to means.
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4. Follow-up
Arrange early follow-up (the period after discharge is high risk), involve the GP, and share information with carers with consent where possible.
Arrange early follow-up (the period after discharge is high risk), involve the GP, and share information with carers with consent where possible.
Compassion and documentation
- Non-judgemental, take every presentation seriously
- Repeated self-harm still needs full assessment each time
- Document the assessment, formulation and plan clearly
Pitfalls
- Using a risk score to deny care
- Discharging without a psychosocial assessment
- Assuming low lethality means low intent
- No follow-up after an emergency presentation
MedPrep - www.medprep.uk - Educational revision aid only. Not clinical guidance. Doses are adult examples; check the BNF, current guidelines and local policy, and seek senior advice. Nov 2026