Why NICE says not to use low, medium or high risk
Clinicians assess risk at admission, before leave, at discharge, in crisis and at every review. For years this often meant checklists and scores that sorted patients into low, medium or high risk. Research has shown these tools predict suicide poorly. Most people rated high risk do not die by suicide, and many who do had been rated low risk.
NICE's self-harm guideline (NG225, 2022) recommends that risk assessment tools and scales, and global low, medium or high stratification, should not be used to predict future suicide or self-harm, or to decide who is offered treatment or who is discharged. The National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH) takes the same position. The focus moves to a psychosocial assessment of needs and risks and a collaborative safety plan.
What should a mental health risk assessment cover?
A good assessment is structured but conversational. It combines what the person tells you, what others tell you, the records and your observations. This approach is often called structured clinical judgement.
| Area | What to explore |
|---|---|
| Current presentation | Why now? Current thoughts of suicide, self-harm or harming others, and how persistent, specific and intense they are |
| Recent events | Loss, conflict, humiliation, debt, eviction, legal problems, changes in care |
| Past self-harm or suicide attempts | Circumstances, how the person felt afterwards, what helped |
| Past harm to others | Context, who was involved, role of substances or mental state |
| Mental state | Mood, hopelessness, psychotic experiences, agitation, impulsivity |
| Substance use | Alcohol and other substances, and links with past episodes |
| Access to means | Whether the person has access to means relevant to their thoughts or history |
| Protective factors | Relationships, children, faith, future plans, reasons for living. These can change quickly. |
| Social circumstances and safeguarding | Housing, money, isolation, domestic abuse, children or adults at risk |
| The person's and others' views | What they think helps or makes things worse; what family, GP and other services report |
How to write a risk formulation (with an example)
A formulation turns information into an explanation. One simple framework is the 5 Ps: presenting problem, predisposing, precipitating, perpetuating and protective factors. Another is to describe likely scenarios: what harm, in what circumstances, how soon, how serious, and what would make it more or less likely.
Mr A, 45, has recurrent depression and was admitted after an overdose following the end of his marriage. Two previous overdoses also followed relationship losses while drinking heavily. His risk of suicide is raised by hopelessness, living alone, money problems, alcohol use and access to his prescribed medicines. It is likely to rise further if he receives divorce papers, loses contact with his children or drinks. Protective factors are his wish to see his two children and his engagement with the ward team. The plan targets his depression and drinking, limits medicine supply, arranges support around contact with his children, and includes a safety plan written with his named nurse.
Notice what the example does. It links past patterns to present triggers, names changeable factors, and leads straight into actions. That is far more useful to the next clinician than a score.
What goes in a safety plan?
NICE NG225 recommends a collaborative, personalised safety plan for people who have self-harmed, and safety plans are widely used for anyone at risk of suicide. The plan belongs to the person, is written in their words, and should be kept somewhere they can reach it, such as their phone.
- Warning signs: Thoughts, feelings or situations that tell them a crisis may be building, for example not sleeping or drinking alone.
- Things I can do myself: Activities that have helped before, such as a walk, music or a breathing exercise.
- People and places that help: Names and numbers for company or distraction, and places they can go.
- People I can ask for help: Trusted family or friends who know about the plan.
- Professional and crisis contacts: Care coordinator, crisis team, GP, NHS 111 (which includes a mental health option in England), Samaritans on 116 123 and 999 in an emergency, with in-hours and out-of-hours numbers.
- Making the situation safer: Practical, agreed steps to reduce access to means, such as smaller prescriptions or a relative looking after medicines.
A safety plan is not a no-harm contract. Asking someone to promise not to harm themselves has no evidence of benefit and can stop people asking for help.
How should leave be planned?
Leave helps recovery and tests coping at home. For detained patients, leave must be authorised by the responsible clinician under section 17 of the Mental Health Act. Informal patients agree leave by discussion and should not be prevented from leaving unless there is a legal power to do so.
- Review mental state and the formulation on the day of leave, not just at ward round.
- Agree where the person will go, who with, when they will return and what they will do if they feel unsafe.
- Inform family or carers who will be with them, with consent where possible.
- Check medication and any risk from medicines at home.
- Agree what staff will do if the person does not return on time, and follow your absent without leave policy.
- Afterwards, ask the person and family how it went and record it.
How do you plan a safe discharge from a mental health ward?
The period just after discharge from inpatient mental health care carries a raised risk of suicide, particularly the first days and weeks, as NCISH reports have repeatedly shown. In England, the NHS Standard Contract includes follow-up within 72 hours for adults discharged from adult acute inpatient care, replacing the older seven-day standard. NICE NG53 also supports early follow-up for people at risk of suicide. The 72 hours is a minimum, not a target: some people need contact sooner.
- Plan from admission: Work with the person, their family and the community team from early on, not on the day of discharge.
- Update the formulation: Consider what has changed and what the person is going back to: housing, relationships, money, legal problems.
- Confirm care and safety plans: Make sure the person has an up-to-date care plan and their own safety plan with crisis contacts.
- Book follow-up: Arrange contact within 72 hours, or sooner, with a named person, date and time, and agree what happens if they cannot be reached.
- Arrange section 117 aftercare if relevant: People detained under certain sections, including section 3, are entitled to free aftercare planned with the local authority and integrated care board.
- Manage medicines and communicate: Think about quantity and safety of supply, and send a prompt discharge summary with the formulation, safety plan, medication and follow-up to the GP and community team.
If an informal patient with capacity wants to leave before a plan is complete, you cannot stop them unless the criteria for a holding power or Mental Health Act assessment are met. Explain your concerns, offer to complete a safety plan, arrange quick follow-up, inform the community team and GP, and record your assessment. If you think they lack capacity or meet criteria for detention, get senior advice and follow the correct legal process.
Can you share information with families about suicide risk?
Families often notice changes first, and many bereaved relatives say they were not listened to. The Triangle of Care (Carers Trust) describes a partnership between the person, carers and professionals. Ask for consent to share, and remember consent can be partial, for example sharing the safety plan but nothing else.
Without consent, GMC confidentiality guidance and the government's consensus statement on information sharing and suicide prevention support disclosure where it is necessary to protect someone from a risk of death or serious harm. Share only what is needed, record why, and seek senior advice if unsure. For people lacking capacity, decide in their best interests under the Mental Capacity Act. Listening to a family member never breaches confidentiality, and what they tell you should be recorded and used.
Seen for discharge review. Mood improved. Denies SI. No psychotic symptoms. Low risk. Discharge with CMHT follow-up.
Mood improved and engaging well. Ella says she has no current thoughts of ending her life but they return "when things get bad at home". Mother phoned today reporting recent violence from partner; Ella confirms he hit her twice this month and her last overdose followed an argument with him. Risk raised by domestic abuse, returning to the same home, past overdoses in this context and access to medicines. Plan agreed with Ella: discharge delayed while alternative accommodation explored; safeguarding and domestic abuse referrals made with consent; MARAC considered with safeguarding lead; safety plan updated; seven days' medication; follow-up within 72 hours. Mother updated with consent. Discussed with consultant.
Learning more about clinical risk and discharge
If you are involved in a serious incident or a patient death, write a factual, contemporaneous account, take part openly in the learning response, use supervision, and get early advice from your defence organisation, trade union or professional body if asked for a statement or if there is an inquest, complaint or regulator referral.
Our course Clinical Risk Assessment and Discharge in Mental Health covers formulation, safety planning, leave, discharge, information sharing and documentation, with a reflection and action plan. Readers in maternity or ambulance settings may also find Maternity Care and Fetal Monitoring Concerns and Paramedic Practice: Assessment and Non-Conveyance Decisions relevant. Follow your local policy and current national guidance; a course does not decide the outcome of any process.
Frequently asked questions
Should risk assessment tools be used in mental health?
Not to predict suicide or decide who gets care. NICE NG225 says risk tools, scales and low, medium or high categories should not be used to predict future suicide or self-harm, or to decide who is treated or discharged. Some services use structured frameworks to make sure key areas are covered, alongside a full psychosocial assessment and formulation.
What is the 72-hour follow-up rule?
In England, the NHS Standard Contract includes follow-up within 72 hours for adults discharged from adult acute mental health inpatient care. It replaced the older seven-day follow-up standard because evidence showed suicide risk is high in the first few days after discharge. It is a minimum, and some people need contact sooner.
What is a risk formulation in mental health?
A risk formulation is a short explanation of why a person might come to harm, in what circumstances, how soon and how seriously, and what makes it more or less likely. It draws on history, current state, triggers and protective factors, and leads directly to a management plan. It replaces relying on scores or labels.
What is the difference between a safety plan and a no-harm contract?
A safety plan is a practical, personalised plan written with the person for what to do when things get worse, including warning signs, coping strategies, people and crisis contacts. A no-harm contract is a promise not to self-harm. No-harm contracts have no evidence of benefit and can stop people seeking help.
Can I tell a patient's family they are at risk of suicide without consent?
Sometimes. Seek consent first. Where it is necessary to protect the person or others from a risk of death or serious harm, GMC guidance and the national consensus statement support sharing relevant information without consent. Share only what is needed, record your reasons and seek senior advice if unsure. You can always listen to families.
What is section 117 aftercare?
Section 117 of the Mental Health Act 1983 gives people who have been detained under certain sections, including section 3, a right to free aftercare services to meet needs arising from their mental disorder and reduce the risk of readmission. Aftercare is planned jointly by the integrated care board and local authority, starting before discharge.
Can an informal patient be stopped from leaving the ward?
Not unless there is a legal power to do so. An informal patient with capacity can leave. If you believe they may meet criteria for detention, holding powers under section 5 of the Mental Health Act may apply, used by the right professional in the right circumstances. Seek senior advice and follow your local policy.
Related courses
Clinical Risk Assessment and Discharge in Mental Health
This course teaches a structured, formulation-based approach to clinical risk in mental health, in line with current NICE guidance that moves away…
Maternity Care and Fetal Monitoring Concerns
This course teaches safe fetal monitoring in labour, including intermittent auscultation, structured CTG review and escalation, using UK guidance and…
Paramedic Practice: Assessment and Non-Conveyance Decisions
This course teaches a structured approach to assessment and safe decision-making when a paramedic considers discharging a patient on scene or…
Sources and further reading
- Self-harm: assessment, management and preventing recurrence (NG225). National Institute for Health and Care Excellence.
- Transition between inpatient mental health settings and community or care home settings (NG53). National Institute for Health and Care Excellence.
- Risk assessment scales, categories and tools should not be used to predict suicide risk. National Confidential Inquiry into Suicide and Safety in Mental Health.
- Information sharing and suicide prevention: consensus statement. Department of Health and Social Care.
- Confidentiality: good practice in handling patient information. General Medical Council.
- Self-harm and suicide in adults (CR229). Royal College of Psychiatrists.
- The Triangle of Care. Carers Trust.
Practitioner Insight is an independent education provider. It is not affiliated with or endorsed by the GMC, MPTS, NMC, HCPC, GPhC or any NHS organisation, and this information is not legal advice. If you have been referred to a regulator, speak to your defence organisation, trade union or legal representative.
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