Synopsis
Assess suicidal thinking and self-harm through a compassionate psychosocial assessment, formulate person-specific scenarios and changing drivers, and translate evidence, strengths and uncertainty into immediate safety actions without relying on predictive scores.
- Ask directly about thoughts of death, self-harm, suicide, intent, method, timing, preparation, access to means, interruption and what has prevented action so far.
- Establish the function and context of any self-harm, including relief, communication, punishment, dissociation, compulsion or suicidal intent, without assuming one purpose from the method.
- Build a chronology of previous acts, lethality, intent, rescue, treatment and periods of recovery; recent change and trajectory often matter more than a static factor list.
- Assess mood, psychosis, agitation, substance use, sleep, pain, physical illness, trauma, relationships, housing, finance, legal stress, access to care and safeguarding.
- Formulate plausible scenarios: what harm may occur, under which triggers, with which means, in what timeframe, and which warning signs indicate escalation.
- Identify protective factors and strengths, then test whether they are available and effective during the anticipated crisis rather than adding them as reassuring points.
- Use collateral information and records with consent where possible; receive urgent safety information even when confidentiality prevents disclosing clinical details in return.
- Agree a collaborative safety plan that includes warning signs, internal coping, safe people and places, professional contacts and practical restriction of lethal means.
- Document the formulation, actions, capacity, information sharing, follow-up owner and uncertainty; reassess after sobriety, treatment, new information and transitions.
Key red flags
A specific plan, rehearsal, final arrangements, concealed preparation, available lethal means or stated inability to remain safe markedly increases immediate concern even when the person appears calm.
Recent discharge, major loss, escalating pain, agitation, insomnia, intoxication, shame, command hallucinations or abrupt withdrawal from support can create rapid change in the risk pathway.
A medically minor act may carry high suicidal intent, whereas severe injury may arise without intent to die; treatment need and psychosocial meaning must be assessed separately.
Children, dependants, work or religious belief are not automatic protection and may also contribute burden, guilt or entrapment.
Do not use a risk scale, global low-medium-high category or absence of a known risk factor to decide discharge, deny care or predict an individual suicide.
Investigation priorities
Understand the self-harm or suicidal crisis, needs, mental state, strengths, context and preferred help.
Management branches
Self-harm has occurred or current suicidal action may be near.
- Stabilise physical injury or poisoning, reduce immediate access to means and arrange observation matched to the actual environment and behaviour.
- Ask directly about intent, method, timing, preparation and ability to collaborate with safety while obtaining urgent collateral facts when needed.
- Arrange the least restrictive setting that can deliver necessary care, documenting capacity, legal basis, information sharing and the receiving clinician.