Lesson 1 - Recognising Suicide and Self-Harm Risk
1. Introduction
Suicide and self-harm are among the most serious clinical concerns encountered in mental health practice. People may communicate distress directly, indirectly or through changes in their behaviour. Every practitioner therefore needs to be able to recognise possible warning signs, ask clear questions and respond safely.
Case workers can play an especially important role because they may have regular contact with patients and notice changes that are less apparent during formal clinical reviews. A person might disclose suicidal thoughts during an ordinary conversation, mention that others would be better off without them, or reveal that they have recently harmed themselves. Sometimes the concern arises not from one statement but from a pattern of increasing withdrawal, hopelessness, substance use, missed appointments or deteriorating self-care.
The case worker’s role is not to predict suicide or complete an independent specialist risk assessment. It is to recognise concerns, remain with the person where necessary, gather essential information, record it clearly and escalate promptly to an appropriately qualified clinician.
This lesson focuses on practical recognition and response. It should be read alongside the organisation’s safeguarding, risk management, lone-working and emergency procedures.
If someone is in immediate danger, has seriously injured themselves, has taken an overdose, or cannot be kept safe, emergency assistance should be requested through 999 or the nearest emergency department. Local crisis services should be contacted in accordance with the person’s care plan and organisational policy.
2. Learning Outcomes
By the end of this lesson, learners should be able to:
Explain the difference between self-harm, suicidal thoughts, suicidal intent and a suicide attempt.
Recognise common warning signs, vulnerabilities, precipitating events and protective factors associated with suicide and self-harm risk.
Ask direct, compassionate questions about self-harm and suicide.
Identify situations requiring immediate or urgent escalation.
Describe the case worker’s responsibilities when responding to a disclosure.
Contribute appropriately to safety planning, documentation and communication within the multidisciplinary team.
3. The Lecture
Understanding the Terminology
Clear language matters. Practitioners should avoid making assumptions about what a particular act or statement means.
Self-harm refers to intentional self-injury or self-poisoning, irrespective of the person’s apparent purpose. It can include cutting, burning, hitting, taking an overdose or ingesting a harmful substance. People may self-harm for many reasons, including trying to manage overwhelming emotions, interrupting feelings of numbness, expressing distress or responding to intrusive thoughts. Some people may have suicidal intent, while others may not intend to die.
Suicidal thoughts can range from a general wish not to exist to detailed thoughts about ending one’s life. Thoughts such as “I wish I would not wake up” are sometimes described as passive suicidal thoughts. More active suicidal thinking may involve considering a method, making preparations or intending to act.
Suicidal intent refers to the degree to which a person expects or wants their actions to result in death. Intent can fluctuate rapidly and may be accompanied by ambivalence. A person can simultaneously want their distress to end and remain uncertain about dying.
A suicide attempt is an act of self-harm undertaken with at least some intention of dying. The medical seriousness of the act does not necessarily reveal the seriousness of the person’s intent. An act that causes relatively little physical injury may still have involved a strong wish to die.
Practitioners should not use phrases such as “attention-seeking”, “a cry for attention”, “manipulative” or “not a serious attempt”. Such descriptions can minimise genuine distress and negatively influence how other professionals respond.
Self-Harm and Suicide Are Related but Not Identical
Many people who self-harm do not intend to die. However, a history of self-harm is associated with an increased likelihood of future self-harm and suicide. Every episode should therefore be taken seriously and explored sensitively.
It is unsafe to assume that someone is at low risk simply because they describe their self-harm as a coping strategy. The purpose, frequency, severity and context of self-harm may change over time. A person who has previously self-harmed without suicidal intent may later experience suicidal thoughts or act with mixed or uncertain intent.
Equally, self-harm should not automatically be described as a suicide attempt. The practitioner should ask the person what they hoped or expected would happen.
Helpful questions include:
“What was happening before you harmed yourself?”
“What did you hope the self-harm would do for you at that moment?”
“Did you think you might die?”
“Did any part of you want to die?”
“How do you feel about being alive now?”
“Have your thoughts changed since it happened?”
The person’s account may contain uncertainty or contradictions. This does not necessarily mean that they are being dishonest. Intent can be confused, mixed or difficult to describe.
Risk Is Dynamic
Suicide risk is not a fixed characteristic. It can change in response to events, relationships, mental state, substance use, access to lethal means and the availability of support.
A person who denied suicidal thoughts yesterday may experience a crisis today. Someone who appears calmer may have improved, but calmness can also occur after they have decided on a course of action. Apparent improvement must therefore be considered alongside the wider clinical picture.
Risk should be understood as a changing combination of:
The person’s current thoughts, feelings and behaviour.
Recent events or losses.
Longer-term vulnerabilities.
Access to potential means.
Current mental state and substance use.
Available support and protective factors.
The person’s willingness and ability to seek help.
What has changed from their usual presentation.
A simple label such as “low”, “medium” or “high” cannot capture this complexity. NICE advises that risk scales and global risk categories should not be used to predict future suicide or determine who receives treatment or discharge. Clinical decisions should instead be based on the person’s needs, safety and an individualised understanding of the situation.
Vulnerability Factors
Vulnerability factors are circumstances or experiences that may increase a person’s susceptibility to suicidal thinking or self-harm. They do not allow us to predict what an individual will do.
Examples include:
Previous self-harm or suicide attempts.
Mental health difficulties, particularly when symptoms are severe or worsening.
Hopelessness, shame, guilt or feeling trapped.
Trauma, abuse, neglect or exploitation.
Recent bereavement, particularly bereavement by suicide.
Relationship breakdown or serious interpersonal conflict.
Bullying, discrimination or social exclusion.
Physical illness, chronic pain or disability.
Alcohol or drug misuse.
Impulsivity or difficulty regulating intense emotions.
Social isolation or loneliness.
Financial, housing, educational, employment or legal problems.
Contact with the criminal justice system.
Family history of suicide.
Recent discharge from inpatient psychiatric care.
Difficulties accessing support.
Exposure to suicide-related content or the suicidal behaviour of others.
Access to potentially lethal means.
In children and young people, additional concerns may include family conflict, school exclusion, academic pressure, online bullying, identity-related distress, exploitation, placement instability and breakdowns in care arrangements.
No single factor proves that someone will harm themselves. Equally, the absence of familiar risk factors does not establish safety.
Warning Signs
Warning signs are changes or behaviours suggesting that risk may be increasing now. They often require more immediate attention than background vulnerabilities.
Possible warning signs include:
Talking or writing about wanting to die.
Saying that life is pointless or that others would be better off without them.
Expressing unbearable emotional pain, hopelessness or entrapment.
Looking for methods or gathering medication or other means.
Making preparations, such as writing goodbye messages or giving away possessions.
Saying goodbye in an unusual or final-sounding manner.
A recent episode of self-harm or an interrupted suicide attempt.
Increasing the frequency or severity of self-harm.
Becoming markedly withdrawn or difficult to contact.
Sudden agitation, distress, insomnia or emotional volatility.
Increased alcohol or drug use.
Reckless behaviour or reduced concern for personal safety.
Missing important appointments or disengaging from care.
A sudden deterioration in functioning or self-care.
Unexpected calmness following a period of severe suicidal distress.
Reporting command hallucinations or beliefs that encourage self-harm.
Feeling unable to control suicidal impulses.
Refusing or being unable to engage with available support.
Warning signs should always be considered within context. A missed appointment alone does not establish suicidal risk. A missed appointment following a serious suicide attempt and recent relationship breakdown would carry much greater concern.
Protective Factors
Protective factors are personal, relational or environmental circumstances that may help someone remain safe.
They may include:
A supportive relationship with family, friends or professionals.
Feeling responsible for children, relatives or pets.
Religious, cultural or personal beliefs that discourage suicide.
Future plans, goals or meaningful activities.
Engagement with treatment.
A willingness to disclose worsening thoughts.
Previous use of effective coping strategies.
Restricted access to potentially lethal means.
A collaborative safety plan.
Stable accommodation and practical support.
Hope that circumstances can change.
Reasons for living identified by the person.
Protective factors should be explored without overstating them. Having children, attending appointments or agreeing to a safety plan does not make suicide impossible. Protective factors may weaken when someone becomes severely distressed, intoxicated, psychotic or impulsive.
Rather than writing “Protective factor: family”, ask what this means in practice. Can the person contact their family? Does the family know how distressed they are? Are they available tonight? Is the relationship genuinely supportive?
Asking About Suicide
Many practitioners worry that asking about suicide will introduce the idea or make the person more likely to act. Asking directly does not create suicidal thoughts. A clear question can give the person permission to discuss something they have been afraid or ashamed to mention.
Questions should be calm, direct and non-judgemental. Euphemisms such as “You are not going to do anything silly, are you?” should be avoided. This wording can sound dismissive and encourages denial.
A conversation might begin with:
“You have described feeling overwhelmed and unable to see a way forward. Sometimes people who feel like this have thoughts about harming themselves or ending their life. Has that been happening for you?”
If the person says yes, the practitioner should explore further:
“What thoughts have you been having?”
“How often are they occurring?”
“How strong are they at the moment?”
“Have you thought about how you might end your life?”
“Do you have access to that method or anything else you could use?”
“Have you made any preparations?”
“Have you decided when or where you might do this?”
“Do you think you might act on these thoughts today?”
“What has stopped you from acting so far?”
“Have you harmed yourself or attempted suicide recently?”
“Are you using alcohol or drugs today?”
“Is anyone with you?”
“What would help you stay safe while we arrange further support?”
These questions are not a checklist that produces a numerical risk score. They help the practitioner understand the current situation and communicate it accurately to a senior clinician.
Listening to the Answer
Asking the question is only useful if we are prepared to hear the answer.
The practitioner should:
Remain calm.
Allow the person time to speak.
Acknowledge the seriousness of their distress.
Avoid appearing shocked, angry or disappointed.
Avoid debating whether their problems are “bad enough”.
Avoid immediately offering simplistic reassurance.
Thank them for being honest.
Explain clearly what will happen next.
Helpful responses include:
“I’m glad you told me.”
“It sounds as though things have become extremely difficult.”
“I want to make sure we get the right support around you.”
“I cannot keep this entirely confidential because I am concerned about your safety, but I will explain who I need to involve and why.”
Statements such as “You have so much to live for” or “Think what this would do to your family” may increase guilt and close down the conversation. The immediate goal is not to persuade the person to feel differently. It is to understand the danger, reduce immediate risk and involve appropriate help.
Recognising Immediate Danger
Immediate emergency action may be required when:
A potentially serious overdose or injury has occurred.
The person is attempting suicide or is about to act.
They have a specific plan, immediate intent and access to the proposed means.
They have taken steps to avoid discovery or rescue.
They cannot or will not move away from an immediately dangerous situation.
They are severely intoxicated, psychotic, confused or highly agitated and cannot safely engage.
They have access to a firearm or another highly lethal method.
They cannot be located after communicating imminent suicidal intent.
There is any other reason to believe that life is in immediate danger.
In such circumstances, call 999 and follow organisational emergency procedures. Do not leave the person alone if it is safe and practicable to remain with them. During remote contact, establish their exact location and maintain contact while emergency assistance is arranged where possible.
A case worker should never physically intervene in a manner that places themselves or others at serious risk. Personal safety remains important.
Urgent but Not Immediately Life-Threatening Concerns
Some situations require urgent same-day clinical review even when there is no confirmed immediate suicide attempt. Examples include:
New or increasing suicidal thoughts.
A recent episode of self-harm.
A developing method or plan.
Reduced confidence in being able to remain safe.
Rapidly worsening mental state.
Increasing hopelessness, agitation or substance use.
Loss of a previously important protective factor.
Significant concern expressed by family members or other professionals.
Repeated difficulty contacting someone following a concerning disclosure.
A child or vulnerable adult being left without adequate supervision or support.
The case worker should contact the responsible clinician, duty clinician or designated senior practitioner immediately and remain available until a clear plan has been agreed. Sending an email or leaving a voicemail does not constitute completed escalation when the concern is urgent.
The Importance of Clinical Judgement
A person may deny suicidal thoughts despite significant concern. People may withhold information because of shame, fear of hospital admission, concern about upsetting relatives, previous negative experiences or a genuine improvement in their state.
Denial should be considered alongside:
Recent behaviour.
Information from family or professionals.
Changes from the person’s usual presentation.
Access to means.
Evidence of planning or preparation.
Mental state.
The person’s ability to engage.
The reliability of available information.
The case worker should not accuse the person of being dishonest. They should explain their concern and seek senior advice.
For example:
“You have said that you do not intend to harm yourself. I hear that. I am still concerned because you sent goodbye messages last night and have collected a large quantity of medication. I need to discuss this urgently with the duty clinician so that we can agree the safest next step.”
Responding to Self-Harm
Any physical injury or possible poisoning should receive appropriate medical assessment. It is unsafe to assume that an overdose is medically minor based on the person’s initial appearance or the absence of symptoms. The substance, dose and time may be unclear, and some toxic effects are delayed.
After immediate physical needs have been addressed, the person should be offered compassionate psychosocial assessment by an appropriately skilled professional. The purpose is to understand their needs, the circumstances surrounding the self-harm, ongoing safety concerns and appropriate support.
The response should not be punitive. Support must not depend upon the person promising never to self-harm again. Repeated self-harm should not lead to reduced compassion or a less thorough response.
Safety Planning
A safety plan is a collaborative, practical plan for use when suicidal thoughts or urges to self-harm increase. It is not a contract, a guarantee of safety or a substitute for clinical care.
Depending on the person’s needs and the organisation’s procedures, a safety plan may include:
The person’s individual warning signs.
Internal coping strategies they can try.
People or places that may provide distraction or support.
Trusted individuals they can tell when they feel unsafe.
Professional and emergency contacts.
Steps to reduce access to means.
Arrangements for follow-up.
Reasons for living, hopes or commitments that matter to them.
The plan should be specific. “Contact someone” is less useful than “Telephone my sister, Aisha, on the number saved under ICE Contact”. “Use coping strategies” is less useful than identifying the strategies that have previously helped.
A person should be able to access the plan when distressed. A copy might be kept on their phone and shared, with agreement, with people involved in supporting them.
Safety plans should be reviewed after a crisis, after self-harm, when circumstances change or when the person reports that the plan is no longer helpful.
Reducing Access to Means
Creating time and distance between a suicidal impulse and a potentially lethal method can save lives.
Possible measures include:
Asking a trusted adult to store medication safely.
Supplying medicines in smaller quantities where clinically appropriate.
Removing or securing items identified in a suicide plan.
Avoiding leaving the person alone near a location associated with immediate risk.
Involving parents or carers in securing medicines and other hazards when working with children.
Alerting the prescribing clinician or pharmacy when medication access is a concern.
Any action must be proportionate, lawful and discussed with a senior clinician. Case workers should not search a person or their property unless specifically authorised, trained and legally permitted to do so.
Confidentiality and Information Sharing
Confidentiality is important, but it is not absolute. Information may need to be shared without consent when this is necessary to protect the person or someone else from serious harm.
Where possible, practitioners should:
Explain what information needs to be shared.
Explain who it will be shared with.
Involve the person in how this happens.
Share only relevant information.
Record the reason for the decision.
If the person refuses consent but the practitioner believes that serious harm may occur, the concern must still be escalated. The decision about wider information sharing should be made with an appropriate senior clinician wherever circumstances allow.
Never promise complete secrecy when someone discloses self-harm or suicidal intent.
Children and Young People
When working with a child or young person, practitioners should use clear, age-appropriate questions and avoid assuming that suicidal language is merely dramatic or attention-seeking.
Parents or carers will usually need to be involved in safety planning and supervision. However, the practitioner must consider whether involving a particular adult could place the young person at greater risk, particularly where there are concerns about abuse, exploitation, honour-based abuse or serious family conflict.
Important areas to explore include:
Whether the young person is currently alone.
Access to medication or other means within the home.
Online activity connected with self-harm or suicide.
Bullying, exploitation or safeguarding concerns.
The availability and reliability of adult supervision.
Whether parents or carers understand the seriousness of the concern.
Whether the young person feels safe at home.
The need for urgent medical or specialist mental health assessment.
Safeguarding procedures should be followed whenever abuse, neglect, exploitation or inadequate protection is suspected.
Remote and Telephone Contact
Remote appointments create additional challenges because the practitioner may not know exactly where the person is or who else is present.
At the beginning of a remote contact where risk may be discussed, it can be helpful to confirm:
The person’s current location.
A telephone number in case the connection fails.
Whether anyone else is present.
An emergency contact, where appropriate.
If immediate risk emerges:
Remain calm and keep the person engaged.
Confirm their exact location.
Contact the duty or senior clinician urgently.
Arrange emergency assistance where indicated.
Do not rely on the person to make another call if they are unable or unwilling to do so.
Record the actions taken and the outcome.
Continue attempting contact if the connection is lost, while following the emergency plan.
Documentation
Documentation should be factual, timely and sufficiently detailed to explain what was known, what was decided and what happened next.
Record:
The person’s words when these are clinically significant.
Current suicidal or self-harm thoughts.
Any method, access, planning, preparation or intent discussed.
Recent self-harm or suicide attempts.
Relevant changes in mental state or circumstances.
Substance use or intoxication.
Protective factors and available support.
Information received from other people.
Advice sought and from whom.
The agreed response and safety arrangements.
Who was contacted and at what time.
Whether emergency services were involved.
Follow-up arrangements.
Any difficulties contacting the person or services.
The rationale for information sharing.
Avoid vague entries such as “risk discussed”, “contracted for safety” or “no concerns”. A clearer record might state:
“Sarah described thoughts of taking an overdose after an argument with her partner. She denied having collected medication and stated that all medicines were currently held by her mother. She did not believe she would act on the thoughts tonight but was unsure how she would cope if the argument continued. Her mother was present and agreed to remain with her. The duty clinician was contacted at 16:20 and arranged an urgent assessment for 18:00. Sarah and her mother were advised to call 999 if she became unable to remain safe.”
Handover and Closed-Loop Escalation
Escalation is complete only when the concern has been received, understood and accepted by someone able to act.
A useful verbal handover should include:
Who the person is and where they are.
What has happened.
What they have said about self-harm or suicide.
Whether there is a method, access, plan, preparation or intent.
Relevant mental state and substance use.
Whether they are alone.
What support is available.
What has already been done.
What you need the receiving clinician to decide.
If the usual clinician is unavailable, follow the next step in the escalation pathway. Do not assume that an unread message will produce a timely response.
Common Mistakes
Relying on a Risk Score
Risk tools may support information gathering, but they cannot reliably predict suicide. A score must never replace conversation, formulation, professional judgement or senior review.
Seeking a Promise
Asking someone to promise that they will not harm themselves provides false reassurance. A person may agree because they want to end the conversation, avoid hospital or please the practitioner. Collaborative safety planning is more useful.
Assuming Denial Means Safety
A denial of suicidal thoughts is one important piece of information, not the whole assessment.
Assuming Self-Harm Is “Only Coping”
Self-harm may serve a coping function and still be medically dangerous or associated with suicide risk.
Overreacting Without Listening
Immediate action may be necessary, but the person should still be heard and involved as far as possible. Automatic responses can discourage future disclosure.
Trying to Manage the Situation Alone
Case workers should seek senior clinical support early. Escalation is a sign of safe practice, not professional failure.
Delaying Documentation
Important details are easily forgotten during a busy shift. Record the discussion and actions as soon as practicable.
4. Clinical Perspective
Clinical Pearls
Ask about suicide plainly. “Are you thinking about ending your life?” is safer and clearer than “You are not thinking of doing anything silly, are you?”
Pay particular attention to change. A significant departure from the person’s usual behaviour may be more informative than any isolated symptom.
Explore access as well as ideas. Thoughts about a method become more concerning when the method is immediately available.
Ask what has kept the person alive so far, but do not treat the answer as a guarantee.
Take collateral concerns seriously. Family members may notice preparations, withdrawal or behaviour that has not been disclosed during the appointment.
A calm presentation does not always mean reduced risk. Consider why the person appears calmer and what has changed.
Repeated self-harm should lead to curiosity, consistency and compassion, not frustration or reduced care.
Practical Tips for Everyday Practice
When someone discloses suicidal thoughts, slow the conversation down. Clarify the immediate situation before moving into broader problem-solving.
If the contact is remote, establish the person’s location early. This avoids losing vital time if emergency assistance later becomes necessary.
Tell the person what you are doing. For example: “I am going to contact the duty clinician now. I would like you to remain on the line while I do that.”
Use the person’s own language in the record where it conveys seriousness. A statement such as “My children would be better off without me” communicates more than writing “low mood reported”.
Check that the next person has received the handover. Closed-loop communication is essential.
After a difficult incident, use supervision or debriefing. Practitioners can experience fear, guilt, sadness or self-doubt after supporting someone who is suicidal.
Common Pitfalls and Misconceptions
It is a misconception that asking about suicide plants the idea in someone’s mind. Direct questioning can make disclosure easier.
It is a misconception that people who talk about suicide will not act. Any suicidal communication should be taken seriously.
It is a misconception that all self-harm is a suicide attempt. Intent must be explored rather than assumed.
It is a misconception that protective factors eliminate risk. Their strength and reliability can change.
It is a misconception that a safety plan transfers responsibility to the patient. Practitioners and services retain responsibility for appropriate assessment, escalation and care.
It is a misconception that “no plan” means “no risk”. A person may act impulsively, conceal a plan or have ready access to lethal means.
Advice for Newly Qualified Practitioners
You are not expected to resolve a suicidal crisis alone. Your most important responsibilities are to notice, ask, listen and escalate.
Do not allow fear of saying the wrong thing to prevent you from asking clear questions. A compassionate, direct question is usually safer than avoiding the subject.
Stay within your competence. Do not independently decide that someone is safe to leave, reduce observation, end contact or decline urgent assessment when there are unresolved concerns.
Know your local pathway before a crisis occurs. You should know how to contact the duty clinician, crisis team, safeguarding lead and emergency services.
Situations Requiring Escalation to a Senior Clinician
Escalate immediately if:
Suicide or self-harm thoughts are disclosed.
Recent self-harm or a suicide attempt is reported.
A method, plan, preparation, intent or access to means is identified.
There is a significant change in presentation or engagement.
The person says they cannot keep themselves safe.
A family member or professional raises credible concerns.
The person is intoxicated, psychotic, highly agitated or confused.
There are concerns about inadequate supervision or safeguarding.
You are uncertain how serious the situation is.
You feel uncomfortable ending the contact.
Uncertainty is itself a valid reason to seek advice.
5. Summary
Self-harm and suicidal behaviour are related but are not interchangeable. Practitioners should explore the person’s intentions and circumstances rather than making assumptions.
Suicide risk is dynamic. It should be understood through the person’s current thoughts, actions, mental state, circumstances, access to means, support and recent changes.
Directly asking about suicide does not create suicidal thoughts. Questions should be clear, compassionate and non-judgemental.
Risk scales and simple labels cannot predict suicide and must not replace individualised assessment and clinical judgement.
Case workers are responsible for recognising concerns, gathering essential information, maintaining immediate safety where possible, escalating promptly and documenting clearly. They should not manage suicidal risk independently.
Immediate danger requires emergency action. Urgent concerns require same-day communication with an appropriately qualified clinician.
Safety planning should be collaborative, personalised and practical. It is not a promise or guarantee that the person will remain safe.
Every disclosure of self-harm or suicide should be met with seriousness, compassion and respect.
6. Further Reading
NICE Guideline NG225: Self-harm—assessment, management and preventing recurrence
NICE Guideline NG105: Preventing suicide in community and custodial settings
Stanley, B. and Brown, G. K. (2012). Safety Planning Intervention: A brief intervention to mitigate suicide risk. Cognitive and Behavioral Practice, 19(2), 256–264.
National Confidential Inquiry into Suicide and Safety in Mental Health. Annual reports and clinical guidance.
World Health Organization. Preventing suicide: a resource for health workers and wider services.
7. Knowledge Check
Question 1
A patient says, “Sometimes I wish I could go to sleep and never wake up.” What is the most appropriate response?
A. Reassure them that they probably do not mean it
B. Change the subject to avoid increasing their distress
C. Ask directly whether they have thoughts of ending their life
D. Ask them to promise that they will not harm themselves
Correct answer: C
Explanation:
C is correct. The statement may indicate passive suicidal thinking and requires direct, compassionate exploration. Asking about suicide does not introduce the idea and may help the person disclose their experience.
A is incorrect because reassurance without assessment can minimise distress and miss important information.
B is incorrect because avoiding the subject prevents proper understanding and may communicate that suicide cannot be discussed.
D is incorrect because a promise does not establish safety and may provide false reassurance. Collaborative assessment and safety planning are required.
Question 2
Which statement best describes self-harm?
A. Any intentional self-injury or self-poisoning, irrespective of apparent purpose
B. Behaviour that always indicates an intention to die
C. Behaviour that is only clinically important when medical treatment is required
D. Behaviour primarily intended to gain attention
Correct answer: A
Explanation:
A is correct. Self-harm includes intentional self-injury and self-poisoning regardless of the person’s stated purpose.
B is incorrect because many people self-harm without intending to die, although suicidal intent must always be explored.
C is incorrect because medically minor self-harm can still indicate severe distress or increased future risk.
D is incorrect because this is a stigmatising assumption. Behaviour communicating a need for help still reflects genuine need and should be approached compassionately.
Question 3
A patient has suicidal thoughts but says their children are a reason for living. What is the best interpretation?
A. Their children guarantee that they will remain safe
B. The presence of any protective factor means urgent assessment is unnecessary
C. This is potentially helpful information but must be considered alongside the complete clinical picture
D. The patient is unlikely to be experiencing genuine suicidal thoughts
Correct answer: C
Explanation:
C is correct. Children may be an important protective factor, but the strength of that protection can change during acute distress.
A is incorrect because no protective factor guarantees safety.
B is incorrect because urgent assessment may still be required depending on intent, planning, access to means and other circumstances.
D is incorrect because suicidal thoughts commonly coexist with meaningful relationships and reasons for living.
Question 4
A patient tells a case worker during a video appointment that they intend to take an overdose immediately after the call. They have tablets beside them. What should the case worker do first?
A. Arrange a routine review for the following week
B. End the call and send an email to the clinician
C. Keep the patient engaged, confirm their location and arrange immediate emergency assistance
D. Ask the patient to dispose of the medication and promise to remain safe
Correct answer: C
Explanation:
C is correct. The patient has stated immediate intent and access to means. The case worker should maintain contact where possible, confirm the location, alert the appropriate senior clinician and arrange emergency help.
A is incorrect because the danger is immediate.
B is incorrect because an email may not be read promptly, and ending the call could leave the person unsupported.
D is incorrect because asking the person to dispose of medication may form part of an emergency response only if safe and guided appropriately, but a promise is not enough and must not delay emergency intervention.
Question 5
Which statement about suicide risk assessment tools is most accurate?
A. A low score reliably predicts that suicide will not occur
B. A high score should automatically result in hospital admission
C. Scores should determine which patients receive treatment
D. Tools must not replace individualised assessment, formulation and clinical judgement
Correct answer: D
Explanation:
D is correct. NICE advises against using risk scales to predict future suicide or determine treatment and discharge decisions.
A is incorrect because no risk score can reliably establish that a person is safe.
B is incorrect because admission decisions require an individualised assessment of needs, risks and possible benefits or harms.
C is incorrect because access to treatment should not be determined by a predictive score.
Question 6
Which of the following is the clearest example of a warning sign suggesting possible current escalation?
A. A family history of depression
B. Giving away valued possessions and sending goodbye messages
C. Having experienced bullying several years ago
D. Living with a chronic physical health condition
Correct answer: B
Explanation:
B is correct. Giving away possessions and sending goodbye messages may indicate preparation for suicide and requires urgent exploration.
A, C and D are incorrect as the best answer because they may represent background vulnerability factors, but they do not in themselves show that risk is escalating now.
Question 7
A young person discloses suicidal thoughts and asks the case worker not to tell anyone. What is the most appropriate response?
A. Promise confidentiality to preserve trust
B. Explain that relevant information must be shared to help keep them safe
C. Agree not to tell anyone unless an attempt occurs
D. Tell all family members immediately without considering the circumstances
Correct answer: B
Explanation:
B is correct. The practitioner should explain the limits of confidentiality, involve the young person where possible and share relevant information with those able to protect them.
A is incorrect because complete confidentiality must not be promised when there is a risk of serious harm.
C is incorrect because waiting for an attempt would be unsafe.
D is incorrect because information sharing should be necessary, proportionate and attentive to safeguarding concerns. Involving a particular relative may not always be safe.
Question 8
What is the principal purpose of a safety plan?
A. To guarantee that the person will not self-harm
B. To transfer responsibility for safety entirely to the patient
C. To provide personalised steps and contacts for managing an escalation in distress
D. To replace professional assessment and follow-up
Correct answer: C
Explanation:
C is correct. A safety plan identifies warning signs, coping strategies, support contacts, professional help and measures to reduce access to means.
A is incorrect because no plan can guarantee safety.
B is incorrect because practitioners and services retain responsibility for appropriate care.
D is incorrect because safety planning complements rather than replaces assessment, treatment and follow-up.
Question 9
A case worker sends an urgent concern by email to a clinician but receives no response. What should the case worker do?
A. Assume that the clinician will eventually read it
B. Record that the email was sent and take no further action
C. Follow the escalation pathway until the concern is received and accepted by someone able to act
D. Ask the patient to contact the clinician themselves
Correct answer: C
Explanation:
C is correct. Urgent escalation requires closed-loop communication. The case worker must establish that an appropriate person has received and understood the concern.
A is incorrect because an unread email does not provide a safe response.
B is incorrect because documentation does not replace action.
D is incorrect because responsibility should not be passed to a distressed patient when urgent professional action is required.
Question 10
A patient denies current suicidal thoughts, but their partner reports that they have collected medication, written goodbye letters and searched online for suicide methods. What is the most appropriate response?
A. Accept the denial and close the assessment
B. Explain the concerns to the patient and seek urgent senior clinical advice
C. Ignore the partner because only the patient’s account is relevant
D. Wait to see whether the patient harms themselves
Correct answer: B
Explanation:
B is correct. The patient’s denial should be considered alongside credible evidence of planning and preparation. The concerns require urgent escalation and fuller assessment.
A is incorrect because denial alone does not establish safety.
C is incorrect because collateral information can be essential, particularly where the patient may be minimising or concealing risk.
D is incorrect because waiting for harm to occur would be unsafe and contrary to the practitioner’s duty of care.
