The impact on nurses when a patient dies by suicide

Keeping patients safe and preventing suicides is a priority for the mental health nursing workforce and, when a patient dies by suicide, family and friends will always be most acutely affected.

“My brain flicked through all the things I’d said to him, and it went from upset, shock, thinking about him and his family, to then thinking – how did this happen?”

Adam Edwards

But research by the Royal College of Psychiatrists suggests that mental health professionals will witness between one and four patient suicides across their career. Each of these deaths can have a significant impact on a nurse.

Mental health nurses and nursing students have told Nursing Times about how proximity to a patient suicide affected the wellbeing and practice of staff involved in caring for that person, and the changes they wish to see to mitigate this.

While working as a community mental health nurse several years ago, Adam Edwards was the care coordinator for a young man with acute mental health challenges, including persecutory delusions that made him believe a relative was trying to kill him.

Mr Edwards recalled dropping off this patient one day at his home, after a disagreement with medics about whether to keep him in hospital. The next day he found out the man had taken his own life.

“This was a young man who I’d worked with loosely for a number of months, and I remember coming into work and everybody was sat around looking distraught,” recalled Mr Edwards, who is now a child and adolescent mental health services (CAMHS) advanced nurse practitioner at Aneurin Bevan University Health Board.

“My manager informed me that this young man, my patient, had completed suicide. I felt absolute shock, I felt numb, I was fearful. I was given the details of what had happened. I’d seen him the day before and dropped him off – it was the last thing we talked about, suicide – making sure he was OK. He had been very unwell, agitated and distressed.

“My brain flicked through all the things I’d said to him, and it went from upset, shock, thinking about him and his family, to then thinking – how did this happen? Was it my fault? Had I missed something? Was there anything in his manner I could have picked up on?”

Adam Edwards

Mr Edwards said these feelings did not abate quickly, and that they led to him feeling hostile with the medical team, with whom he had disagreed about discharging the man from an inpatient facility.

He blamed them at first – something he described as a “traumatic response” to the suicide – but said mediation and intervention from his colleagues helped.

Simon Jones, a senior NHS leader in Wales, a mental health nurse by background and the father of a teenager who took his own life, compared suicide to a stone dropping into a pond.

He said loved ones and family members were hit the hardest, but that clinicians and other professionals involved with the patient were hit by the “ripples” too.

He called for a “rebalance” in the way suicides were handled in the health service and said that, in his opinion, the wellbeing of the nurse should be taken into account as part of post-death formalities.

“Such is the anxiety of [Welsh NHS] boards around regulation, that the focus is all now on that defence of processes, policies and the organisation,” he said.

“While that’s all going on… chances are the nurse who found the person has a shift to finish [and] they’re expected to be back the next day.

“It’s part of working in the healthcare profession, but in mental health there’s a different kind of attachment and all the while you have this fear inside – ‘what if I have another [suicide]? They’ll start questioning my practice’.”

Support structures for nurses in these situations, Mr Jones said, should be reformed.

He described a feeling among nurses that clinical supervision – frequently offered after a patient suicide – was a punishment.

“I think the balance isn’t right… retrospective clinical supervision sessions are supposed to be supportive but, in a lot of cases, they are in the context of remedial action, not support and development,” he said.

Simon Jones

CAMHS nurse Mr Edwards said it would be impossible to fully prepare a nurse for the possibility of someone taking their own life, and stressed that the emphasis in the aftermath of a suicide should always be on the person who has died and their family.

But, he added: “There’s a growing awareness that there’s a need to look after staff. We need a workforce that is robust.”

Mr Edwards referred to research suggesting that trauma, and suicide itself, could be “contagious”. Office for National Statistics figures suggest that nurses are at a higher risk of suicide than the general population.

In recent years, the issue of the wellbeing of health staff, who are often exposed to traumatic experiences at work, has risen up the agenda of the health service.

Mr Edwards said, in Wales, the level of support for nurses had improved in recent years, but that dedicated staff to support health workers impacted by trauma and patient suicides would help.

“We have a trauma framework that recognises there needs to be compassion towards the workforce,” he added.

“I think it’s just taken a while for people to recognise that there is a need to really look after the workforce.”

“Chances are the nurse who found the [patient who died by suicide] has a shift to finish [and] they’re expected to be back the next day”

Simon Jones

In 2023, NHS England published a national toolkit aimed at preventing suicides among the health workforce and the NHS Confederation released a postvention toolkit for when a death in the workforce occurs.

Meanwhile, NHS England deputy director for mental health nursing Dr Emma Wadey recently commissioned a study of mental health nursing students to look at the impact of exposure to suicide while in training.

A suicide can impact on practice, as well as wellbeing, for those in the ripples.

At a Royal Society of Medicine conference in 2023, Dr Steven Voy, a consultant child and adolescent psychiatrist in Scotland, who researches suicide risk among young people, quoted a consultant nurse who responded to a patient suicide.

This nurse said they experienced an “overwhelming” sense of guilt and personal responsibility, as well as difficulty concentrating at work.

Mental health clinicians, Dr Voy said, often became more risk averse after a patient suicide, and kept future patients inside hospital settings for longer. He said this put pressure on services and meant that the correct care decision was not necessarily always made.

He advocated for individualised and tailored support for nurses and other clinicians, alongside bolstering “generalisable” support, such as signposting, occupational health and dedicated pastoral support staff.

Euan Hails

Dr Euan Hails, a CAMHS consultant nurse at Aneurin Bevan University Health Board, surveyed nurses in the area about the impact of patient suicides together with Mr Edwards.

Dr Hails said the survey suggested some postvention measures were ineffective.

One nurse who witnessed a suicide on her ward told the survey she was “too upset to talk” in front of others and that the group therapy she was offered was “no help”. This nurse, Dr Hails said, had to seek out different support herself. Dr Hails advocated for more flexibility in support.

Research by the Royal College of Psychiatrists has found that “many” of the deaths by suicide that mental health professionals experience during their careers took place while the clinicians were in training.

Third-year mental health nursing student Frank Colville was, while working part time as a healthcare assistant during his course, involved in the care of two patients who died by suicide. He said the nursing syllabus – particularly that for mental health pathways – should mention suicide earlier and more often.

He recalled feelings of guilt for being upset after a teenage patient took their own life shortly after being moved from the setting in which he worked. Although not directly responsible for the patient, he had spoken with them not long before they died and was involved in their treatment.

“That feeling came up from some members of staff – that they failed, even though they thought they had done the right thing”

Frank Colville

“I remember hearing someone at [the Royal Society of Medicine conference] say it feels wrong in the tragedy of the family and friends, and [that of] everyone left behind, to focus on the mental health team’s feelings. In a way I felt like that, but even more so in terms of that ripple effect,” he said.

“I was right out of the centre, and it felt wrong to think I was really sad.”

Frank Colville

After the suicide, Mr Colville saw the moral injury among staff who felt they could have done more to help the patient.

“That feeling came up from some members of staff – that they failed, even though they thought they had done the right thing,” he added.

“[Mental health nurses] are very up close and personal in a way some nurses aren’t.”

Self-reflection after a death is inevitable, Mr Colville added, but it can easily become destructive if the nurse is not supported.

He said: “I think self-blame is natural, self-critique, thoughts of ‘what if?’; that’s a natural inclination – especially for people who deeply care. It’s harder to pass the buck and say: ‘Well, I did my job.’ If you deeply care about a patient.

“I don’t think it’s easy to avoid that self-blame and that questioning. But it can [become] unhealthy.”

Now nearing the end of his nurse training, Mr Colville said he felt the preparation for the prospect of a patient suicide could be improved in education, particularly in relation to “how to deal with the emotions”.

He described his experience of patient suicide as “harrowing” and said he was aware of some student nurses who, during their very first placement, had been involved in the care of a patient who took their own life.

As such, Mr Colville said he would like suicide spoken about openly in training “from the get-go”, warning: “I don’t know if it’s still taboo or something, but it shouldn’t be.”