The report recommends:

1.The suicide rate in the general population and in the main demographic sub-groups should be monitored closely as evidence of the effectiveness of the Protect Life strategy.
2.The causes of the higher rate of suicide in Northern Ireland in comparison to England and Wales should be investigated.
3.The forthcoming mental health strategy for Northern Ireland should highlight the importance of risk management and include specific measures to tackle risk of suicide and serious violence.
4.Policy-makers and services should develop youth mental health services spanning the age range up to 25 years, with the skills and capacity to address substance misuse and self-harm.
5.Services for self-harm, substance misuse and mental illness should jointly review how they collaborate in the care of young people, particularly in deprived areas.
6.Reducing alcohol misuse and dependence should be seen as a key step towards reducing the risk of suicide and homicide, requiring a broad public health approach including health education and alcohol pricing.
7.Mental health services should ensure that they have full availability of services for alcohol and drug misuse, including dual diagnosis services.
8.In-patient services should adapt or strengthen protocols for preventing and responding to absconding.
9.In-patient services should abandon the use of intermittent observation.
10.Services should ensure that comprehensive care planning takes place prior to hospital discharge as a key component of the management of risk.
11.Patients discharged from hospital should be followed up within seven days.
12.Services should introduce an assertive outreach function into community mental health services, through staff training, reduced case loads, and new team structures.
13.Mental health services should review their risk management processes to ensure that they are based on comprehensive assessment rather than risk factor checklists, and backed up by appropriate skills training and access to experienced colleagues.
14.Professional and policy leaders should ensure that, when serious incidents occur under mental health care, they strike an appropriate balance between identifying blame and recognising the complexities of clinical risk management, both in public statements and in how the incidents are investigated.
15.Initiatives to combat the stigma of mental illness should emphasise the low risk to the general public from mentally ill patients living in the community.
16.Courts and mental health services should review the sentencing of mentally ill people with a view to establishing alternatives to imprisonment.