Introduction In an ageing population, very old men appear most vulnerable to suicide. Most suicide research in late life is quantitative and focuses on determining the risk factors for suicidal behaviour. There is a close relationship between self-harm in older people and suicide; with shared risk factors and greater intent to die and lethality of self-harm in older people. Few studies have explored the experience or meaning of self-harm in older people, the experiences of care and outcomes. This study seeks to understand the outcomes for a cognitively, culturally and linguistically diverse cohort of older people who have harmed themselves, their needs, and perceptions of clinical care. We hypothesise that participants who have not had their needs met following the self-harm will remain distressed, with ongoing thoughts of or actual self-harm, and poorer engagement with clinical services. Methods A cohort of 27 people aged 80 or more and their 29 nominated carers who were interviewed after an episode of self-harm a year earlier, were followed-up. Outcomes including recurrence of self-harm, hospitalisation, contact with mental health services, place of residence, and death were recorded. In addition to information obtained by interview, the medical records of patients were screened for outcomes. Individual qualitative interviews utilised narrative inquiry to facilitate participants’ discussion of their reflections upon the self-harm, clinical care and outcomes. Audio recordings were transcribed and N-VIVO used to perform the thematic analysis. Results Eighteen people aged over 80 who had self-harmed and 25 of their carers were available at follow-up. Six of the patients and one carer died of natural causes during the follow-up period. There were no deaths by suicide. Four participants declined to participate and one could not be contacted. In the follow-up period four participants (4/18 = 22%) had repeated self-harm and 16/27 (60%) were living in residential care. Three of the four patients who repeated self-harm were living in a facility, which for two patients was the main contributing factor to repeat self-harm. By contrast, not moving into residential care after the initial self-harm was a key reason underlying repeat self-harm for another patient. Repeat self-harm in the fourth patient related to symptoms of psychotic depression. Themes from the patient interviews were grouped under three headings; reflections on the self-harm (subthemes: denial and avoidance; secrecy; the persistent wish to die); perceptions of alienation from the clinicians (mistrust; ignored and invalidated) and the perceived outcomes of self-harm which were largely negative (persistent suffering and hopelessness; rejection; being a burden; miserable in residential care), but not exclusively (the problem was fixed; eliciting care). Carer themes included reflections on the self-harm (subthemes: denial and avoidance; secrecy; the persistent wish to die); perceptions of alienation from the clinicians (therapeutic nihilism; ignored and invalidated; craving communication; risk management) but also a divergent theme of holistic integrated care; and reflections on perceived outcomes (carer burden; untreated depression and suffering; resigned acceptance; better understanding of the patient). Reactions to residential care were complex and predominantly negative - subthemes included distress at initial adjustment to residential care; grief and guilt at residential care; defeated and waiting to die; desperate to leave; and poor quality care. A divergent subtheme regarding residential care was they are cared for now. Conclusions There was considerable synergism between patient and carer themes, suggesting triangulation of data generation. Specifically, reflections on self-harm were characterised by denial, avoidance, secrecy, and often a persistent wish to die. Such maladaptive responses suggest a role for interventions which enhance insight and promote openness. The considerable reported carer burden identified at baseline and still present a year later was independently identified and appreciated by patients; a key target for ongoing clinical care. Self-harm would ideally be met with a clinical response of better engagement of patients and carers, not alienation and invalidation as was reported. Education for clinical staff should anticipate and actively address such perceptions. Some older people moved into residential care as a consequence of their self-harm. A striking aspect of the perception of outcomes for both patients and carers was the distress associated with living in residential care. Although nursing homes may be seen as a solution to provide a safe environment or ensure routine care, in reality patients and carers experience considerable difficulty adjusting to placement, and associated responses of defeat and misery. Clinicians need to better understand the complex emotional responses to residential care for patients and carers. Anticipating and proactively addressing these responses could better support patients and carers in this situation. Older people and their carers may be affected by the sequelae of self-harm long after the event. The responsiveness of clinical care may wane over time, leaving patients and carers feeling isolated in their distress. For those who enter residential care after self-harm, particular interventions should be developed to facilitate, support and reduce associated negative emotional responses in both patients and carers. This research was funded by Not applicable.