Lessons learned in the fight against suicide

A new report has highlighted some important areas for attention that could help to reduce suicides. In response, NHS Resolution has made nine recommendations for NHS Trusts and national bodies to highlight potential lessons for those delivering mental health services.

Dr Alice Oates, the report’s author, found a number of areas for improvement. These include greater support for those with substance misuse problems, improved quality of risk assessments and wider access to a range of mental health services. Effective communication with patients and families is also highlighted as being pivotal in providing adequate support.

The study, conducted by NHS Resolution looked at 101 deaths by suicide between 2010 and 2017 and analysed 25 claims made against the NHS relating to non-fatal suicide attempts.

It examined some of the factors that contribute to suicide claims and the quality of investigations following such incidents.

Key findings

The results are split into two parts. Part one of the report analyses the problems identified from the clinical details of each claim and offers recurring clinical themes and areas for improvement. The five areas where there were common issues in clinical care are:

  • Substance abuse: a third of individuals in the cohort had an active diagnosis of substance misuse at the time of death. Only 10% of these were referred to specialist services.
  • Poor communication: particularly intra-agency communication was considered a contributing factor, often due to lack of staff time.
  • Risk assessments: were found to be inaccurate, poorly documented and irregularly updated in 78% of the cases reviewed in the study.
  • Observation: processes were inconsistent.
  • Prison healthcare: coroners were more than twice as likely to issue a report to prevent future deaths (PFDs) during the inquest of a suicide in prison.

Part two of the report analyses the quality of the serious incident (SI) reports and identifies four main areas of concern:

  • Lack of family involvement and staff support through the investigation and inquest process.
  • The quality of root cause analysis was generally poor and did not focus on systemic issues.
  • Due to the poor SI report quality, the recommendations were unlikely to reduce the incidence of future harm.
  • Inconsistent PFDs issued by coroners, coupled with poor mechanisms to ensure that changes in response to the PFDs had been made or addressed.


The report makes nine recommendations at both a national and local level:

1. A referral to specialist substance misuse services should be considered for all individuals with an active diagnosis of substance misuse. If a referral is refused, reasons should be clearly documented.

  • National implementation plan: the new Life Chances Fund offers up to £30million for outcomes-based interventions to tackle alcoholism and drug addiction.
  • Local implementation plan: all local areas to have multi-agency suicide prevention plans in place by 2017 in accordance with the national Suicide Prevention Strategy.

2. There needs to be a systemic and systematic approach to communication to ensure important information regarding an individual is shared with all appropriate parties.

  • National implementation plan: sustainability and transformation partnerships to set out plans for integrating mental health into new models of care. Partnerships are now evolving into ‘accountable’ care systems.
  • Local implementation plan: trusts should evaluate their current systems of communication both internally (at medical shift handovers) and externally (e.g. discharge letters being sent to a GP). Digital systems are also being put in place to aid communication.

3. Risk assessment should not occur in isolation. Risk assessment training should include input from the individual being assessed, the wider multi-disciplinary team and any involved families or cares.

  • National implementation plan: NICE guidelines to advise against using ‘tick box’ risk assessments.
  • Local implementation plan: by 2020 Trusts should include risk assessment as part of their mandatory training requirements, including refreshing this training every three years.

4. All relevant staff (including agency staff) should undergo specific training in therapeutic observation when they are inducted into a trust or changing wards.

  • National implementation plan: in spring 2019 the Royal College of Psychiatrists College Centre for Quality Improvement are due to publish observation processes standards for staff.
  • Local implementation plan: all mental health trusts should identify a psychiatrist and a nurse who have a responsibility for championing the observation policy in their hospital.

5. NHS Resolution should continue to support strategies for learning from deaths in custody.

  • National implementation plan: external bodies, such as Her Majesty’s Inspectorate of Prisons and the Care Quality Commission (CQC) are to work together and support relevant prison safety programmes.

6. The Department of Health and Social Care should discuss work with specified NHS bodies to create a standardised and accredited training programme for all staff conducting SI investigations.

  • National implementation plan: relevant parties to implement recommendation by 2020/21.

7. Commissioners should ensure family insight into the care provided is included in all SI investigations.

  • National implementation plan: SI framework and NHS England guidance to be published this year, the ‘Duty of Candour’ and charities to provide emotional and legal support for families.
  • Local implementation plan: each investigation to have a lead investigator.

8. Trust boards should ensure that staff involved with inquests are made aware of the impact inquests and investigations can have on individuals and teams. Every trust should provide written information to staff at the outset of an investigation following a death, including information about the inquest process.

  • National implementation plan: Chief Coroner to develop an appraisal scheme for Coroners.
  • Local implementation plan: local trusts to meet on an annual basis to share their PFDs and responses to them.

9. NHS Resolution supports the stated wish of the Chief Coroner to address the inconsistencies of the PFD process nationally.

  • National implementation plan: Training for all coroners around the PFD process. Monitoring of the PFDs given, both in terms of number and content, should lie with both the CQC and other external bodies, with this information being shared to drive improvement in health care systems.


Whilst the report highlights those issues well known to those working in mental health services, we are pleased these recommendations have been endorsed by important stakeholders who we hope will take up the recommendations to ensure vital improvements are made. NHS Resolution and their panel solicitors are in a unique position to identify trends and encourage learning from suicide-related events, in order to support the cause for improvements and better integration across the NHS and mental health services.

We are pleased to endorse everything Dr Oates has highlighted in her report. We are also reassured that the Department of Health and Social Care was a key stakeholder in this report and has identified mental health as an area which requires significant investment. In particular, an improved PFD process is crucial in providing powerful leverage for change in patient care and improved expertise in the inquest process.

Read other items in Healthcare Brief - December 2018

Download NHS Resolution press statement (PDF, 236 KB)

This work reflects our renewed commitment … to learn from inquests, share learning from harm and work in partnership with others to drive forward the patient safety agenda, in this instance with a focus on mental health.

Helen Vernon, Chief Executive of NHS Resolution

This third edition of our Medical Law Guide reviews the main issues that case handlers will encounter, consent and capacity, to inquests and judicial review in healthcare. We examine their practical implications, drawing from our experiences of dealing with similar situations.

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