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Learning from suicide-related claims: a thematic review of NHS Resolution data

To coincide with World Suicide Prevention Day, NHS Resolution has today published a report setting out recommendations with a view to reducing the risk of suicide-related incidents and improving Trusts' responses.

The report, authored by Dr Alice Oates, NHS Resolution’s Clinical Fellow, seeks to help Trusts improve their suicide prevention work and, in turn, improve patient care and prevent future harm.

Analysis of claims and areas of concern

NHS Resolution’s report is the product of a comprehensive thematic review of suicide-related claims, drawing upon its unique dataset, including compensation claims relating to suicide between 2015 and 2017.  In particular, the study examines factors which contribute to suicide claims, including shared clinical characteristics of those who commit suicide as well as the quality of internal investigations following suicide and the standard of support offered to families, carers and staff.

Whilst the report recognises areas of good practice, a number of significant concerns are identified.  In particular, the study referred to poor support being offered to those with substance misuse problems, inadequate communication with patients and families, and a lack of a range of services to support individuals.  The quality of risk assessments, therapeutic observation and Serious Incident (SI) investigations also required improvement in some Trusts.


The report sets out 9 detailed recommendations for NHS Trusts and other bodies which highlight potential learning for those delivering mental health services. The key recommendations are summarised below:

  1. Where patients present to mental health or acute services with an active diagnosis of substance misuse, consideration should be given to making a referral to specialist substance misuse services.
  2. A systemic and systematic approach to communication is required in order to ensure that important information regarding an individual is shared with appropriate parties. Trusts should also prepare to adapt to new models of care.
  3. Risk assessment should not occur in isolation but as part of a wider needs assessment of individual wellbeing. The report suggests that Trusts should move away from stratifying risk assessments into crude “cut offs” of risk and encourage more descriptive formulations of risk.  Recommendations are also made in respect of risk assessment training.
  4. The head of nursing in every mental health Trust should ensure that staff undergo specific training in therapeutic observation during their induction or when changing wards.  Recommendations are also made in respect of agency staff.
  5. NHS Resolution should continue to support both local and national strategies for learning from deaths in custody including, in particular, through ongoing work to review learning from litigation in cases involving prison healthcare.
  6. A number of key organisations, including the Department of Health and Social Care and Health Education England, should engage in discussions to consider creating a standardised and accredited training programme for all staff conducting SI investigations.
  7. Family members and carers of patients should be actively involved throughout the SI investigation process.
  8. Trust boards should have an awareness of the potential impact of inquests and investigations and written information should be provided to staff at the outset of an investigation following a death.  The report also sets out potential support mechanisms for staff, including identifying staff who have been involved in multiple SI investigations in order to highlight the potential need for additional pastoral support.
  9. NHS Resolution recognises the need to address the inconsistencies of the PFD (report to prevent future deaths) process nationally and recommendations include the provision of training to coroners.


The concept of shared learning as a driver for improving patient safety is familiar to all health service providers and whilst NHS Resolution’s report will be of particular interest to mental health service providers, its recommendations are of significance to the wider NHS in the context of suicide prevention and work following suicide-related incidents.

The full report can be accessed by clicking here.

Should you wish to discuss the above or how the recommendations relate to your organisation, please contact a member of our Healthcare team.

Please note that this briefing is designed to be informative, not advisory and represents our understanding of English law and practice as at the date indicated. We would always recommend that you should seek specific guidance on any particular legal issue.

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