Learning from Suicides: NHS Resolution looks at the way forward

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Learning from Suicides: NHS Resolution looks at the way forward

Published 25 September 2018

Against the backdrop of learning from patient deaths remaining high on the national agenda across the healthcare sector, NHS Resolution's recently published report by Dr Alice Oates - 'Learning from suicide-related claims - A thematic review of NHS Resolution data' - takes a fresh look at the patterns/recurring issues arising in suicide cases, both in relation to the care itself and how these cases are investigated and learned from.

The report includes nine recommendations for improvement plus many practical suggestions about how best to effect change, including sharing numerous examples of excellent practice already happening in some organisations.

We look at the headline points to take from the report.


Although mental health cases made up just 3% of all clinical negligence claims in 2017/18 and only 2% of their total value, the human cost of patient suicides is - as the report emphasises - immeasurable.

In order to try and identify learning points as a driver for improvement, NHS Resolution has undertaken a thematic review of 101 suicide-related deaths which were dealt with under its inquests scheme over the period 2015 - 2017, with the review being led by a psychiatrist working with NHS Resolution as a clinical fellow, Dr Alice Oates.

What themes did the review pick up?

Care-related themes

The problems in care picked up by the review will be all-too-familiar to those involved in patient suicide investigations/inquests, with the recurring nature of these underlining the importance of finding ways to bring about effective change.

The five main care-related themes identified by NHS Resolution's review are:

  • Substance misuse - In over half the cases, the patient had a history of substance misuse. However, referral to specialist substance misuse services had occurred in only 10% of those, plus the report highlights that referral pathways for patients with both mental health and substance misuse problems are often complex and disjointed.
  • Communication - Almost half the serious incident (SI) investigations reviewed cited poor communication as a contributory factor - especially issues relating to communication with family/carers and between inpatient services and others involved in the care. Verbal exchanges not being documented emerged as another frequent problem.
  • Risk assessment - Another recurring theme was inadequate risk assessment, including risk assessments being out-of-date or overlooking recent/emerging information. The report underlines the need for more holistic approaches to risk assessment which avoid unhelpful 'high'/'low' classifications of risk.
  • Observations - Issues with patient observations also arose frequently, including patients not being on an appropriate level of observations, delays in doing observations and staff not being aware of why they were being done. The report also highlighted the impact of staff shortages on effective observations.
  • Prison healthcare - Frequently occurring problems in the 9% of cases which related to prison deaths were connected with ACCT (Assessment, Care in Custody & Teamwork) procedures not being properly followed (e.g. appropriately qualified staff not being involved), plus issues with communication of healthcare information on transfer or release.

Investigation-related themes

SI investigations

Another central focus of NHS Resolution's review is the quality of Trust SI investigations where patients have taken their own lives, with the main message being that - if investigations do not get to the bottom of why things went wrong, change will not happen.

Looking at the 89 SI investigations relating to the cases reviewed, the headline findings were:

  • Not asking 'why?' - SI investigations tended to focus on what happened rather than why - e.g. finding that a particular policy/procedure was not followed but not asking why not. Overall, attempts at root cause analysis lacked depth and detail and often did not look at underlying systems, meaning that the recommendations made were unlikely to prevent recurrence.
  • Limited/no family involvement - Families are still not being properly involved in the investigation process in many cases, with some families not having been informed of the investigation at all and others not having been informed of the outcome. This is in spite of the statutory Duty of Candour.
  • Poor staff support - About half of SI reports reviewed showed no evidence of staff having been offered support during/after the investigation.
  • Learning not being shared - SI reports rarely had a clearly defined plan as to how or where learning might be fed back.


The report also makes a number of findings about the coroner's inquests which follow patient suicides, with all the cases included in this review having been subject to an inquest.

As well as emphasising the need to ensure that staff are adequately supported in relation to the inquest process, the report focuses in particular on Prevention of Future Deaths (PFD) reports issued by coroners.

PFDs were issued in over a third of the cases reviewed and the themes arising from these mirrored those picked up by the review overall - especially communication, risk assessments and observations. Specific points for improvement highlighted by the review related to the lack of consistency across the country in terms of when PFDs are issued and - in particular - the current lack of any clear system for sharing learning from PFDs.

Key learning points?

Based on these key themes, the report makes nine specific recommendations for change. See the report itself for full details, but these include:

  • By 2020, Trusts to develop a risk assessment training strategy and to have begun mandatory staff training in risk assessment, plus refresher training every 3 years;
  • By the end of 2019, all mental health Trusts to ensure that all staff (including agency) have been trained in therapeutic patient observations and are not assigned to carry out observations unless they have had that training;
  • By 2020/21, a standardised, accredited training programme to be developed for all staff undertaking SI investigations (responsibility for this to involve discussions between various bodies, including the Department of Health & Social Care and Health Education England);
  • From now, commissioners to ensure that SI investigations are not 'closed' unless assured that families/carers have been actively involved in the investigation process;
  • Learning from PFDs to be shared nationally (e.g. via CQC) to drive improvement.

The report also gives many examples of good practice in all these areas from Trusts across the country which other organisations will find a helpful source of ideas when looking at how they might improve - e.g. examples of multi-agency working models, ways of supporting families/staff and risk assessment training programmes which are proving successful.

As well as setting out the various national initiatives already underway or in the pipeline to help improve how we learn from patient deaths, the report also makes many practical suggestions for changes which Trusts might consider introducing at local level, such as:

  • Adopting a staff support system such as a Critical Incident Support Service or allocating a Staff Support Officer to those going through SI investigations;
  • Nominating a psychiatrist and a nurse to take on responsibility for championing the observation policy in their hospital;
  • Encouraging clinical staff/trainees to get involved in quality improvement work relating to communication issues;
  • Regularly reviewing SI data to identify trends and establishing local networks to share good practice emerging from SIs;
  • Consider meeting with other local Trusts annually to share PFD reports and responses.

These are just a few examples - see the report itself for more suggestions.

What next?

Trusts now need to consider how they measure up against the key findings and recommendations for change as set out in NHS Resolution's thematic review. Evidence of Trusts having taken this on board is certainly likely to be something the CQC will be looking out for as part of its inspections, especially in relation to the 'safe' and 'well-led' domains.

Meanwhile, we can expect more change to come as the national push towards improving learning from serious incidents/patient deaths continues apace, including the new SI Framework expected this year and progress towards statutory 'safe space' investigations as proposed in the draft Health Service Safety Investigations Bill, which we will no doubt hear more about in the months to come.

How can we help?

Our national teams of healthcare regulatory and clinical risk lawyers have extensive experience of supporting and advising healthcare providers on a wide range of matters relating to patient deaths/suicides. This expertise means we are well placed to help with issues identified in NHS Resolution's suicide themes review, including:

  • Regular clinical risk forums to help facilitate shared learning;
  • Assistance with thematic review of your organisation's claims, inquests and PFDs to help identify recurring patterns/areas of focus for learning;
  • Clinical governance scrutiny to assess the effectiveness of incident investigations, organisational learning and board leadership/culture on learning;
  • Reviewing draft serious incident investigation reports/action plans;
  • Supporting providers and individuals throughout the inquest process, including advice on Prevention of Future Deaths Report risks;
  • Representation and support in relation to further investigations which may be linked to incidents/patient deaths, including CQC/HSE or police investigations.


Sean Doherty

Sean Doherty


+44 (0)113 251 4807

Corinne Slingo

Corinne Slingo


+44 (0)117 918 2152

Peter Downey

Peter Downey


+44 (0)113 251 4758

Amy Fishburn

Amy Fishburn


+44 (0)113 251 4855

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