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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.
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:
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:
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.
Based on these key themes, the report makes nine specific recommendations for change. See the report itself for full details, but these include:
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:
These are just a few examples - see the report itself for more suggestions.
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.
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:
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