To coincide with World Suicide Prevention Day on 10 September 2018, NHS Resolution's report Learning from suicide-related claims: a thematic review of NHS Resolution data, examines some of the factors that contribute to suicide claims and the quality of investigations following these tragic incidents.
The report examined in detail 101 deaths occurring between 2010 and 2017. It identifies five clinical areas where there were common issues:
- substance misuse;
- communication;
- risk assessment;
- observations; and
- prison healthcare.
The second part analyses the quality of the Serious Incident Reports carried out by trusts and identifies a lack of focus on systemic issues, a lack of family involvement and staff support, and consequently recommendations unlikely to reduce the incidence of future harm.
The report makes nine key recommendations to reduce the risk of suicide-related incidents and improve the response of trusts. In particular, NHS Resolution is calling for improvements and better integration across the NHS and mental health services to ensure at risk patients are given more support and care.
The recommendations, which are summarised on pages 12 to 15 of the report and have been agreed with key external bodies, highlight potential learning for those delivering mental health services in England and draws on the unique dataset held by NHS Resolution to explore best practice.
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