NHS Resolution Report on Learning from Suicide-Related Claims

The review, released this month, analyses NHS Resolution data in respect of litigation claims which have been brought following suicide attempts. Both examples of good practice and areas for improvement are identified, including recommendations being made with a view to reducing future harm.

Suicide is the leading cause of death in young adults (aged between 20 and 34 years of age) in the UK. Whilst suicide rates are decreasing in England, in excess of 4,500 people took their lives in 2016.

Where a cause of death is unknown, violent, occurs in custody or is unnatural it will be referred to the coroner for investigation, which may result in an Inquest. The purpose of an Inquest will be to establish cause of death, but it is not to identify civil/criminal liability or apportion blame.

The NHS Resolution report, whilst making clear mental health care in England is very safe, also recognises the need to highlight common failings in order to improve the safety of services for patients. It does so by assessing the data of 101 compensation claims, brought between 2015 and 2017 in respect of individuals who had taken their own lives. Admissions of liability were made in 46% of these claims.

The review also considers a number of cases relating to non-fatal suicide attempts and the impact these have, not in only in respect of costs to the NHS, but also on those close to the injured party, to include both family and staff responsible for their care.

As a result of the data analysis and review’s findings, a number of key recommendations are made:

• where an individual with an active diagnosis of substance abuse presents to acute or mental health services, referral to specialist substance misuse services should be considered. In the event of non-referral, the reasons behind the decision should be clearly documented
• communication between parties needs to follow a systematic approach to ensure the presenting individual is well supported. This could include NHS Trusts taking new approaches to facilitating effective communication across services
• risk-assessment training should be carried out frequently and such assessments should not occur in isolation, but as part of a wider approach to include input from the presenting individual, multi-disciplinary teams and those such as family members and carers
• all mental health nursing staff should undergo training in therapeutic observation and only once they are assessed as competent in this area, should they be assigned observation roles
• both local and national strategies for learning from deaths in custody should be continued to be supported by NHS Resolution
• consideration should be given to creating a standardised, accredited training programme for all staff involved in carrying out Serious Incident (“SI”) investigations to ensure consistency in how the investigations are carried out
• family and carers should be actively involved throughout investigation processes and SI investigations should not be closed off until this has been done
• trusts should ensure staff are appropriately supported through Inquests, to include written information about the Inquest process, updates on SI investigations and regular follow-up both throughout, and after, investigation and inquest processes
• training should be given to Coroners nationally to address inconsistencies in the process behind reports to prevent future deaths.

The importance of learning from mistakes and identifying areas for improvement is clear from the above. It is hoped that the findings of the report and its recommendations will be given due consideration and implemented where appropriate.

With such action, hopefully further tragedies can be avoided, family and staff involved can be appropriately supported and the burden on the NHS in respect of the associated, often significant costs of litigation, can be reduced.