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NHS Resolution’s review of suicide-related claims makes recommendations to help prevent future harm

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.

If you have any questions or comments in relation to this article please contact

Rob Wilson
Partner, Clyde & Co LLP 

Clyde & Co LLP and Premium Medical Protection Ltd accept no responsibility for loss occasioned to any person acting or refraining from acting as a result of material contained in this summary. No part of this summary may be used, reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, reading or otherwise without the prior permission of Clyde & Co LLP. © Clyde & Co LLP 2020

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