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Learning from suicide: a thematic review

NHS Resolution has published its report, “Learning from suicide related claims: A thematic review,” written by Dr Alice Oates. As is noted in the foreword to this 148 page report, “NHS Resolution is in a unique position in that it holds information about every personal injury claim made against NHS trusts in England over the past 23 years. This information, when correctly distilled, can be used to identify national themes about potential problems associated with NHS care. These themes can then be used to focus improvement work to reduce the likelihood of similar problems in the future. The learning generated from reviewing claims could then be used to improve care, improve safety, reduce avoidable harm and decrease future litigation costs.”

The review analysed claims made to the NHS between 2015 and 2017 after an individual has attempted to take their life, (where member organisations received funding to provide legal representation at inquest via NHS Resolution’s inquest scheme) with the aim of:

Identifying the clinical and non-clinical themes in care from both completed suicide and assisted suicide that resulted in a claim for compensation.
Disseminating the shared learning and using this as a driver for change and quality improvement.
Highlighting evidence of good practice that could address areas for improvement, signpost potential solutions and make recommendations for change.

The review forms part of the ambition of the former Secretary of State for Health and Social Care, Jeremy Hunt, to “aim for nothing less than zero inpatient suicides.” The review comes against against the background of 4,575 suicides registered in 2016 in England (continuing a year-on-year decreasing trend) with approximately 25% of people who go on to take their lives having been in contact with mental health services in the year before their death.

101 claims between 2015 and 2017 that were reviewed. Admissions of liability were made in 46% of the claims reviewed.

There were some examples of good practice in relation to a number of trusts that had a proactive approach to engaging families, staff and patients in improvement work. However:

Those with an active diagnosis of substance misuse were referred to specialist services less than 10% of the time.

Risk assessments were often inaccurate, poorly documented and not updated regularly enough. There was little account taken of historical risk.
Observation processes were inconsistent.
Communication with families was poor.
Support offered to families and staff was variable.
There was evidence of poor quality serious incident investigations at a local level:
- The family were involved in only 20% of investigations
- Only 2% of investigations had an external investigator and 32% of incidents were investigated by a single investigator
- The recommendations were unlikely to stop similar events happening in the future

The review makes 9 recommendations:

A referral to specialist substance misuse services should be considered for all individuals presenting to either mental health or acute services with an active diagnosis of substance misuse. If referral is decided against, reasons for this should be documented clearly.
There needs to be a systemic and systematic approach to communication, which ensures that important information regarding an individual is shared with appropriate parties, in order to best support that individual.
Risk assessment should not occur in isolation – it should always occur as part of a wider needs assessment of individual wellbeing. Risk assessment training should enable high quality clinical assessments, which include input from the individual being assessed, the wider multi-disciplinary team and any involved families or carers.
The head of nursing in every mental health trust should ensure that all staff including: (1) mental health nursing staff (including bank staff and student nurses who may be attached to the ward); (2) health care assistants who may be required to complete observations; and (3) medical staff who may ‘prescribe’ observation levels undergo specific training in therapeutic observation when they are inducted into a trust or changing wards. Staff should not be assigned the job of conducting observations on a ward or as an escort until they have been assessed on that ward as being competent in this skill. Agency staff should not be expected to complete observations unless they have completed this training.
NHS Resolution should continue to support both local and national strategies for learning from deaths in custody.
The Department of Health and Social Care should discuss work with the Healthcare Safety Investigation Branch (HSIB), NHS Improvement, Health Education England and others to consider creating a standardised and accredited training programme for all staff conducting SI investigations.
Family members and carers offer invaluable insight into the care their loved ones have received. Commissioners should take responsibility for ensuring that this is included in all SI investigations by not ‘closing’ any SI investigations unless the family or carers have been actively involved throughout the investigation process.
Trust boards should ensure that those involved in arranging inquests for staff have an awareness of the impact inquests and investigations can have on individuals and teams. Every trust should provide written information to staff at the outset of an investigation following a death, including information about the inquest process.
NHS Resolution supports the stated wish of the Chief Coroner to address the inconsistencies of the PFD process nationally. NHS Resolution recommends that this should include training for all coroners around the PFD process.