Learning from suicide-related claims; NHS Resolution A thematic review of NHS Resolution data (September 2018)

Summary

Healthcare provision in the NHS is very safe but on rare occasions when things go wrong, it is important that those involved are properly informed and supported, compensation is paid fairly, unnecessary costs are contained and that we learn in order to improve.

Negligence also comes at significant personal and financial cost for the NHS, not all of which is visible.

NHS Resolution has conducted a thematic review into learning from suicide related claims with in the NHS.

Content

This thematic review presents a detailed analysis of claims made after an individual has attempted to take their life.Claims relating to completed suicide and attempted suicide are reviewed, regardless of whether the claim resulted in financial compensation. It identifies common problems with care and provides recommendations for improvement to support service delivery.

Results

The results are split into two parts. The first part analyses the problems identified from the clinical details of each claim and the second part analyses the quality of the serious incident reports.

Part one identifies recurring clinical themes and areas for improvement. Five areas where there were common issues in clinical care are discussed in depth:

• substance misuse
• communication, particularly failures in intra-agency working
• risk assessment
• observations
• prison healthcare.

Part two identifies four main areas of concern, where:

• There was a lack of family involvement and staff support through the investigation and inquest process.
• The quality of root cause analysis undertaken as part of the Serious Incident (SI) investigation was generally poor and did not focus on systemic issues.
• Due to the poor SI report quality, the recommendations arising from SI investigations were unlikely to reduce the incidence of future harm.
• Reports to prevent future deaths (PFDs) were issued to trusts by the coroner with little consistency and there were poor mechanisms to ensure that changes in response to the PFDs had been made or addressed the issues highlighted.