Learning from suicide-related compensation claims: an updated thematic review (NHS Resolution, 8 October 2026)

Summary

This NHS Resolution thematic review explores learning from suicide-related compensation claims made against mental health trusts in England. The report highlights opportunities to strengthen communication, support effective family involvement, improve risk assessment processes and address organisational factors that can influence patient safety and care.

Content

Key findings

Patient, family and significant others

• Family, carers and significant others were often not involved in risk assessment or care planning. The absence of family engagement, or the family voice not being heard meant that key risks were missed or overlooked.

• The application of ‘Consent to share information’ was poorly understood by clinicians.

• 84% of patients who went on to take their life had a previous psychiatric history. 38% had a history of poor compliance with treatment or engaging with mental health teams.

• 68% of patients had a history of self-harm with 59% having also made a previous attempt at taking their life. 76% of patients had previously stated they had thoughts of self-harm or suicide.

Safety culture

• 32% of claims reflected delays in assessment, which were attributable to a range of factors such as poorly defined roles and responsibilities, lack of local guidance or adherence to referral processes, and demands for the services outweighing capacity.

• 86% of claims indicated issues with the implementation of risk assessment. This largely concerned the use and completion of risk assessment tools.

• Where the physical environment in clinical settings was mentioned, risk factors such as poor layout of wards and visibility from the nurse’s station were cited in 27% of these claims.

• Clinical observations were not always aligned to patient risk, and documentation of rationale for the level of observation was often inadequate or absent.

• Suboptimal record keeping was cited in 86% of the claims that mentioned risk assessment implementation issues. These included absent records, partially completed records, or records that had not been reviewed or updated.

Workforce

• Poor communication between staff was observed in 68% of claims. A lack of verbal or written notes was a factor in 51% of claims.

• There was a perception among families that services were complicated and difficult to understand, and as such they were unsure who was responsible for care, particularly when more than one service was involved. It was also noted in 14% of claims that it was difficult to contact the correct professional.

• Concerns around clinical leadership were evident with 49% of claims citing unclear responsibilities and 11% including inappropriate delegation. Team factors included conflicting team goals, poor delegation, absence of feedback and lack of respect for colleagues.

• Challenges in joint working were evident with a lack of or inadequate joint working policy and awareness of how other services operate services.

• 24% of claims described a high unit workload or caseload, and 19% mentioned staffing shortages or skill mix.