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learning from suicide related claims: a thematic review of NHS Resolution data

10 September 2018

Mental health is often categorised as a ‘Cinderella’ service and there is no doubt that there is a growing awareness of the need to improve care and services in this area. Against this background, NHS Resolution’s report ‘Learning from suicide related claims: a thematic review of NHS Resolution data’ published on 10 September 2018 to coincide with World Suicide Prevention Day, is a vital piece of work, highlighting areas for NHS Trusts to focus improvement work in this area and reduce the incidence of harm in the future.

The report, authored by Alice Oates, Clinical Fellow at NHS Resolution, presents a detailed analysis of claims relating to suicide between 2015 and 2017 and identifies themes in care associated with these cases.

Five main clinical themes are identified, namely, support available for those with active substance misuse; problems with risk assessments; observation processes; communication issues; and the care provided to those in prison.

The report also identifies shortcomings in the serious incident investigation process, including lack of family involvement and support for staff through the investigation and inquest process; issues in the quality of root cause analysis undertaken with recommendations unlikely to reduce the incidence of future harm; and inconsistencies with prevention of future death reports issued by coroners.

The report supplements other work ongoing in this area including The Five Year Forward for Mental Health, the Learning from Deaths programme and the forthcoming review of the Serious Incident Framework by NHS Improvement, due later this year. It makes nine recommendations for NHS bodies and national bodies to support improvement work in this area and achieve better integration across the NHS and mental health services. Crucially, in this respect, NHS Resolution has secured the support of the relevant organisations to ensure change happens.

This further demonstrates the commitment of NHS Resolution, as set out in its Strategy to 2022, to share the learning from incidents of harm. By sharing the learning from this unique dataset of claims and highlighting areas of good practice from around the country, it represents a valuable opportunity to reduce the risk of suicide related incidents.

We are delighted that Dr Alice Oates will be presenting the key findings and recommendations from her report at our Mental Health Safety and Learning forum in our Nottingham office on Thursday 20 September 2018.

The forum will also provide healthcare organisations with an opportunity to share improvement work in this area and we are delighted that two local Trusts have kindly agreed to come and share work being done to improve the quality of serious incident investigations and support staff following an incident. We will also discuss the wider Learning from Deaths programme, including the latest National Quality Board (NQB) Guidance for working with bereaved families and carers and the circumstances in which a Coroner is under a duty to issue a Prevention of Future Deaths report.

Registration will be from 9:30 with a 12.30pm finish for lunch and networking. Places are limited so please do contact Warren Gorman (e: warren.gorman@brownejacobson.com; t: +44 (0)330 045 2180) if you and/or any other colleagues would like to attend as soon as possible.

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