Analysis of failures contributing to death by suicide: An ONS study

As inquest practitioners, we all too often come across common themes of failures in mental health care that have been found to contribute to the death of a vulnerable individual by suicide. It is frustrating as a practitioner to see the same themes in your own practice – staffing issues, inadequate policies, missing documentation, inadequate training and poor communication, to name but a few.

This has recently become more than just anecdotal evidence amongst lawyers practising in this field as the Office for National Statistics (ONS) have recently published their first report into the analysis of Prevention of Future Death Reports for Suicide. The purpose of this study to provide insight into those working on suicide prevention, rightly acknowledging that each suicide is a tragedy for those impacted by the death.

Prevention of Future Death Reports 

Coroners have a duty to issue a Prevention of Future Deaths (PFD) report to any person or organisation where, in the opinion of the coroner, action should be taken to prevent future deaths.

ONS Analysis Data 

On 29 March 2023, the ONS released the results of their analysis into the Prevention of Future Death Reports for Suicide submitted to coroners from January 2021 to October 2022. This is the first analysis of its kind from the ONS.

A total of 164 PFD reports in cases of suicide across 2021 and 2022 were available for analysis. (To give context, 440 PFD’s were prepared in 2021 across all deaths). Within this, 485 concerns were raised, with an average of three concerns per report.

The NHS were the most frequent recipient of PFD reports (42% of all reports reviewed), followed by government departments.

The most commonly raised concerns which it was felt were contributing towards avoidable deaths were:

• Processes: Inadequate adherence to processes, particularly inadequate documentation and monitoring that may have prevented a death. This was the most common concern. This included processes not being recorded or standard operating procedures not being followed, or in some cases, there were concerns that there were not even any processes in place; and if there had been, deaths may have been prevented. Concerns were raised that processes were not clear or were not followed due to inadequate staffing.
• Policies: Concerns around policies included no or inadequate policies in place and where there were policies, sometimes these were not used in practice. Policies also had knowledge gaps and required review.
• Staffing: Issues highlighted encompassed inadequate volumes of staff or lack of qualified staff to meet demand. Organisational culture was also raised as a concern across a number of reports, including inadequate training of staff in services and problems with recruitment and retention of qualified staff. Training was reported as inadequate or not applied consistently. This included recommendations that had previously been identified from past incidents that had not been implemented in a timely manner, therefore potentially contributing to avoidable future deaths.
• Access: Issues accessing services included delays, inadequate staffing and the assignment of an inappropriate service.
• Assessment and clinical judgement: Concerns were highlighted regarding risk not being correctly assessed or in some cases, no risk assessment being undertaken at all. There were also concerns regarding staffing issues involved in assessment, including risk not being updated when new information came to light or an incorrect diagnosis being given.
• Care Plans: Concerns relating to care plans were also highlighted, which included issues with the care plan process. Firstly, that there were failures in updating and communicating care plans with those involved in the patients’ care, and separately, that care plans were either not in place or were not suitable; such that they were unclear or omitted key details which meant they could not be appropriately followed.
• Communication: This includes inadequate communication between services and inadequate communication with the deceased themselves or with other professionals closest to them. In some cases, families were not engaged in care – this meant not all possible information was obtained. Further reports included concerns with inadequate or incomplete medical notes that lacked necessary updates.

It is hoped that this analysis will shine a light in government on the effect of cuts to mental health at the coal face, whilst also being of use to practitioners during inquest proceedings when asking a coroner to consider preparing a PFD report. Practitioners should also make use of the PFD library on the Courts and Tribunals website to access key themes of previous failings, if there are concerns (as raised above) that previous recommendations have not been adequately implemented.

Find out more about Irwin Mitchell's expertise in supporting people and families affected by suicide and care issues at our dedicated medical negligence section.