Volume 1, Issue 2 ISSN 2632-363X
Learning from suicide-related claims A thematic review of NHS Resolution Data Dr Alice Oates BMedSci (Hons) MBChB MRCPsych PG Cert (Hons)1
Abstract or Summary This thematic review presents a detailed analysis of clinical negligence claims made after an individual has attempted to take or has taken their life. Claims relating to completed 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. The full report can be found at: https://resolution.nhs.uk/resources/learning-from-suicide-related-claims/
Keywords Suicide, suicide prevention, clinical negligence claim, learning, good practice
Introduction Suicide has a devastating, lifelong impact on the family, carers and staff bereaved when a person takes their life. While compensation claims relating to suicide are a small, highly specific group of incidents that may involve potentially avoidable harm, this may not reflect the entirety of care across the NHS. This review looks at cases both where liability has been admitted – which by definition means that there were errors that should have been prevented – and where liability was denied, as in both instances claims will contain learning that should be shared. This thematic review analyses in-depth the data held by NHS Resolution on compensation claims that relate to suicide between 2015 and 2017. The claims that are reviewed are those where member organisations received funding to provide legal representation at inquest via NHS Resolution’s inquest scheme. In addition, there is a review of non-fatal suicide attempts following which a claim was pursued. The purpose of this review is to identify the clinical and non-clinical issues in care that arose in those claims, share this learning with 1
South London and Maudsley NHS Foundation Trust, London, UK
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the wider system to act as a driver for improvement, and make recommendations to reduce further harm.
Methods NHS Resolution’s claim management system (CMS) was searched for all claims relating to suicide that were accepted for funding under NHS Resolution’s inquest scheme between 2015 and 2017. The CMS holds a wealth of information, which can include the original hospital serious incident (SI) investigation, statements from clinicians, expert reports, and records of inquest, among other documents. An in-depth review of the documents was conducted using thematic analysis methodology.
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.
