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Suicide Prevention and Patient Safety

Suicide prevention needs to be taken more seriously globally by governments, health systems as an urgent public health concern.

WHO (World Health Organisation) states that close to 800,000 people die due to suicide every year, which translates to one person dying every 40 seconds. For each adult who died by suicide there may have been more than 20 others attempting suicide. Suicide is the second leading cause of death among 15 to 29-year-olds globally, and occurs throughout the lifespan.

WHO published a report in January that is designed to act as a useful and inspiring resource for governments across the world to help them in establishing suicide prevention policies and in making the issue a global health priority. WHO recognizes National Health Service (NHS) efforts in suicide prevention in England as a global success model:

“The suicide rate in England is currently close to the lowest on record and is low by European standards. After a rise following the global recession, it is now back on a downward trend. The male suicide rate has fallen for four consecutive years. The suicide rate in people using mental health services is also falling and the number of suicides by inpatients has reduced by half.”

Patient Safety Failings

Whilst there is a strong NHS and government commitment to change and improvement in mental health care and suicide prevention,endemic patient safety problems remain in this care area. Significant patient safety failures exist such as patient, health carer communication breakdowns. Patient safety care failures that have been identified in suicide prevention can often be seen to mirror those found in physical care and have resulted in some cases of legal compensation claims being made.

NHS Resolution

NHS Resolution is the organization that manages NHS litigation on behalf of hospitals and other health care organizations and it has produced a thematic review of its data from covering suicide related legal claims. The report is very useful as it provides a detailed analysis of claims relating to completed and attempted suicide. Common problems with care are identified and service delivery improvement recommendations are made. There were 101 compensation claims selected for review between 2015 and 2017. The top three causes of death were hanging, jumping (multiple injuries), and self-poisoning.

The 101 claims analyzed were clinically varied but some main themes could be identified: Substance misuse, Communication, Risk assessment, Observations, Prison healthcare.

In terms of the communication theme, there were 41 Serious Incident reports that gave poor communication as a contributory factor (46 percent) of those available for review. This led to 70 recommendations being made for communication improvements. Several areas of communication breakdown were identified including family or carers, general practitioners, third parties, handover processes, documentation to support verbal communication.

The quality of serious investigation reports

The report identifies several central themes relating to the quality of SI reports which are very concerning and represent major patient safety failings:

  • Low quality investigations which were generally focused on RCA (root cause analysis) which did not lead to an understanding of ‘why’ the incident happened.
  • Recommendations were made which were unlikely to prevent recurrence. There was a lack of focus on systemic change.
  • Little reference to sharing of learning across organisations and wider to promote improvement.
  • A lack of family involvement and support.

The report covers several other areas relating to suicide prevention and gives very practical and helpful advice which will promote systemic and sustainable improvements and changes in mental health care and prevention of suicide. Clear recommendations are made in the thorough report.


John Tingle

John Tingle

John Tingle is a regular contributor to the Bill of Health blog. I am a Lecturer in Law, Birmingham Law School, University of Birmingham, UK; and a Visiting Professor of Law, Loyola University Chicago, School of Law. I was a Visiting Scholar at Harvard Law School in November 2018 and formerly Associate Professor at Nottingham Law School, Nottingham Trent University in the UK. I have a fortnightly magazine column in the British Journal of Nursing where I focus on patient safety and the legal aspects of nursing and medicine. I have published over 500 articles and a number of leading texts in patient safety and nursing law. My current research interests are in global patient safety, policy and practice, particularly in African health care systems. My most recent publication is: "Global Patient-Safety Law Policy and Practice," edited by John Tingle, Clayton O'Neill, and Morgan Shimwell, Routledge 2018.

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