The focus of health resource allocation in the NHS has traditionally been on the physical health sector and mental health has generally come a poor second in terms of priority. This is changing and there is now a strong government and NHS commitment to improve mental health services. Suicide and suicide prevention are one facet of this work. Suicide is a major national and global problem and urgent action is needed to reduce its incidence.
Global approach
The World Health Organization (WHO) (2019) has stated 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 who attempted it. Suicide is the second leading cause of death among 15–29-year-olds globally and occurs throughout the lifespan (WHO, 2019).
A WHO report (2018) has been designed to help governments across the world establish suicide prevention policies and make the issue a global health priority. The report contains examples of success stories in suicide prevention from each WHO region, including the NHS in England (WHO, 2018).
The report conveys a useful global perspective on suicide:
‘Suicide continues to be a serious problem in high-income countries. However, 79% of all suicides occur in low- and middle-income countries which bear the larger part of the global suicide burden … Although in high-income countries three times as many men die by suicide as women, the male-to-female ratio for suicide is more even in low- and middle-income countries, at 1.6 men to each woman.’
Suicide prevention in England
WHO (2018) recognises efforts in suicide prevention in the NHS 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 … 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.’
A suicide prevention: cross-government plan has been published (Department of Health and Social Care (DHSC), 2019a) which sets out the action being taken up to 2020 to carry out the suicide prevention strategy for England. There is also the recently published fourth progress report Preventing Suicide in England on the cross-government outcomes strategy to save lives (DHSC, 2019b). The report states that, in England, 13 people take their own life every day and that we cannot allow this shocking reality to continue (DHSC, 2019b). Suicide prevention is now a key NHS policy priority in the NHS in England.
Patient safety failings
Although there is a strong commitment to improving mental health care and suicide prevention at the top levels of the Government, and the NHS, problems remain. Significant patient safety failures exist—some involving what should be fairly simple matters such as patient/health worker communication. Patient safety failures that have been identified in suicide prevention often mirror those found in physical care and have resulted in some legal compensation claims.
Litigation and suicide prevention
NHS Resolution has produced a thematic review of its data covering suicide-related legal claims (Oates, 2018). It provides an 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. Prescribed medication was the most common feature in self-poisoning. Hanging was more common among males, and self-poisoning more common among females.
The 101 claims analysed were clinically varied. Main themes identified included:
Theme 1: substance misuse
There were 55 claims (54%) where the individual was recorded as having a history of substance misuse. Less than 10% of those diagnosed with active substance misuse at the time of death were engaged with a specialist substance misuse service. The report recommends:
‘Clinicians should consider a referral to specialist substance misuse services for all individuals presenting to either mental health or acute services with an active diagnosis of substance misuse. If referral is decided against, reasons for this should be documented clearly.’
Theme 2: communication
There were 41 serious incident (SI) reports that gave poor communication as a contributory factor (46%) of those available for review. This led to 70 recommendations being made for communication improvements. Several areas of communication breakdown were identified (Oates, 2018: 50). These included communication breakdowns with:
In relation to nurse handover, 10 recommendations were made, as well as 4 relating to the quality of verbal handover. Written communication in the form of documentation attracted 74 recommendations. These included (Oates, 2018: 52):
The report recommends:
‘There needs to be a systemic and systematic approach to communication, which ensures that important information regarding an individual is shared with appropriate parties, in order to best support that individual …’
This recommendation applies equally to physical acute care and recognises an essential failing in patient safety and care quality generally. A root cause of litigation, complaints and adverse health events is ‘failures in the communication process’. If we improve how we communicate with patients and other health professionals then there will be fewer adverse events, complaints and litigation.
Theme 3: risk assessment
Risk assessments were considered inadequate in most cases reviewed (78%). The report states that most were deemed inadequate either because they had not been updated following new risk information coming to light, or had failed to consider anything other than the most basic features of risk:
‘Three SI reports identified that risk assessments had not been updated in a timely manner to reflect current risks due to staff shortages.’
Recommendations to improve risk assessment included staff training, the use of risk-assessment tools and completing risk assessments at all care transfers (Oates, 2018: 59).
The report recommended:
‘Risk assessment should not occur in isolation—it should always occur as part of a wider needs assessment of individual wellbeing. Risk assessment training should enable high quality clinical assessments, which include input from the individual being assessed, the wider multidisciplinary team and any involved families or carers.’
Theme 4: observations
Of the 29 patients admitted to inpatient mental health units, almost half were subject to inadequate observation processes (Oates, 2018: 63). In five (17%) claims the observation was not carried out within the prescribed time interval. Patients were often on an inappropriate level of observation. Recommendations included that all relevant staff in every mental health trust should undergo specific training in therapeutic observation.
The quality of trusts' serious investigation reports
The report identifies several central themes relating to the quality of SI reports that are very concerning and represent major patient safety failings (Oates, 2018: 91):
Significant errors in SI reports included incorrect gender recorded, incorrectly spelt names and evidence that some sections had been copied and pasted from other SI reports.
The report points to difficulties with effective RCA in that investigators may fall into an ‘unhealthy quest’ to find a single root cause for SIs.
Family and carer involvement
Also discussed in the report is support for and the involvement of families and carers. The report states that it is estimated that there are around 1.5 million family members, close friends and other informal carers who provide unpaid support for people with serious mental health problems (Oates, 2018: 104). These family members and others can often offer the best insights into an individual and their problems and care needs. In 18 SI reports family carers had not been involved adequately and there were 21 recommendations to improve involvement.
Conclusion
Somebody, somewhere in the world dies by suicide every 40 seconds (WHO, 2019). This state of affairs cannot continue and the WHO initiatives in suicide prevention are to be welcomed. The NHS in England has made good progress in this care area. However, it still has patient safety problems Oates (2018).Significant care failings have occurred which have led to legal claims for compensation. These largely workforce problems must be resolutely resolved otherwise the increased Government investment in mental health care is not going to translate into better care quality outcomes. Oates' report (2018) gives practical and helpful advice which will help to promote systemic and sustainable improvements and change in mental health care and the prevention of suicide.