NHS Resolution’s new report identifies themes associated with suicide-related claims made against mental health trusts in England. 

NHS Resolution has published a new thematic review examining suicide-related compensation claims made against mental health trusts in England. It identifies recurring themes associated with claims, with communication challenges emerging as a cross-cutting issue affecting patient care, family involvement and organisational learning.

“Through this review, we have sought to understand what compensation claims can tell us about the challenges healthcare organisations face when caring for people at risk of suicide,” said lead author Louisa Bradley, safety and learning lead (North) at NHS Resolution. 

“While many of the contributory factors identified in our 2018 review remain evident, particularly around communication, family involvement and risk assessment, this updated analysis provides a deeper understanding of the organisational, leadership and system conditions that can undermine safe and effective care,” she continued. 

It analyses 960 suicide-related claims received by the Clinical Negligence Scheme for Trusts (CNST) between 2018 and 2025, alongside a detailed qualitative review of a representative sample of cases.

The report finds that family engagement was absent in more than three-quarters (76%) of cases reviewed. Issues with risk assessment implementation were identified in 86% of cases, and delays in assessment were identified in 32% of claims analysed, often linked to unclear referral pathways, poorly defined roles, capacity pressures and lack of local guidance. Poor communication between staff was also identified in 68% of claims, including issues related to handovers, record-keeping and escalation processes.

“A collaborative approach involving patients, their families and significant others, and clinicians is essential for compassionate care and safety, enabling real learning and improvement when things have gone wrong,” said Dorit Braun, chief executive of non-profit Making Families Count, which aims to bridge the gap between healthcare services and traumatically bereaved or seriously harmed families.