Prevention of Future Death Reports for Suicide submitted to coroners in England and Wales: January 2021 to October 2022

• Coroners have a duty to issue a Prevention of Future Death (PFD) report to any person or organisation where, in the opinion of the coroner, action should be taken to prevent future deaths; the analysis of Prevention of Future Death reports submitted by coroners is the first of its kind in the Office for National Statistics (ONS).

• A total of 164 PFD reports were available for analysis (96 (59%) from 2021 and 68 (41%) from 2022; for context, around 5,000 suicides are registered in England and Wales each year.

• Reports contain a "Coroner's concerns" section, and are sent to organisations where action could be taken; in this analysis, a total of 485 concerns (across 164 reports) were raised, with an average of three concerns per report.

• The most commonly raised primary concern related to the processes followed, particularly inadequate documentation and monitoring (such as a lack of clinical note taking) that may have prevented a death; 54% of the PFD reports analysed included at least one concern relating to processes.

• Staffing of services was also mentioned across health and public services and communal establishments; this included inadequate volumes of staff or lack of qualified staff to meet demand, inadequate training of staff in services and problems with recruitment and retention of qualified staff.

• Results also found issues in accessing services that may have resulted in their death (32% of reports), as well as issues with communication (34% of reports).

• The NHS (including health boards, trusts, clinical commissioning groups, primary care services, health and care partnerships and ambulance services) were the most frequent recipient of PFD reports (42% of all reports).

Statistician's comment

"This is our first analysis of Prevention of Future Death reports. It highlights the range of concerns raised by coroners following a suicide, including processes not being followed, and inadequate documentation and monitoring, that may have prevented a death. We also saw concerns relating to a lack of communication between services who were looking after individuals before they took their own life, and reports were also raised that training was inadequate for staff involved in the care of at-risk individuals. Every death by suicide is a tragedy and has a devastating impact on family, friends and communities and we hope today's analysis will provide valuable insight for those concerned with suicide prevention."

James Tucker, Head of Analysis in the Data and Analysis for Social Care and Health Division, Office for National Statistics.

Follow James Tucker on Twitter @ONSJames.

Coroners can issue a Prevention of Future Death (PFD) report to individuals or organisations where they feel action should be taken to prevent future deaths. The role of the coroner is to identify areas of concern, rather than identify specific solutions. PFD reports are sent to a wide range of organisations, including the NHS, government departments, professional bodies, and public services. The report is also sent to the deceased's family and is made available on the Courts and Tribunals Judiciary website.

This article presents qualitative analysis conducted on PFD reports submitted between January 2021 and October 2022, categorised as suicides. The aim was to identify themes from concerns raised in the PFD reports that may inform future research or policies for suicide prevention, including a new Suicide Prevention Strategy.

A total of 164 PFD reports were available (96 (59%) from 2021 and 68 (41%) from 2022). For context, around 5,000 suicides are registered in England and Wales each year, so PFD reports are only issued for a small number of cases. A total of 485 concerns were identified, with an average of three concerns per report (range: 1 to 12). Of the 164 reports, around 62% of the deceased were male, 37% were female, and the gender of the deceased was unknown for a small proportion of the reports. The average age at date of death was 36.4 years (range: 14 years to 81 years).

The NHS (including health boards, trusts, clinical commissioning groups, primary care services, health and care partnerships and ambulance services), was the most frequent recipient organisation of Prevention of Future Death (PFD) reports (see Figure 1: 69 PFD reports, 42% of all reports) across most primary themes. This was followed by government departments. Further information on addressees can be found in our accompanying dataset.

We coded coroners' concerns into 12 primary themes:

• processes

• access to services

• assessment and clinical judgement

• policy

• communication

• products

• training

• culture

• improvements not being implemented

• care plan

• room, cell, or ward physical environment

• general risk factor

Within these primary themes, 83 sub-themes were identified, that are defined in our accompanying dataset.

Processes

A total of 142 concerns from 89 PFD reports (54% of all reports) related to "processes", with "inadequate monitoring and documenting of processes" (32 mentions) being the most common sub-theme (see Table 1). This sub-theme related to processes not being recorded or standard operating procedures not being followed, thus potentially contributing to a death. For concerns under the sub-theme "no processes in place" (29 mentions), evidence demonstrated that there were no processes or standard operating procedures, and if they had been in place a death may have been prevented.

Access to services

There were 84 concerns relating to "Access to services" in 52 PFD reports (32% of all reports). Sub-themes included "delays in accessing services" (21 mentions), "inadequate staffing" (17 mentions) and "services not being appropriate" (16 mentions) (see Table 2). Analysis identified that delays were because of increased demand for services leading to lengthy wait times, and in some instances, services were not appropriate for patients requiring specialist care. There was also inadequate staffing with too little staff, or not enough qualified staff.

Assessment and clinical judgement

There were 78 concerns relating to "assessment and clinical judgement" in 55 PFD reports (34% of all reports). Sub-themes included "risk not correctly assessed" (22 mentions) and "no risk assessment undertaken" (14 mentions) (see Table 3). Risk was not correctly assessed where patient history was not considered or communication between services was poor, preventing the patient from receiving appropriate treatment. Evidence also indicated that services failed to undertake a risk assessment where it was required to maintain patient safety.

Policy

There were 77 concerns under "policy" in 45 PFD reports (27% of all reports). Sub-themes included "no policy in place (processes)" (16 mentions), and "inadequate policy" (12 mentions) (see Table 4). "No policy in place" referred to both organisational policy and national policy, and covered areas including discharge, safeguarding and medication. "Inadequate policy" indicated that a policy was present, but it did not mitigate risk and potentially contributed to a death.

Communication

There were 55 PFD reports including 68 concerns relating to "communication" (34% of all reports). Sub-themes included "inadequate communication between services" (35 mentions) (see Table 5), meaning information involving the patient was not communicated which may have contributed to failures in care. In addition, "family not involved in care" (12 mentions) highlighted that the family of patients were not engaged, meaning not all possible information was obtained and used to inform services.

Products

A total of 41 concerns were categorised under the primary theme of "products" from 25 PFD reports (15% of all reports). Sub-themes included "access to medical products (e.g. medication)" (12 mentions) (see Table 6), that referred to the deceased having access to medication, equipment or other medical products that may have contributed to a death.

Training

There were 50 concerns from 30 PFD reports related to "training" (18% of all reports). Sub-themes included "current training not adequate" (38 mentions) (see Table 7), that referred to staff training not being mandatory, training not sufficiently covering a topic, training not being applied in practice, or training not being updated following incidents. This was the most frequent sub-theme across all primary themes.

Culture

A total of 28 concerns raised from 25 PFD reports related to "culture" within an organisation (15% of all reports). The most frequent sub-theme was "inadequate staffing and/or way of working" (17 mentions) (see Table 8). This refers to issues with recruitment or the retention of suitably qualified staff, as well as the code of conduct among staff in services that are in demand with limited resources. These issues were related to failures of care that may have contributed to death, such as signing-off procedures that had not been completed.

Improvements not being implemented

There were 25 concerns relating to "improvements not being implemented" from 20 PFD reports (12% of all reports). Sub-themes included "information, guidance, and training for staff" (11 mentions) and "access or CCTV at high-risk areas" within the community (8 mentions) (see Table 9). For both sub-themes, recommendations that have been identified from previous incidents have not been implemented in a timely manner, therefore potentially contributing to future deaths.

Care plan

A total of 29 concerns from 25 PFD reports related to "care plan" (15% of all reports). Sub-themes included "issues with the care plan process" (11 mentions) and "care plan not suitable" (10 mentions) (see Table 10). "Issues with the care plan process" related to failures in updating and communicating care plans with those involved in the patients' care. For concerns under "care plans not suitable", care plans were unclear or omitted details relating to a patient's circumstances and were therefore unable to be followed appropriately.

Many concerns highlighted in our analysis were categorised under the primary theme of "Processes", where issues in processes or standard operating procedures (including processes being unclear, delayed or not in place) may have contributed to the death. The main sub-themes were "current training not adequate", "inadequate communication between services" and "inadequate monitoring and documenting of processes". These themes highlight concerns across current care and service provision where review and improvement are required to prevent future deaths occurring.

Care plan

A care plan is a document that outlines health and social care requirements of a person, and how those needs will be met through treatment, services, and support. The care plan outlines who will provide the care, the timescale of care and how support will be delivered.

Coroners' concerns

Coroners' concerns, also referred to as "concerns" for the purpose of this research, are points highlighted on the Prevention of Future Death (PFD) reports where the coroner believes action should, or could, have been taken to prevent death.

Thematic analysis

Thematic analysis is a method of analysing qualitative data. It is used in the analysis of text and involves extracting and interpreting common themes from the data that appear frequently.

Prevention of Future Death (PFD) reports

PFD reports are publicly available on the Courts and Tribunals Judiciary website and cover both England and Wales. The intention of the PFD report is to benefit the public.

The Courts and Tribunals Judiciary website indicates that coroners have a duty to make a report detailing actions that should be taken to prevent future deaths (see Courts and Tribunals Judiciary, Revised Guidance No.5. Reports to Prevent Future Deaths for further information). These reports can be sent to persons, organisations, local authorities, government departments or agencies. These reports are also sent to the Chief Coroner.

Reports typically follow a standard structure of the following sections: This Report is Being Sent To, Coroner details, Coroner's Legal Powers, Investigation and Inquest, Circumstances of Death, Coroner's Concerns - The Matters of Concern, Action Should be Taken, Your Response and Copies and Publication. Some parts of the PFD reports are redacted for public safety and privacy purposes, and therefore redacted content could not be included in any analysis.

Approach to analysis

Reports were imported into QSR NVivo 12 Qualitative Analysis software for an inductive thematic analysis. Inductive thematic analysis is where researchers have no preconceptions of themes and have not pre-set any themes. All reports (100%, n = 164) were manually coded by a single researcher initially, and then this same researcher re-reviewed the coding structure to refine the codes further. Following this, a second researcher re-analysed 40% (n = 65) of the PFD reports. Initial agreement between the two researchers was 82% (calculated by the number of agreed codes, divided by the total number of codes). Where researchers disagreed with codes created, these researchers discussed their views and came to a consensus (agreement after review = 97%). For the remaining 3% of codes, the initial coding decisions from the lead researcher was taken.

Strengths and limitations

The main strengths of this study are that:

• it provides a high level of detail from inquests and individual circumstance, that cannot be achieved through quantitative analysis alone

• it uses PFD reports, which contain valuable information provided by coroners that are not frequently used in analysis

• the method of analysis was followed according to well-established qualitative analysis practices

• the research was obtained through expert consultation and met policy user needs

The main limitations of this study are that:

• findings relate to specific individual circumstances for cases where PFD reports were produced, therefore may not be reflective of all concerns across all suicide deaths

• this analysis examined PFDs that were uploaded to the coroner's website between January 2021 and October 2022. However, because of the length of time inquests take to conduct, the date of death may be several months prior to this. Therefore, the concerns highlighted in PFD reports may not reflect concerns for cases with a more recent date of death