08/10/2026
“Above all, improving communication within teams, collaboration with those receiving care, and strengthening engagement with families and significant others remains central to delivering safe, therapeutic mental health care and reducing suicide risk.”
NHS Resolution has today published its updated thematic review of suicide related claims. A topic they last reported on in 2018. The analysis of their claims data and their qualitative review demonstrate the importance of supporting existing and ongoing strategies and initiatives to improve care and prevent the tragedy of avoidable patient suicide.
In 2024/25 mental health claims represented 3.4% of the total number of claims. 44% of the 2,200 clinical negligence claims between 2018 and 2025 were related to suicide. These 960 cases have a value of £141 million including legal costs. In 229 claims (40%) admissions of liability were made.
NHS Resolution carried out a qualitative analysis of 37 claims where liability had been admitted and compensation paid and their key findings centre on the overarching theme of communication with reference to:
Patients, family and significant others – who were often not involved in risk assessment or care planning and this meant key risks were missed or overlooked. Often the information that families and friends can provide does not find its way into the knowledge or risk assessment that is undertaken. Similarly, difficulties with sharing information where the patient, not uncommonly, refuses consent to share information with their family can lead to missed opportunities to manage risks better.
Safety culture – 32% of claims reflected delays in assessment and 86% indicated issues with the implementation of risk assessment (use and completion of risk assessment tools).
The review emphasizes the dangers of static risk assessment and the use of risk assessment tools as a way of predicting suicide. It highlights the importance of the dynamic approach advocated by NHS England of “formulation, therapeutic engagement and collaborative exploration of risk and safety plans along with a biopsychosocial approach”.
Risk factors such as ward layout and lack of alignment between clinical observations and patient risk were noted (e.g a patient at high risk of suicide but on general hourly observations). Documentation of the rationale was often poor. Sub-optimal record keeping was cited in 86% of the claims with a recognition that pressures on the service contributed to this. Referral failures and failures to follow up were also recognized factors.
Workforce – poor communication between staff was observed in 68% of claims and note keeping was a factor in 51% of claims. Concerns were also noted around clinical leadership in most of the claims analyzed with 49% citing unclear responsibilities. Other issues were found with joint working and workloads, staff shortages and skills. Handover issues were a contributory factor in 35% of claims analyzed.
When compared with the previous NHS Resolution review, some new areas of concern were identified – Leadership, conflicting team goals and unclear team responsibilities. However, all the themes identified in 2018 remain in 2025.
In the context of the reports published by HSSIB this year into the care of patients in emergency departments, the review notes the particular challenge in acute healthcare settings where there were “conflicting team goals and expertise in managing physical health vs mental health”. They note that plans provided by liaison psychiatry teams were difficult to implement due to the environment and resourcing issues, affecting, for example, the ability to manage ligature risks or the ability to carry out observations. Communication issues also featured here where there can be assumptions of shared skills and language across the teams which was misplaced along with differences in understanding of risk. The challenges of joint working were noted in 2018 and certainly remain.
This thematic review does not look to impose a new raft of recommendations but the themes identified highlight those areas where continued work will support learning and development, complementing existing guidance and strategies. The review highlights the value of the following:
Strengthening the use of claims data within local governance
Ongoing assurance concerning family involvement and information sharing
Shift from risk tools to formulation based approaches
Improving inter-professional communication across care transitions
This welcome review provides an evidence-based case for taking action to improve communication and collaboration in order to support mental health and other professionals.
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