NHS Resolution has today published a new thematic review examining suicide-related compensation claims made against mental health trusts in England.
The report, Learning from suicide-related compensation claims, 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 review identifies recurring themes associated with claims, with communication challenges emerging as a cross-cutting issue affecting patient care, family involvement and organisational learning.
Key findings from the report include:
- family engagement was absent in 76% of cases reviewed
- issues with risk assessment implementation were identified in 86% of cases
- 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 identified in 68% of claims, including issues related to handovers, record keeping and escalation processes.
The report also highlights wider themes relating to family involvement, risk assessment, record keeping, follow-up arrangements, ward safety and workforce pressures.
Louisa Bradley, Safety and Learning Lead (North) at NHS Resolution and lead author, said:
Every suicide is a tragedy that affects families, carers, staff and communities. 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. 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. The findings highlight opportunities to strengthen communication, involve families more effectively, improve risk assessment processes and support staff to deliver safe and compassionate care. We hope this report will support organisations to reflect on their own practice, share learning and continue working together to improve patient safety.
Megan Bidder, Director of Safety and Learning at NHS Resolution, said:
One of the most important findings from this review is that suicide prevention is not solely about individual clinical decisions. The claims highlight how organisational factors, team communication, service pressures and family involvement can all influence patient care. By understanding these wider conditions, organisations can take a more system-wide approach to learning and identify practical improvements that support safer, more person-centred care.
Alison McGovern, Minister for Social Care and Mental Health, said:
Every suicide is a tragedy that has a devastating and lasting impact on loved ones, families and entire communities. This government is determined to tackle suicide, and we owe it to those who have lost loved ones, and to everyone who relies on mental health services, to learn from cases where care fell short. This report provides vital evidence to help us make NHS services work better for patients, with care that is more responsive and tailored to what people need.
Dr Dorit Braun, CEO and Director at Making Families Count, said:
This report highlights that the failure to properly involve families in mental health care is unsafe. It also shows that information sharing with families is often not well understood. This has been known for a long time, and it is desperately sad that patients continue to be failed when their families are desperate to help keep them safe. 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.
Nichola Crust, Senior Safety Investigator at Health Services Safety Investigations Body (HSSIB), said:
We welcome this important analysis from NHS Resolution. Many of the themes it identifies reflect findings from HSSIB’s investigations into learning from deaths and mental health crisis care, particularly the need to involve families, improve communication and information sharing, strengthen risk assessment and safety planning, and ensure care is coordinated across services.
The report forms part of NHS Resolution’s commitment to share data and insights as a catalyst for learning and improvement across the healthcare system.
The report is available to read on our Resources page.
