The first ever analysis of coroners’ ‘Prevention of Future Deaths’ reports from suicide inquests has highlighted where potential preventative actions could have been taken. 
The Office for National Statistics (ONS) has published its first analysis of the reports - created by coroners when they believe action could be taken to prevent future deaths - from suicide inquests in England and Wales from January 2021 to October 2022.
A total of 164 Prevention of Future Death (PFD) reports were available for analysis – for context, around 5,000 suicides are registered in England and Wales each year.
The ONS analysis showed concerns related to:
- Processes - particularly inadequate documentation and monitoring (such as lack of clinical note taking) that may have prevented a death.
- Staffing of services across health and public services and communal establishments – including inadequate volumes of staff, lack of qualified staff, inadequate training or problems with retention of qualified staff.
- Issues in accessing services,
- Issues in communication.
The report said 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.
In a statement published alongside the research findings, James Tucker, head of analysis in the data and analysis for social care and health division at the ONS, said: “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.
Among work taking place in West Yorkshire, senior staff at the three NHS mental health trusts – Leeds and York Partnership NHS Foundation Trust, South West Yorkshire NHS Foundation Trust and Bradford District Care NHS Foundation Trust – have been examining common findings from Serious Incident Investigations and inquests following tragic suicides of service users.
This work has led to the identification of access to crisis support, communication and transitions as core issues in suicide prevention in West Yorkshire.