Thematic Analysis of Coroner's Prevention of future deaths (PFDs) reports in Mental Health related suicides Dr Dean Manning Core Psychiatry Trainee

Abstract

Background: I am a Core Psychiatry trainee currently working in a Crisis Resolution and Home Treatment Team (CRHT) in which many patients are referred with suicidal ideation in the context of their Mental Health. Aim: To identify professional and organizational-related themes highlighted in Coroner’s PFDs reports in Mental Health related suicides.. Methods: We reviewed Coroner’s PFDs reports via the UK Judiciary website. We filtered reports by those which are both Mental Health related deaths and included the keyword ‘suicide’. 100 reports were reviewed starting with the most recent. Themes were identified and grouped into patient-related, professional-related, and organizational-related factors that may have contributed to the death by suicide. Results: Reports were reviewed from across the UK. The highest number of reports were from the Coroner area of Manchester South (12%). 61% of reports were of males. Analysis: The main professional-related factors identified from thematic analysis of the PFDs reports were; issues around risk assessment and management (45%), lack of interprofessional communication and collaboration (33%), inadequate clinical queries/assessments (25%), Conclusions and Recommendations: It is hoped by identifying common themes arising from PFDs reports in Mental Health related suicides we can identify areas for change in practice that could lead to reduction in death by suicides.