To mark Samaritans Awareness Day on 24 July, we reviewed MDU files opened in the last year where a patient died by suicide.

In 2024, our members reported 421 cases relating to suicide. Over 70% of these arose from general practice, with psychiatry representing the next most common specialty in 20% of cases.

Inquests were by far the most common reason doctors contacted us, although in a number of these cases other processes followed or ran alongside the inquest, such as a complaint, a claim or a GMC investigation.

Many doctors reported the impact a patient's death by suicide had on them personally, and this was frequently amplified by the scrutiny of a medico-legal process. It's understandably stressful - particularly if there is a concern raised by the family, coroner or another agency as to whether more action could have been taken.

Here are some of the challenges we see, and some ways to mitigate the associated risks.

Assessing risk

Coroners frequently asked practices what assessment of risk had been undertaken when clinicians saw a patient presenting with self-harm and/or suicidal ideation.

In April this year, NHS England published its guidance supporting the government's work to reduce suicide. This highlighted that 80% of those who died by suicide and were in contact with mental health services were considered as being at low or no risk of suicide at their final assessment before death, reiterating the difficulties faced when trying to predict suicide.

NICE's guidance on self-harm emphasises that rather than using global risk stratification tools and scales (which the guidance says should not be used to determine who is offered treatment, or to make decisions about whether or not to discharge patients), assessments should be focused on the person's needs and how to support their immediate and long-term psychological and physical safety.

This is a collaborative process between the clinician and patient. It can be helpful to make sure patients can be provided with a degree of continuity of care regarding their mental health, to allow them to build rapport and trust with the health professional.

This may also help the patient to feel more able to open up, and the clinician will already be familiar with the patient's background.

Clear communication

Part of the coroner's role is to consider if a case highlights that action should be taken to prevent future deaths. In several cases we saw from members, concerns had been raised about systems for co-ordinating patients' care between primary care and community mental health services.

This presents a further challenge for doctors. For example, do you know the expected response times from your local mental health services different categories of referral? Or if you need a same-day response to a concern about a patient, do you know the appropriate route to access that response?

What about when a patient says they have been in contact with another service, but the surgery has yet to receive any correspondence - can you contact that service for an update? This will add to the practice's administrative burden, but it might reveal information important to a risk assessment.

Involving family

Both NICE and NHS England also highlight the role family members can play in supporting patients at risk of suicide. NICE advises seeking consent from patients early on to share information with those closest to them, and it may be important to revisit this with patients who initially refuse.

It also says you should be aware that even if the patient hasn't consented to involving them in their care, family members or carers can still provide information about the person.

When someone close to a patient contacts you with concerns about a loved one, you should make clear that while it is not a breach of confidentiality to listen to their concerns, you might need to tell the patient about information you have received from others - in line with the GMC's guidance on confidentiality.

Medication reviews

Decisions about prescribing for patients with a history of self-harm and suicidal ideation was another frequent theme in files.

In some cases, this was a result of prescriptions being issued on repeat without considering risk management. In the setting of a busy general practice, it's not always possible to review the entirety of a patient's records when you need to review a repeat prescription request, and you have competing demands on your time.

However, as doctors remain responsible for the prescriptions they sign, it is important to make sure you have enough information to decide whether it is safe to issue medication, and if so, in what quantity. This might pose a particular risk if details of a patient's previous harm or suicidal ideation are only contained in older notes, or letters from other services.

Having systems in place to ensure any risk factors are recorded in a way that makes them easy to review can help clinicians make informed decisions. NICE also advises that when a patient presents to primary care with self-harm, GPs should ensure they have a medicines review.

The importance of documentation

Sometimes it became apparent during the course of a coroner's inquiry that GPs had undertaken detailed assessments of a patient, but that this wasn't clear from the records. In some cases, this meant other clinicians weren't aware of the risk identified, while in others, the coroner and/or GMC had raised a question about what took place and if this was adequate.

With the ever-present time pressures of general practice, it is always challenging to capture often detailed and nuanced discussions around mental health. However, as comprehensive records fulfil several functions, including supporting continuity of care when a patient is seen by a colleague, and providing evidence if a question about the standard of your care is ever raised, it is important to take steps to ensure you are able to do so.

This is also important because the GMC emphasises in 'Good medical practice' (2024) that doctors must make sure that formal records of their work (including patients' records) are clear, accurate, contemporaneous and legible.

When documenting a consultation, as well as stating the outcome of your assessment, it can be useful to make sure it's clear how you reached that decision. If you have given the patient advice on what to do if they have thoughts of suicide or self-harm, try to record specifically what advice and signposting you provided.

Having a record template that provides a reminder of what to include can be useful, although it's important that this doesn't inadvertently introduce inaccuracies to a record through a standard piece of text being left in by mistake.

Summary

Caring for patients who are at risk of dying from suicide can be very challenging for doctors. Communication between services is sometimes limited, and risk stratification tools are imprecise.

However, the practical points given above, along with clear documentation, can help you demonstrate you have taken carefully thought-out decisions at each stage of your involvement.

Learning from cases involving patient suicides

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