BACKGROUND Suicide prevention remains a high priority topic across government and the National Health Service (NHS). Prevention of Future Death (PFD) reports are produced by coroners to highlight concerns that should be addressed by organisations to prevent future deaths in similar circumstances. OBJECTIVE This research aimed to understand themes from concerns raised in PFD reports for deaths from suicide to inform future policies and strategies for preventing suicide. METHODS We employed a retrospective case series design to analyse PFD reports categorised as suicide using qualitative inductive thematic analysis. Primary themes and subthemes were extracted from coroners' concerns. Following theme extraction, the number of concerns coded to these themes across reports and the frequency of recipient organisation being named as addressee on these reports were assessed as primary outcomes. FINDINGS 12 primary themes and 83 subthemes were identified from 164 reports (4% of all available reports). The NHS was the most frequent recipient of these reports, followed by government departments. Coroners raised issues around processes within or between organisations and difficulties accessing services. The most common concerns fell under the primary theme 'processes' (142 mentions), followed by 'access to services' (84 mentions). The most frequent subthemes were 'current training not adequate' (38 mentions) and 'inadequate communication between services' (35 mentions). CONCLUSIONS Our results specify areas where review, improvement and policy development are required to prevent future suicide deaths occurring in similar circumstances. CLINICAL IMPLICATIONS These themes highlight concerns across current care and service provision where reform is required for suicide prevention.

中文翻译：

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预防未来死亡自杀报告的主题分析：2021 年 1 月至 2022 年 10 月。


背景 预防自杀仍然是政府和国家医疗服务体系 (NHS) 的高度优先主题。预防未来死亡 (PFD) 报告由验尸官制作，旨在强调组织应解决的问题，以防止未来类似情况下的死亡。目的 本研究旨在了解 PFD 报告中提出的有关自杀死亡问题的主题，为未来预防自杀的政策和策略提供信息。方法 我们采用回顾性病例系列设计，通过定性归纳主题分析来分析归类为自杀的 PFD 报告。主要主题和次主题是从验尸官的关注中提取的。主题提取后，跨报告编码为这些主题的关注点数量以及接收组织在这些报告中被指定为收件人的频率被评估为主要结果。结果 从 164 份报告（占所有可用报告的 4%）中确定了 12 个主要主题和 83 个次主题。 NHS 是最常收到这些报告的机构，其次是政府部门。验尸官提出了有关组织内部或组织之间的流程以及获取服务的困难的问题。最常见的担忧属于主要主题“流程”（142 次提及），其次是“获取服务”（84 次提及）。最常见的副主题是“当前培训不足”（38 次提及）和“服务之间的沟通不足”（35 次提及）。结论 我们的结果明确了需要进行审查、改进和政策制定的领域，以防止未来在类似情况下发生自杀死亡。临床意义 这些主题凸显了当前护理和服务提供方面的担忧，需要进行改革以预防自杀。