Suicide: learning from case reviews
Summary of risk factors and learning for improved practice around suicide
Suicide in young people often follows the accumulation of different vulnerabilities and adversities over time.1,2 Risk factors can include:
- abuse or neglect, including non-recent abuse
- mental health problems
- conflict within key relationships
- drug or alcohol use
- bullying
- lack of stable or consistent care
- social isolation.
Case reviews highlighted how professionals didn’t always recognise and connect different risk factors or look for opportunities to hear the child’s voice.
Learning from case reviews underlines the importance of understanding the cumulative effect of different risk factors, speaking to children about their world and promoting positive, trusting relationships in children’s lives.
References
Sleap, V. et al (2021) Suicide in children and young people: National Child Mortality Database Programme thematic report: data from April 2019 to March 2020 (PDF). Bristol: National Child Mortality Database (NCMD).University of Manchester and Healthcare Quality Improvement Partnership (HQIP) (2017) Suicide by children and young people: National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (NCISH) (PDF). Manchester: University of Manchester.
Browse our full series of learning from case reviews briefings
Our series of thematic briefings highlight the learning from case reviews conducted when a child dies, or is seriously harmed, as a result of abuse or neglect. Each briefing focuses on a different topic or learning for specific sectors, pulling together key risk factors and practice recommendations.
More about case reviews
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