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Our Trust suicide prevention group will continue to monitor and review all suspected suicide data in order to identify themes and learning and take relevant actions. 

From a statistical perspective, the graph above indicates that Trust wide, each month is within the upper and lower process control limits, demonstrating that the number of suicides are within normal variation. 

Overall, current Trust data shows that the number of people known to North West Boroughs Healthcare taking their own life is not increasing.

A review of suspected suicide data for 2020 is currently being completed. Further findings will be shared. 

Initial lessons learned and actions taken are included in the table below from the learning from deaths report (December 2020). 

Learning points

Action required


Capacity and pathways around crisis response

Implementation of the new crisis response home treatment team will be monitored and progress reported to the Trust Patient Journey Group.

Crisis line established for self-referrals, capacity enhanced by assistant psychologist recruits in place December 2020. 

Enhance pathways around substance misuse

Monitoring of progress through Trust Quality, Safety, Safeguarding, Governance Group.

A Trust pathway is in development, with Wigan implementing the pathway with We Are With You. 


Training is currently being developed and rolled out.   

Improving family and carer engagement and experience

The Kinnect work is one of the quality priorities within the 2020/21 Quality Strategy, progress will be monitored and reported to Quality Committee

Kinnect pathway development now complete. 


Roll out of training and pathway to be complete by end of Q4. 


Family voice included in 72hour review form. 

Improving risk formulation

Development and implementation of this work is being led through the Crisis Transformation workstream. 

Standardised biopsychosocial screening has been developed and rolled out. 

Implementing the Supportive Observation and Engagement Policy

Least restrictive  practice group overseeing compliance which feeds into the Quality Safety Safeguarding Governance Group

A training package has been developed to roll this out with a standard operating procedure. 


It was launched mid-December, with 23 per cent Trust compliance by 24 December.  

Addressing Workforce pressure

Monthly Operational Performance Group monitoring capacity and demand and reporting into the Executive Performance Group.

Continue to review any rise in referrals and the capacity to respond, implementing control measures accordingly.