Suicide & Self-Harm Risk Failures

A Suicide & Self-Harm Risk Failures assessment is an expert evaluation of psychiatric care provided to individuals at risk of self-directed harm. It examines whether the standard of care fell below that of a responsible body of practitioners, particularly concerning risk screening, observation levels, and the implementation of safety management plans.

The assessment applies the Bolam test and Bolitho criteria to determine if the clinician’s actions were logically defensible. It also addresses legal causation, establishing, on the balance of probabilities, whether a proactive intervention would have been likely to prevent the self-harm or suicide event.

• Risk stratification — the adequacy of the initial and ongoing risk assessments conducted by the clinical team
• Breach of duty — identification of failures to follow NICE guidelines or internal trust policies
• Environmental safety — evaluation of ligature point audits and the removal of hazardous materials
• Observation protocols — analysis of whether the frequency of checks was appropriate for the patient’s presentation
• Communication failures — assessment of handovers and information sharing between multidisciplinary teams
• Causation analysis — determining whether the failure materially contributed to the adverse outcome, where that test is legally applicable

These assessments require a forensic psychiatrist with extensive experience in inpatient safety and risk management frameworks. The expert must be able to navigate complex medical records and provide a robust opinion that stands up to cross-examination.

Our experts provide a meticulous review of the clinical evidence, focusing on the foreseeability of the event and the reasonableness of the clinical decisions made at the material time.