Statement: Thematic suicide review update | News

Statement: Thematic suicide review update

A spokesperson for Cambridgeshire and Peterborough NHS Foundation Trust said: “Last year, CPFT announced its intention to conduct a thematic suicide review with the purpose of identifying further learning and common themes from adults who had died by suicide while under the Trust’s care since 2017. 

CPFT is committed to learning from these tragic incidents and, while the thematic review was planned with the best of intentions, it has become clear in speaking with several families and loved ones with lived experience that the review would not answer the individual and highly personal questions some families might have. 

Since the announcement, we have strengthened our processes by adopting the new national Patient Safety Incident Reporting Framework (PSIRF) as well as enhancing our own Learning from Deaths programme. This has enabled us to better identify and embed learning from deaths by suicide in a meaningful way. 

With this in mind, the Trust Board has made the decision not to proceed with the thematic suicide review as originally intended, but is committed to working with Dr Ellen Wilkinson, the independent Chair of the review, to engage NHS partners, as well as families and loved ones with lived experience of suicide, to further our suicide prevention work locally, supported by national initiatives, best practice guidance and Quality Improvement methodology.

We remain committed to listening to the families and loved ones of those affected by suicide and within the scope of the review and will continue to engage with them as we embed learning to improve our services.

We would like to thank Aqua for the work it has undertaken to date.”


  • The purpose of the thematic suicide review was to identify common themes and additional learnings outside of the Coronial process and CPFT’s own serious incident review processes. 
  • PSIRF replaced the previous Serious Incident Framework following national acknowledgement of the need for a new approach to responding to patient safety incidents.
  • At the heart of PSIRF is a commitment to compassionate engagement and involvement of carers and families affected by suicide and the application of a range of system-based approaches to learning from these deaths.
  • CPFT will cross reference our own learnings with other work in this area such as the National Confidential Inquiry into Suicide and Safety in Mental Health and the review of Probable Suicides in Mid and West Wales, in addition to the recently announced Government-backed Lampard Inquiry, which will look at inpatient mental health deaths in Essex.
  • CPFT will continue to engage with those with lived experience as well as suicide prevention experts to guide and challenge us to be the best we can for our patients and their families.

Please click here for details of further support available for those affected by these issues.

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