Improving implementation of recommendations from Serious Adverse Incident (SAI) reviews of patient deaths by suicide
: A qualitative analysis

  • Colette Ramsey

Student thesis: Doctoral ThesisDoctor of Philosophy


Introduction: Suicides by mental health patients accounted for 28% of all suicides in the UK from 2006-2016. A Serious Adverse Incident (SAI) review and report are completed for every patient death, to identify recommendations which may assist in reducing future patient suicides. Aim: This study will explore the process of implementing recommendations from these reviews, following patient suicides in Northern Ireland (NI) over the period 2015-2016. It will review how recommendations from SAIs are translated into practice with the aim of improving mental health services. In an international landscape of change in mental health service provision, this work addresses a gap in our understanding of how to successfully turn recommendations from reviews into positive action for change. Methods: A systematic review examined the international literature on the process of implementing recommendations from serious adverse incidents. All recommendations were then extracted from anonymised SAI reports in NI for the period 2015-2016. An interpretive thematic approach was then completed to provide an in-depth understanding of the data. Primary data was then collected from mental health professionals in 5 focus groups across Health and Social Care Trust (HSCT) in Northern Ireland. Examples of recommendations were incorporated into the semi-structured focus group discussion, to explore how these have been implemented in practice. This qualitative data was then analysed using Thematic Analysis. Results: This research provides in-depth qualitative insights on the implementation of recommendations following reviews of patient deaths by suicide, and the effectiveness of this implementation to enhance suicide prevention within mental health services. Six clear themes from the findings identified ways to aid effective implementation and reduce future patient suicides: improved structure and clarity of recommendations; more effective processes for dissemination of recommendations; consistent evaluation of the effectiveness of implemented recommendations; improved information sharing and patient record systems in mental health services; development of policies and protocols for collaboration with families and carers throughout the care and treatment process; and improved overall leadership and culture to support learning and the implementation of recommendations. Conclusion: These findings enrich the evidence base for multidisciplinary professionals working with people at risk of suicide. The findings also complement the existing evidence on implementing changes after suicides, with in-depth qualitative insights to enhance suicide prevention within mental health services. The thesis concludes with 28 clear recommendations for actions based on these findings.

Date of AwardDec 2022
Original languageEnglish
Awarding Institution
  • Queen's University Belfast
SponsorsNorthern Ireland Department for the Economy
SupervisorKaren Galway (Supervisor) & Gavin Davidson (Supervisor)


  • Implementation
  • suicide prevention
  • patient suicides
  • zero suicide
  • serious adverse incident reviews
  • mental health suicide

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