Suicide is among the most frequent causes of death among children and adolescents in the UK (Office for National Statistics, 2025a), with up to a quarter of adolescents experiencing thoughts of ending their life (Cha et al., 2018).
Theories such as the interpersonal theory of suicide (Joiner, 2005; Van Orden et al., 2010) offer frameworks for explaining why suicide occurs through identifying key vulnerabilities and their interactions, such as the co-occurrence of thwarted belongingness and perceived burdensomeness, which can become particularly dangerous when suicide means are accessible. Yet it’s often difficult to see how factors might play out in real life, and, most importantly, the specific points where systems break down and where it is possible to intervene.
A recent study by Sharland and colleagues (2025) used a publicly available source of qualitative data to explore preventable factors in child suicides: the Prevention of Future Death reports. While suicide in children and adolescents is complex and hardly ever due to a single identifiable cause or vulnerability (Sleap et al., 2021), Sharland et al. emphasise that learnings can be drawn by examining past structural and systemic failures to inform prevention strategies, particularly given there is no centralised mechanism to allow learning from these deaths to inform practice.
Suicide in children and adolescents is often the outcome of multiple vulnerabilities, and understanding previous systemic failures can aid future prevention strategies.
Methods
The authors analysed Prevention of Future Death (PFD) reports, which are documents written by coroners in cases where it’s believed that “action should be taken to prevent future deaths” (Courts and Tribunals Judiciary, n.d.). Most PFD reports are published online and addressed to relevant agencies, such as NHS trusts, government authorities, or professional organisations.
The authors analysed all 37 available PFD reports concerning suicides of children and adolescents below the age of 18 that were published between 1 January 2015 and 30 November 2023. These reports concerned 36 unique deaths and amounted to 12% of PFD reports on child deaths and 0.9% of all PFD reports within that period.
To understand the “themes and patterns of failures” detailed in the reports, two of the authors inductively coded coroners’ concerns for each death. Then, related codes were grouped into themes and sub-themes. Descriptive statistics such as number of concerns, age, gender, diagnoses and addresses, were also collated and reported.
Results
While this information was not consistently available, the average age of the deceased children across the reports was 16 years old, and 19 (53%) were reported as female. Most of the deceased (64%) had been known to NHS Child and Adolescent Mental Health Services (CAMHS), though only 11% had been detained under the Mental Health Act and 42% had a documented history of suicidal ideation or suicide attempts. Autism was the most frequently reported diagnosis (25%), followed by mood disorders (19%) and anxiety (14%).
The authors identified a total of 145 concerns in the 37 eligible reports. They grouped these concerns into six key themes and 23 subthemes, organised by frequency of reporting:
Governance and service provision
Concerns related to inadequate service delivery were the most frequently reported coroner concern. This included procedures and protocols not being followed appropriately, as well as issues with monitoring and escalation. Absent or inadequate specialised service provision, such as child social care, inpatient, crisis, or autism services, was the second most frequently identified concern. This resulted in inappropriate service provision, such as children being allocated to adult care services. Urgent beds were often unavailable, and autism-specific supports, including specialist caseworkers, were absent in certain cases.
Staffing, training and resourcing
Among the analysed reports, staff concerns (though it is unclear whether this primarily referred to NHS, social care, school, or other staff) included a lack of mandatory and appropriate training, with autism mentioned as a key example. Insufficient staffing and funding meant that, at times, services were unable to meet the demand and therefore fulfil their duties. In addition, in some cases, staff were not appropriately qualified to “meet the needs of the child involved” or were managing excessive caseloads.
Communication
Delayed and absent communication often prevented key information from being passed on, including between services and families. Subsequently, appropriate actions that could have reduced the risk of suicide were not taken. Further, a lack of communication with local authority care after a death limited opportunities to learn and mitigate future risk.
Remaining themes
The authors found that supposedly ‘integrated’ services were often siloed and disconnected, particularly in relation to CAMHS and disability supports. In the context of local authority care, the authors described insufficient learning from past suicides leading to inadequate risk assessments. Where mental health services were available, they were often difficult to access due to long waitlists for specialist beds and diagnoses, particularly in relation to autism, thereby resulting in a lack of appropriate support. Finally, coroners raised issues related to harmful content on social media and lack of safeguards online, such as age verification or parental controls.
Inadequate, absent, or inaccurately followed procedures in service provision and care were the most frequently reported coroner concern.
Conclusions
This study is the first attempt to synthesise and analyse coroners’ concerns regarding preventable factors contributing to child suicides in the UK. These concerns included issues with service procedures, availability, organisation and delivery, communication between services and with families, diagnostic delays, and online safety. The authors further highlight that “children with neurodiversity, including autism, appear to be of particular concern”, emphasising the importance of further researching this group in the context of suicide prevention.
Nine of the 36 deceased children in the sample were diagnosed with autism, with the authors highlighting the need for further research to focus on suicide prevention in this group.
Strengths and limitations
This was a thoughtfully conducted analysis providing a clear synthesis of the most frequently reported coroner concerns across PFD reports, lending itself well to policy implications.
A significant strength of this study is its comprehensive coverage of PFD reports related to child suicides, starting from the timepoint when dedicated PFD reports for suicides and child deaths were introduced in 2015. The authors also took steps to ensure that all child suicides were included by searching in other categories, reducing the likelihood of relevant information being missed and increasing the reliability of the findings.
Second, it is commendable that the authors actively engaged with multiple lived experience advisory groups across this study. This meant that the themes were reviewed for alignment with lived experience and subsequently refined, which likely increased the relevance of the paper beyond clinicians and policy makers. However, it would’ve been interesting to know more about the process, including changes made based on consultations.
There are also some limitations to keep in mind.
While this study is referred to as a ‘thematic analysis’ in the title, the methods used aligned with content analysis, which the authors also acknowledged. This may confuse readers expecting a more interpretative analysis. However, I found that a descriptive content analysis was sufficient for the study’s research questions and aims.
The inter-coder reliability was initially relatively low (66%) but rose to 99% following discussion. While I didn’t find this discrepancy particularly alarming giving the nature of the qualitative data from the PFDs, I was left wondering about the reasons behind this and how such a large change in the inter-coder reliability was achieved. In addition, I was hoping to see more about how the inter-coder reliability process was carried out, given that the analysis was inductive.
PFD reports don’t typically include specific demographic characteristics unless they are directly relevant to the case at hand (though I recognise that some characteristics may not be reported due to privacy concerns). Therefore, despite providing in-depth analyses of structural factors contributing to specific deaths, PFD reports can’t be relied on for an equity-based analysis. This is important, particularly in light of findings that suicide rates vary by ethnicity, with mixed ethnicity children being most at risk (ONS, 2025b; read Pauline’s Mental Elf blog to learn more). Further research is needed beyond what PFD reports can provide.
Finally, PFD reports are published some time after the date of death, and in this study, the mean delay was 626 days. This means that the dataset might not be sufficiently representative of the impact of COVID, as the authors acknowledge.
While Prevention of Future Death reports provide useful information on system-level failures, they might not sufficiently account for individual and community factors.
Implications for practice
This study provides a wealth of useful insights for clinicians and practitioners. For instance, clinicians could take note of the many preventable issues in these reports and consider how they might appear in their own practice. Yet crucially, the reports demonstrate that many contributing factors are systemic in nature, such as the nationwide lack of beds or wait times for diagnoses, and not resolvable by any one individual.
Some of the authors’ findings, such as procedural failings being the most frequently reported concern, appear quite alarming, but it’s important to note that PFD reports are only issued where clear concerns have been identified following an investigation. Therefore, we cannot generalise the concerns reported in this study to all child suicides. For example, there may be a number of child suicides, which did not yield a PFD report, where all statutory procedures were followed appropriately. This means there likely are other opportunities for suicide prevention; for example, a prior Mental Elf blog outlined a meta-analysis linking harsh parenting and family dysfunction to youth suicide.
As an autism researcher, I was struck that a quarter of the sample were autistic, and autism-specific factors were mentioned prominently in the study. I find this to be crucial to keep in mind given there’s been growing discussion about potential overdiagnosis in the current political climate. Further, the evidence that diagnostic delays were named as a contributor to several deaths is alarming, particularly since the waitlists for assessments have increased significantly during the pandemic with no sign of recovery (NHS England, 2026). Yet an autism diagnosis is not a panacea, and autistic people report enduring issues accessing post-diagnostic supports (Camm-Crosbie et al., 2019; Khudiakova et al., 2026). Therefore, tailored supports specifically for autistic children and adolescents should be prioritised.
Another autism-specific factor recurring in the study was a lack of training or awareness. It’s worth noting that the deaths occurring in this study took place before The Oliver McGowan code of practice on statutory learning disability and autism training came into effect, similar to most of the literature cited. The code mandates that all health and social care professionals receive appropriate, quality-assured training on autism and learning disability (Gov.uk, 2025). It would be interesting to see if this training has translated into any changes, specifically in CAMHS and acute care services.
Ultimately, this analysis identifies key areas where policy could intervene, before systems break down with fatal consequences.
Statement of interests
Valeria Khudiakova has just finished supervising two undergraduate dissertations involving analyses of PFD reports, resulting in familiarity with PFD reports as a data source and their general limitations. However, both dissertations were different in scope (including being restricted to the post-COVID timeframe and not focusing on child suicides) and methodology. Beyond this, she has no conflicts of interest to declare.
Edited by
Dr Nina Higson-Sweeney.
Links
Primary paper
Emma Sharland, Emma Wallace, Lauren Revie, Isobel Ward, Cathryn Rodway, Daniel Ayoubkhani, & Vahé Nafilyan (2025). A thematic analysis of Prevention of Future Death reports for children who died by suicide in England and Wales: January 2015 to November 2023. The British Journal of Psychiatry, 1–6. https://doi.org/10.1192/bjp.2025.10425
Other references
Camm-Crosbie, L., Bradley, L., Shaw, R., Baron-Cohen, S., & Cassidy, S. (2019). ‘People like me don’t get support’: Autistic adults’ experiences of support and treatment for mental health difficulties, self-injury and suicidality. Autism, 23(6), 1431-1441. https://doi.org/10.1177/1362361318816053
Cha, C. B., Franz, P. J., M. Guzmán, E., Glenn, C. R., Kleiman, E. M., & Nock, M. K. (2018). Annual Research Review: Suicide among youth–epidemiology, (potential) etiology, and treatment. Journal of Child Psychology and Psychiatry, 59(4), 460-482. https://doi.org/10.1111/jcpp.12831
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