Suicide: learning from case reviews Summary of risk factors and learning for improved practice around suicide

Girl by garageCase reviews highlight that the warning signs of teenage suicide are often overlooked as typical adolescent behaviour. This means that young people are not always receiving the help that they need.

The learning from these reviews highlights that professionals should take young people’s suicide talk seriously and work hard to engage with and support young people.

Published: 2014


This briefing summarises the learning from case review reports. It is an analysis by the NSPCC Information Service, highlighting risk factors and key learning for improved practice.

Reasons case reviews were commissioned

This briefing is based on case reviews published since 2010, where the young people involved have made an attempt on or taken their own lives and the reports were sufficiently detailed to be useful for identifying and sharing learning points.

Risk factors for suicide identified in case reviews

Suicide is rarely triggered by a single event. It is the result of an accumulation of adversities over time.

  • bereavement, including family history of suicide
  • history of abuse
  • exposure to domestic violence
  • parental mental health problems
  • parental alcohol or substance misuse
  • breakdown of relationships with family or boy/girlfriend
  • lack of stable accommodation or consistent source of care
  • copycat suicides
  • social isolation
  • bullying
  • mental health problems including depression
  • behaviour disorders including attention deficit hyperactivity disorder (ADHD)
  • risk taking including drug or alcohol misuse, criminal behaviour and underage sexual activity
  • lack of parental control and boundaries
  • perceived or actual pressure to achieve
  • financial worries. 


Learning for improved practice

Case reviews involving suicide nearly all related to adolescents, and the majority related to boys. The case reviews identified a number of warning signs that a young person was considering suicide. These included:

  • disclosures of suicidal feelings - often verbal, but also letters, suicide pacts or pieces of creative writing
  • change in sleep patterns - sleeping more or less than usual
  • change in appetite - eating more or less than usual
  • sudden mood swings - in some cases a notable uplift in mood preceded a suicide attempt
  • feelings of hopelessness, rejection or being a burden to others
  • self neglect - often signalled by a decline in personal hygiene and appearance
  • self harm - often through deliberate cutting, but also aggressive acts such as hitting walls
  • withdrawing from family and friends and stopping engagement with support services.

 Every warning sign of suicide should be taken seriously and acted on accordingly.

Young people's suicide threats and attempts were often interpreted as teenage histrionics rather than cries for help. 

Suicide threats should be routinely assessed for motivation and level of intent. 

Professionals should be alert to the different ways young people may express suicidal feelings, whether it be direct disclosure or through the indicators outlined above. 

The failure of young people to attend appointments or take advantage of the services offered to them should not result in the withdrawal of services. Young people who are feeling suicidal will often withdraw themselves from those who are able to help and support them. Services should instead look at ways of being more accessible to young people, such as providing ways to access support without having to meet face to face with service providers. 

Suicidal feelings are often treated as purely mental health issues. This means that many of the factors contributing to the way the child feels remain unaddressed. It also means that in cases where a child is not diagnosed as suffering from depression, professionals are mistakenly reassured that a child will not attempt to take their own life.

Young people can be put at risk of significant harm from their own behaviour. Suicidal feelings should be treated as a child protection issue and trigger a similar level of response to children at risk of harm from others.

All the services working with a child should be informed if a child is feeling suicidal or has attempted to kill themselves as they all have a role in protecting the child.

Suicide is rarely a response to a single event. It is usually the result of a build-up of problems over time. Professionals should consider the cumulative impact of adversities on children, regardless of whether or not they appear to be coping well. Parents' problems should not be allowed to overshadow the needs of their children. 

Young people are often returned home from hospital after suicide attempts without any guidance on how to reduce the risk of a further attempt. Parents should be given support and advice on how to protect their child following a suicide attempt. Young people should be referred to children's mental health services to make sure they get the help they need.

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More information and resources

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Working together with the Association of Independent LSCB Chairs to make finding the learning from case reviews published in 2014 and 2013 easy to find.

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Child protection system

The services and process in place across the United Kingdom to protect children at risk of  abuse, neglect or harm.

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Research and resources

Read our latest research, leaflets, guidance and evaluations that share what we've learned from our services for children and families.

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