Suicides in children and young people are a major public health concern. Prevention of Future Death (PFD) reports are an underutilised resource detailing coroners’ concerns which, if actioned, are believed to be able to prevent future deaths. Research has investigated common themes for suicide during 2021 and 2022 but there are no published studies that thematically analyse these reports for children alone.

To identify key themes raised by coroners from PFD reports published between 2015 and 2023 for children who have died by suicide.

PFD reports for suicides in children were downloaded from the Courts and Tribunals Judiciary website. Descriptive statistics were collated from reports. Reports (n = 37) were analysed using inductive content analysis to determine primary and sub-themes using QSR NVIVO 14 Qualitative Analysis software.

Reports came from 30 coroners’ areas, with most reports being sent to government departments and NHS Trusts/Clinical Commissioning Groups. The qualitative analysis resulted in six primary themes being identified: service provision, staffing and resourcing, communication, multiple services involved in care, accessing services and access to harmful content and environment. Furthermore, 23 sub-themes were identified such as standard operating procedures/processes not being followed or being inadequate, a lack of specialist services and a disconnect between integrated services. A quarter of reports were on children diagnosed with autism, and there were specific issues highlighted in concerns relating to services and staffing for children with neurodiverse conditions.

The key findings from this report highlight themes raised by coroners relating to deaths of children by suicide. This included themes around service provision, staffing and resourcing of mental health services and communication between services and families. Children with neurodiversity, including autism, appear to be of particular concern.