Aim As part of the Child Death Review Pilot in Wales, we aimed to analyse the theme of suicides and events of undetermined intent in children and young people. We aimed to study precipitating factors and pointers for prevention. The problem of suicide in young people was highlighted recently in Wales by the cases in Bridgend County.

Methods We studied suicides and events of undetermined intent in children and young people under 18 years in Wales from 1 October 2006 to 30 September 2009. Information came from records where consent was obtained (only in a minority of cases); executive summaries of Serious Case Reviews and reports of Inquests. The cases were reviewed by a panel, the literature analysed and an Action Plan produced.

We ascertained 21 cases in the 3 years: there were 16 boys/young men and five girls/young women. They came from all over Wales. The ages ranged from 13 years 9 months to 17 years 11 months. 13 of the 21 cases were in 2008. All cases of suicides were due to hanging; we did not ascertain any cases from overdose. The panel was struck by how a combination of factors increases the risk of suicide in young people. These were:

• ▶ Clearly deprived circumstances,

• ▶ A history of self-harm,

• ▶ A history of abuse,

• ▶ Drugs and alcohol,

• ▶ Bullying,

• ▶ Links with other cases.

• ▶ There were three boys/young men who hanged themselves with no obvious precipitating factors or after a very minor disagreement.

Conclusions Suicides in young people under 18 do need to be considered separately from adults as there are factors which have particular relevance to them, particularly bullying and abuse. There is a need for an adequate protocol for supporting young people after a serious suicide attempt. Child and Adolescent Mental Health Services will need to develop resources to provide co-ordinated support as well as being a diagnostic agency.