After an inpatient suicide: The aim and outcome of review mechanisms

Abstract

Objective: To describe the intent and process of reviews undertaken following the death by suicide of an inpatient and suggest possible improvements. Method: The current processes of review undertaken in Victoria following the death by suicide of an inpatient were considered in the context of a review of unnatural, unexpected or violent inpatient deaths undertaken by the Chief Psychiatrist of Victoria in late 2011. Results: Review processes seeking to elucidate a cause or to find errors in the system that may have contributed to an incident are not always suitable nor sufficient in cases of inpatient suicide, where the patient's actions (as opposed to the actions or inactions of clinicians) ..