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Australas Psychiatry. 2013 Aug;21(4):359-64. doi: 10.1177/1039856213486306. Epub 2013 Apr 29.

After an inpatient suicide: the aim and outcome of review mechanisms.

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Inner West Area Mental Health Service, Victoria (formally Chief Psychiatrist of Victoria), Parkville, VIC, Australia.



To describe the intent and process of reviews undertaken following the death by suicide of an inpatient and suggest possible improvements.


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.


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) led to patient death; therefore, the cause of death is not independent of the patient's condition and the treatment provided.


While Root Cause Analysis remains a useful methodology, review of inpatient suicides should go beyond examination of systems issues only, and include consideration of the care and treatment provided: whether it met accepted clinical standards and was delivered by staff with adequate skills to consider the inherent risks of mental illness. Review of aggregate data has a useful role in identifying significant common features associated with inpatient deaths.


hospital procedures; inpatient suicide; mental health; review process; risk management; root cause analysis; suicide

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