Death by Suicide and / or Attempts While In-Care

Suicidal behaviours are complex and multi-factorial which make them very challenging predictors of future conduct. This challenge impacts family, colleagues, and clinicians alike. Reliable predictors of suicidal behaviour remain elusive despite advances in early screening and assessment tools. However, the care of individuals at risk of suicide can be improved through preventative measures that focus on the essential elements of suicide care and facility design while in-care for those at risk.
In 2015, the following two events were recognized as “never events” in Canada: “Patient under the highest level of observation leaves a secured facility or ward without the knowledge of staff” and “Patient under the highest level of observation commits suicide or attempts suicide that results in serious harm” (Canadian Patient Safety Institute & Health Quality Ontario, 2015). “Never events” are “patient safety incidents that result in serious patient harm or death that are preventable using organizational checks and balances” (Canadian Patient Safety Institute & Health Quality Ontario, 2015).

Expected Outcomes

Adopt standardized, evidence-based suicide / self-harm prevention, identification, and management protocols / strategies. 

Implement formal strategies to provide targeted client self-harm and suicide prevention education and training to staff and families.

Adopt standardized quality indicators to review and monitor mental health services and care processes. 

Definitions and Acronyms 

  • ACU - acute care unit 
  • Client – includes all persons who receive healthcare and related services including patients, residents and persons in-care
  • ED – emergency department
  • MRP – most responsible practitioner, often a midwife, nurse practitioner or physician

Common Claims Themes and Contributing Factors

  • Facility and space design deficiencies in dedicated mental health rooms, spaces, and programs (refer to the Inadequate Mental Health Facility and Space Design Risk Reference Sheet for further details):
    • Blind corners and activity areas not visible from the nursing station;
    • Failure to act on known facility design deficits and equipment issues;
    • Inconsistent use of harm and abuse-resistant materials, furnishings, and fixtures, including ‘breakaway’ (anti-ligature) bars in client rooms (closets), and showers / bathtub;
    • Failure to remove anchor and other ligature points;
    • Inadequately located and inconsistently stocked resuscitation carts to respond to self-harm attempts.
  • Facility and space design issues in EDs and general medical-surgical units (i.e., design and space not conducive to monitoring, observing, and treating at risk mental health clients).
Organization (inpatient and ED)
  • Failure to develop and implement recommended actions and / or implement an effective contingency plan arising from:
    • Identified or reported facility and design concerns (e.g., ligature points);
    • Internal and external reviews and investigations (e.g., coroner) of previous suicide attempts. 
  • Inadequately implemented client and visitor contraband search policies.
  • Lack of clarity regarding permissive and mandatory privacy and reporting obligations resulting in high profile self-harm, suicide, and homicide incidents.
  • Inconsistent policies and practices used in assessing and implementing various client observation levels.
  • Lack of, outdated, and / or inconsistent suicide prevention policies, particularly for the ED and medical-surgical units. 
  • Lack of compliance with security and safety practices for at risk clients.
Emergency Department    
  • Inconsistent and inadequate assessments and monitoring of at risk clients.
  • Absence of and inadequate access to mental health expertise to care for at risk clients.
  • Lack of and / or misuse of audio-video surveillance to augment client monitoring including within seclusion rooms (e.g., used for practitioner convenience or in place of needed in-person / bedside surveillance where indicated).
Passes and Privileges  
  • Improper and inconsistent assignment of passes and privileges, including assignment based on admission status (voluntary and involuntary) versus clinical status.
  • Exclusive reliance on an individual healthcare provider's judgment to identify suicide risk status, observation levels, and passes.
  • Laxed approach to sign in / sign out processes.
Knowledge and Judgement
  • Failure to perform suicide risk assessments and reassessments as per program or organization protocol and/or as clinically indicated.
  • Inadequate observation and decreased vigilance:
    • During staff breaks and shift changes;
    • Towards at risk voluntary clients.
  • Delay or lack of:
    • Notifying the client's MRP of atypical or worsening behavioural or mental deterioration;
    • Consultation and collaboration with specialists or specialized teams;
  • Delayed referrals to designated / scheduled or higher acuity facilities.
  • Inconsistent and incomplete discharge planning and community referrals / supports prior to discharge (e.g., not scheduling meeting with family where indicated; not confirming follow-up in the community).
  • Inadequate chart or form design for tracking mental status and suicidal ideation.
  • Inadequate charting by exception practices.
  • Inconsistent documentation of:
    • Suicide risk assessments;
    • Scheduled and ad hoc client rounds or checks;
    • Rationale for increasing privileges and / or passes or decreasing the level of observation.

Mitigation Strategies

Care Processes    

  • Adopt a standardized, evidence-based suicide risk assessment and screening tool(s) that includes clearly defined triggers for client assessments and reassessments (Canadian Patient Safety Institute & Mental Health Commission of Canada, 2021).
  • Adopt a standardized client observation algorithm or decision aid that includes (but is not limited to):
    • Standardized and clearly defined classification for each level of observation or supervision;
    • The need to communicate the client’s level of observation or supervision during handovers or transitions;
    • Who has authority to reduce or increase the level of observation or supervision, and under what circumstances.
  • Implement strategies to support an adequate and safe level of coverage and client supervision during periods of lower staffing levels.
  • Implement strategies to ensure individually tailored care plans are developed and implemented for at risk clients, including (but not limited to) a formal safety plan that includes a plan for foreseeable self-harm incidents (e.g., whether ‘closed door’ or ‘open’ door is required for showering, bathing, using the toilet, or sleeping; potential client triggers such as the presence of a family member or police officer).
  • Implement strategies to ensure the care plan, including the safety plan, is readily available to all involved care providers.
  • Adopt a standardized protocol for client passes and privileges (Alberta Health Services, 2016) (Byrick & Walker-Renshaw, 2016) (BC Mental Health and Addiction Services, 2011). 

Additional Considerations

Key elements to consider in a standardized client passes and privileges protocol:
  • The need for and type of assessments or evaluations to be performed before off-unit privileges are granted;
  • Who can authorize passes and privileges, and under what circumstances;
  • Logistics of the pass or privilege;
  • The requirement that all clients formally sign in and out with a staff member.
  • Adopt a standardized contraband protocol. 

Additional Considerations

Key elements to consider a standardized contraband protocol:
  • A comprehensive list of potentially harmful and prohibited items;
  • The requirement that all family, friends, and visitors (police, etc.) check-in with staff for a review of contraband items.
  • Adopt ED-specific suicide risk assessment tools and care guidelines (Canadian Patient Safety Institute & Mental Health Commission of Canada, 2021) which require in-person assessment of all at risk clients by a mental health crisis team member before discharge.
  • Implement evidence-based strategies to support high risk clients post-discharge (inpatient units and ED).

Incident / Emergency Response

  • Implement formal processes to follow-up on registered at risk clients (inpatient, ED and ambulatory / clinic clients) who leave without being assessed or who are absent without explanation for scheduled appointments (Gerardi, 2007).
  • Implement a standardized evidence-based rapid response protocol for unauthorized leaves, elopements, and / or missing at risk clients (Emanuel, et al., 2017) (Gerardi, 2007).

Additional Considerations

Key elements to consider in a rapid response protocol for unauthorized leaves, elopements or missing at risk clients:
  • Search procedures defining staff roles and responsibilities, including the need to conduct timely searches regardless of the client’s voluntary or involuntary admission status;
  • Immediate notification of the MRP (versus notification after the search);
  • Timely notification of the family or substitute decision maker and police;
  • Privacy considerations (note: breach of the client’s privacy may be required if the client poses an imminent threat of harm to themselves or a third party).
  • Implement a standardized incident response protocol for all in-care suicide attempts and deaths (Ballard, et al., 2008).

Team Training and Education 

  • Implement formal strategies to support and enhance the teams’ clinical knowledge, skills (technical and non-technical), and practical experience surrounding the prevention, recognition, and response to suicide risk, prevention, management, and response, including (but not limited to), scheduled interprofessional and cross-department skill drills and simulations. 
  • Ensure the team training and education strategies consider or involve: 
    • Practitioner and team situation awareness and human factors;
    • Knowledge, skills, and practical experience required for the given care setting;
    • Program areas or sites with limited practical experience with at risk clients such as EDs and medical-surgical units; 
    • “Sitters”, unregulated care providers, locums, agency, contracted care providers in addition to regulated health professionals.

Client and Family-Centre Care

  • Engage client and family advisors in the development / review of the program’s standardized evidence-informed client and family education, training and discharge planning, and follow-up process for clients. 
  • With the client’s consent, involve the client’s family in discharge planning; develop a formal process to ensure client and family concerns related to discharge planning (e.g., lack of community supports and resources for at risk transgender youth in home community) are documented, shared with, and acknowledged by the interdisciplinary care team (National Action Alliance for Suicide Prevention, 2019) (CAMH, 2020).    


  • Adopt a standardized and structured communication practice to facilitate sharing of critical client information during various client handovers and transfer points. 


  • Implement formal strategies to monitor, measure, and improve documentation of the interdisciplinary team caring for at risk clients in the inpatient and ED settings.  

Additional Considerations

Areas of improvement to consider when monitoring, measuring, and improving documentation in the inpatient, mental health, and ED settings:
  • Results from initial and ongoing suicide risk assessments (e.g., timely and complete);
  • Interdisciplinary care plans including safety plans;
  • Actions taken in response to immediate and foreseeable safety needs;
  • Scheduled and ad hoc client assessments, checks, and rounds;
  • Actions taken in response to a reported missing clients or witnessed elopements (e.g., timing and activation of missing person code);
  • Rationale for increasing or decreasing level of care and observation / supervision;
  • Communications with client , family, substitute decision maker (e.g., expressed concerns for self-harm or safety of third party) or external primary care providers;
  • Communications with the MRP (e.g., the name of the MRP, time call, level of urgency and concern communicated, and the MRP’s orders and recommendation and changes to care plan).
  • Training, education materials, instructions provided and communications with clients, family and substitute decision makers and community and primary practitioners in particular during discharge planning.

Monitoring and Measurement    

  • Adopt a standardized, interdisciplinary, collaborative, and evidence-based protocol for conducting quality of care reviews involving attempted self-harm and / or suicide resulting in client harm or death (Machen, 2023); incorporate system thinking and human factors concepts into the review process. 
  • Adopt standardized quality indicators for mental health services (Health Quality Ontario, n.d.) (Setkowski, van Balkom, Dongelmans, & Gilissen, 2020) (Organisation for Economic Co-operation and Development, 2017) (Butler, et al., 2017).
  • Incorporate learning from local, provincial, and national death by suicide / attempts while in-care safety reviews (e.g., coroner reports) and data into local protocols as well as staff, client and family education and training.  

  • Agency for Healthcare Research and Quality. (2023). Preventing falls in hospitals. Retrieved from
  • Alberta Health Services. (2016). Inpatient privileges and passes. 
  • Ballard, E. D., Pao, M., Horowitz, L., Lee, L. M., Henderson, D. K., & Rosenstein, D. L. (2008). Aftermath of suicide in the hospital: institutional response. Psychosomatics, 49(6), 461–469. doi:10.1176/appi.psy.49.6.461
  • BC Mental Health and Addiction Services. (2011). The provincial suicide clinical framework. Provincial Health Services Authority.
  • Brickell, T. A., Nicholls, T. L., Procyshyn, R. M., McLean, C., Dempster, R. J., Lavoie, J. A., . . . Wang, E. (2009). Patient safety in mental health. Edmonton, AL: Canadian Patient Safety Institute and Ontario Hospital Association.
  • Butler, A., Adair, C., Jones, W., Kurdyak, P., Vigod, S., Smith, M., . . . Goldner, E. (2017). Towards quality mental health services in Canada: A comparison of performance indicators across 5 provinces. Vancouver, BC: Centre for Applied Research in Mental Health & Addiction (CARMHA).
  • Byrick, K., & Walker-Renshaw, B. (2016). A Practical Guide to Mental Health and the Law in Ontario. Ontario Hospital Association.
  • CAMH. (2020). Suicide prevention: A review and policy recommendations. 
  • Canadian Patient Safety Institute & Health Quality Ontario. (2015). Never Events for Hospital Care in Canada. 
  • Canadian Patient Safety Institute & Mental Health Commission of Canada. (2021). Suicide risk assessment toolkit: A resource for healthcare workers and organizations. Retrieved from
  • Emanuel, L., Taylor, L., Hain, A., Combes, J., Hatlie, M., Karsh, B., . . . Walton, M. (2017). Mental Health Care: Absconding and Missing Patients. Healtcare Excellence Canada. Retrieved from Healthcare Excellence Canada.
  • Gerardi, D. (2007). Elopement. Retrieved from Patient Safety Network:
  • Health Quality Ontario. (n.d.). Major of depression: Care for adults and adolescents. Retrieved from
  • Incident Analysis Collaborating Parties. (2012). Canadian incident analysis framework. Edmonton, AB: Canadian Patient Safety Institute.
  • Machen, S. (2023, 5). Thematic reviews of patient safety incidents as a tool for systems thinking: a quality improvement report. BMJ Open Quality, 12(2), e002020.
  • National Action Alliance for Suicide Prevention. (2019). Best practices in care transitions for individuals with suicide risk: Inpatient care to outpatient care. Washington, DC: Education Development Center, Inc.
  • Organisation for Economic Co-operation and Development. (2017). Health care quality indicators - Mental health care. Retrieved from
  • Setkowski, K., van Balkom, A. J., Dongelmans, D. A., & Gilissen, R. (2020). Prioritizing suicide prevention guideline recommendations in specialist mental healthcare: a Delphi study. BMC Psychiatry, 20(55). doi:10.1186/s12888-020-2465-0