Death By Suicide/Suicide Attempts While In Care

Service: Risk Management
Subject: Care
Setting: Mental Health

Suicidal behaviours are complex and multi-factorial which make them very challenging predictors of future conduct. This challenge confronts 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 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

  • Patient under the highest level of observation commits suicide or attempts suicide that results in serious harm

“Never events” are patient safety incidents that result in serious patient harm or death that are preventable using organizational checks and balances (Health Quality Ontario and Canadian Patient Safety Institute, 2015).

Note: facility design and privacy breaches related to death by suicide/suicide attempts while in-care are addressed in separate Risk Reference Sheets.

Common Claim Themes


  • Facility design issues (e.g., inconsistent use of breakaway bars and preventive maintenance for maglock doors).
  • Failure to develop and implement recommended actions and/or implement an effective contingency plan arising from reviews of previous suicide attempts.
  • Poorly implemented patient and visitor contraband search policies, including prohibited items obtained from other patients.
  • Privacy breaches following high profile self-harm, suicide, and homicidal incidents (refer to Privacy Breach Risk Reference Sheet for mitigation strategies).
  • Inconsistent policies and procedures used in assessing and implementing various patient observation levels.
  • Lack of, outdated and/or inconsistent suicide prevention policies, particularly for the Emergency Department (ED), medical/surgical units and mental health programs).

Emergency Department

  • Inconsistent and inadequate assessments and monitoring of at risk patients.
  • Absence of and inadequate mental health expertise to care for at risk patients.

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 judgment to identify suicide risk status, observation levels, and passes.

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 patients.
  • Delay or lack of: 
    • Notifying the patient’s MRP of atypical or worsening behavioural or mental deterioration;
    • Consultation and collaboration with specialists or specialized teams;
    • Transfers to higher level of care when required.

Documentation and Communication

  • Poor chart or form design for tracking mental status and suicidal ideation.
  • Poor charting-by-exception practices.
  • Inconsistent documentation of:
    • Suicide risk assessments;
    • Scheduled and ad hoc patient rounds or checks;
    • Rationale for increasing privileges and/or passes or, decreasing the level of observation.

Case Study 1

Following an attempted suicide within the community, a patient was admitted under a Mental Health Act form to the Acute Care Unit (ACU) at a psychiatric hospital. During the intake process, the attending physician assessed the patient as being at high risk of suicide. Two days after the patient’s admission, the patient was found deceased, in bed, following an apparent suicide by asphyxiation. Expert review of the case was critical of the care provided to the patient, noting that the patient had not received adequate monitoring while in the ACU. A review of the patient’s medical record revealed that prior to the patient’s death, the patient had been not observed by nurses for a period of ten hours. Furthermore, expert review revealed ambiguities in the facility charting requirements for admitted patients, which lead to significant gaps in the charting of nurses, who expressed confusion with regard to the organization’s practice of “charting by exception”.

Case Study 2

A fifty year old patient was admitted to the hospital’s in-patient mental health unit for treatment of substance abuse, depression, and suicidal ideation. The level of observation assigned to patient ranged from 15 minutes on admission to 30 minutes overnight. Fifteen days after admission, the patient was found hanging from a door handle in the patient’s room. The patient sustained severe anoxic brain injury as a results of asphyxiation. Expert review of the case was not supportive in particular of the fact that the patient had access to shoelaces (contraband) and had already attempted suicide using shoelaces prior to admission to the unit. Experts also highlighted improper staffing levels (e.g., one RN during dinner break) when the patient attempted suicide.

Mitigation Strategies

Reliable Care Processes

  • Adopt a standardized, evidence-based suicide risk assessment and screening tool(s) that includes clearly defined triggers for patient assessments and re-assessments.
  • Adopt standardized patient 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 a patient’s level of observation during handoffs or transitions;
    • Who has authority to reduce or increase the level of observation, and under what circumstances.
  • Implement strategies to support an adequate and safe level of coverage and supervision during periods of lower staffing levels (e.g., breaks, nights, and weekends).
  • Ensure care plans for at risk patients specify (but are not limited to):
    • Whether ‘closed door’ or ‘open door’ observation is required for showering or bathing, and using the toilet;
    • The role of family and friends (as appropriate).
  • Adopt a standardized passes and privileges algorithm or decision aid that addresses (but is not limited to):
    • The need for and type of assessments or evaluations to be performed before off-unit privileges are granted (e.g., risk assessment, mental health assessment, and suicide risk assessment);
    • Who can authorize passes and privileges, and under what circumstances;
    • The requirement that all patients formally sign in and out with a  staff member.
  • Adopt a standardized evidence-based contraband protocol that includes (but is not limited to):
    • A comprehensive list of potentially harmful items (e.g., pens, lighters, nail clippers, shoelaces, gown belts, jewelry, medications, etc.);
    • The requirement that all visitors (family members, police, etc.) check-in with staff for a review of contraband items.
  • Adopt a standardized process to ensure a patient safety plan is developed and implemented that includes a plan for foreseeable self-harm incidents.
  • Adopt ED-specific suicide risk assessment tools and care guidelines which require ‘hands-on’ assessment of all at risk patients by a psychiatrist and/or mental health crisis team member before discharge.
  • Implement strategies to support high risk patients post-discharge (in-patients units and ED), including (but not limited to) non-demand ‘caring contracts’ (i.e., text, email or phone calls expressing care, concern, and interest as a means of suicide and harm reduction).

Response to Unauthorized Leaves, Elopements, Missing Patients, Suicide Attempts, and Deaths

  • Implement formal processes to follow up on registered patients (e.g., ED patients) who leave without being assessed or who are absent without explanation for scheduled appointments.
  • Implement a standardized evidence-based rapid response algorithm or decision aid to guide decision making for unauthorized leaves, elopements and/or missing patients occurrences that include (but is not limited to):
    • Search procedures defining staff roles and responsibilities, including the need to conduct timely searches regardless of the patient’s voluntary or involuntary admission status;
    • Immediate notification of the most responsible practitioner (versus notification after the search);
    • Timely notification of the family or substitute decision maker and police;
    • Privacy considerations.
  • Implement a standardized process to manage in-care suicide attempts and deaths, including (but not limited to):
    • Immediate and appropriate internal notification (e.g., clinical leadership, risk manager, administrator on-call);
    • Timely and appropriate external notification (e.g., coroner, family, police, liability insurer);
    • Process for conducting an internal review;
    • Cooperation with police and coroner’s investigations;
    • Privacy considerations;
    • Securing and locking health records (with a copy to the unit for ongoing care as appropriate);
    • Offering team debrief and support.


  • Implement formal, multifaceted, and targeted safety strategies to support and enhance staff knowledge, skill, and experience with suicide risk, prevention, and management (e.g., interdisciplinary workshops, in-situ simulations, and emergency skill drills, sharing of learnings and trends from periodic chart audits, analysis of reported incidents and events, and medical-legal matters); ensure the educational strategies are extended to all regulated and unregulated staff (e.g., sitters, personal support workers) as well as agency and float staff.

Communication and Documentation

  • Implement formal strategies to ensure comprehensive transfers of accountability during patient handoffs (e.g., breaks, shift changes, transfers, etc.). 

Strategies for practitioners

  • Ensure complete and timely documentation for all suicide-risk patients including (but not limited to):
    • Interdisciplinary care plan;
    • Scheduled and ad hoc patient assessments, checks, and rounds;
    • Rationale for increasing or decreasing level of care and observation;
    • Communications with family or substitute decision maker (e.g., expressed concerns for self-harm) and family practitioner;
    • All call or paging attempts, including the name of the physician, time called, and level of urgency communicated.

Monitoring and Measuring

  • Adopt a standardized process and protocol for identifying and reviewing suicide attempts and deaths (e.g., screening tool to detect morbidity cases for review, what incidents are to be reviewed, composition of the review committee, when and how the reviews should take place).
  • Implement formal strategies to monitor and measure the complete and timely documentation by staff in ED and in-patient units including (but not limited to):
    • Results from initial and ongoing suicide risk assessments;
    • Interdisciplinary care and treatment plan;
    • Actions taken in response to immediate and foreseeable safety needs;
    • Actions taken in response to a reported missing person (e.g., timing and activation of missing person code);
    • Scheduled and PRN monitoring and supervision activities (including rounds and checks);
    • Reports, consultations, and transfer of care discussions to and from the most responsible practitioner, in particular, observed and reported self-harm and suicidal risk factors and indicators;
    • Handover and shift change communication;
    • Education materials, instructions and communications with patients, family and substitute decision makers and community and primary practitioners.
  • Implement formal strategies to monitor and measure the effectiveness of, and adherence to, suicide identification, prevention, and management strategies, including (but are not limited to):
    • Formal quality measures and indicators (e.g., percentage of patients aged 18 years and older who score a positive result on validated suicide risk screening tool who receive an assessment during the same healthcare visit; number of clients with a safety plan developed (same date of screening) during the reporting period);
    • Learnings from suicide attempts and deaths (e.g., chart audits, trigger tools, incident reports, team debriefs, critical incident and quality of care committee reviews, coroner’s reports and recommendations, medical legal claims).


  • HIROC claims files.
  • Accreditation Canada. (2015). Required organizational practices handbook 2016. Ottawa, ON.
  • Bowers L, Banda T, Nijman H. (2010). Suicide inside: A systematic review of inpatient suicides. J Nerv Ment Dis. 198(5):315-328.
  • Centre for Addiction and Mental Health. (2011). Suicide prevention and assessment handbook. 
  • Combs H, Romm S. (2007). Psychiatric inpatient suicide: A literature review. Primary Psychiatry, 14(12):67-74.
  • Canadian Patient Safety Institute and Health Quality Ontario. (2015). Never events for hospital care in Canada: Safer care for patients. 
  • The Joint Commission. (2016). Detecting and treating suicide ideation in all settings. Sentinel Event Alert.
  • Mills D, Watts V, Miller S, et al. (2010). A checklist to identify inpatient suicide hazards in veterans affairs hospitals. Jt Comm J Qual Patient Saf. 36(2):87-93.
  • National Action Alliance for Suicide Prevention: Transforming Health Systems Initiative Work Group. (2018). Recommended standard care for people with suicide risk: Making health care suicide safe. Washington, DC: Education Development Center, Inc.
  • Ontario Hospital Association and Canadian Patient Safety Institute. (2011). Suicide risk assessment guide: A resource for health care organizations.  
  • Sakinofsky I. (2014, May). Preventing suicide among inpatients. Can J Psychiatry. 59(3):131-140.
  • Suicide Prevention Resource Center. (2008). Is your patient suicidal? Emergency department poster and clinical guide. 
  • Suicide Prevention Resource Center and National Action Alliance for Suicide Prevention (n.d.). Zero suicide data elements worksheet.
  • U.S. Department of Veterans Affairs, VA National Center for Patient Safety. (2018). Mental health environment of care checklist (MHEOCC). [Excel].