This article describes the caseload of completed suicides at a single psychiatric facility & reviews the perceived deficiencies in the care of those patients. There were 276 completed suicides over the study period, yielding suicide rates of 206 per 100,000 registered patients & 123.5 per 100,000 inpatient discharges. The male to female ratio was 2:1 & patients with schizophrenia or depression accounted for 63.7% of the caseload. Only 18% of inpatients were involuntary & only 10% were under individual observation at the time of suicide. Individual psychiatrists had up to 15 suicides in their caseloads. Deficiencies & recommendations pursuant to case audits are summarized. (56 refs.)