Lessons From a Comprehensive Clinical Audit of Users of Psychiatric Services who Committed Suicide

A total of 629 psychiatric patients who had committed suicide in the state of Victoria, Australia between July 1989-June 1994 were identified. 72% of the patients were male, 62% were under 40 years old, & 51% were unmarried. 67% had previously attempted suicide. 311 had received care within 4 weeks of death. 20% of the suicides were considered preventable. Key factors associated with preventability were poor staff-patient relationships, incomplete assessments, poor assessment & treatment of depression & psychological problems, & poor continuity of care. Opportunities exist for the psychiatric service system to alter practices at several levels & thereby reduce patient suicides. (19 refs.)