Tracking Tragedy: a Systemic Look at Homicide by Mental Health Patients and Suicide Death of Patients in Community Mental Health Settings Third Report of the Committee

This third report focussed on people receiving community care for depression & who died by suicide. The extent to which New South Wales Mental Health Services provided assessment & treatment in line with suggested practice guidelines was examined. Some of the findings regarding the 113 clients included in the review were: most clients had a past history of contact with mental health services & of past suicide attempts; assessments were mainly done by mental health nurses & psychiatry registrars but around two-thirds of assessment were neither seen by nor discussed with a psychiatrist; treatment provided was of brief duration; medication was the main treatment modality; & ongoing monitoring of suicide risk was documented in only 27% of cases.