Year: 2014 Source: Australasia Psychiatry.(2013).21(4):359-364. DOI: 10.1177/1039856213486306 SIEC No: 20140241

To describe the intent and process of reviews undertaken following the death by suicide of an inpatient and suggest possible improvements. While Root Cause Analysis remains a useful methodology, review of inpatient suicides should go beyond examination of systems issues only, and include consideration of the care and treatment provided: whether it met accepted clinical standards and was delivered by staff with adequate skills to consider the inherent risks of mental illness. Review of aggregate data has a useful role in identifying significant common features associated with inpatient deaths.