S70: A systems approach to suicide prevention – what can we learn from health care system reviews into suicide deaths?

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By September 16, 2018 No Comments

Authors: Marianne Wyder, Kathy Stapley, and David Crompton

Year: 2018

Event: 2018 TheMHS Conference


Type of resource: Conference Presentations and Papers

Abstract: Many of those who die by suicide have had contact with mental healthcare services either as an inpatient or outpatient prior to their death. In Australia such deaths are assessed and where deemed appropriate are reviewed by Human Error and Patient Safety (HEAPS) or Root Cause Analysis (RCA) methodologies. These approaches take a ‘no blame’ approach and focus on system factors that may have contributed to these deaths. In this presentation we will present results from a systematic review of all deaths through suicide who had recorded contact with Metro South Addictions and Mental Health Services between 2014 and 2017 within 30 days of their death. This analysis focussed on what occurred during the last contact with the mental health care system, risk assessment and outcomes of these. It will also present an overview of the service recommendations and highlight critical points where issues are more likely to occur.

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