Session Resources S012: “Root Cause Analyses RCAs of Suicides of mental health clients: Identifying systematic processes and service level prevention strategies”

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By September 10, 2015 No Comments

Authors: Paul O'Halloran, David Chircop, Donna Gillies

Year: 2015

Event: 2015 TheMHS Conference

Subject: Talking About & Preventing Suicide

Type of resource: Conference Presentations and Papers

Abstract: The ability to predict imminent risk of suicide is limited, particularly among mental health clients. The methodology of Root Cause Analysis (RCA) can be used by health services to identify service-wide approaches to suicide prevention.

To i) develop a standardised taxonomy to guide future RCAs; ii) quantitatively summarise service-related factors associated with suicides; and iii) identify service-related suicide prevention strategies.

The RCAs of all people who died by suicide within one week of contact with the mental health service over five years were thematically analysed using a data collection tool.

Data were derived from RCAs of all 64 people who died by suicide between 2008 and 2012. Major themes were categorised as individual, situational and care-related factors. The major theme was recent denial of suicidality. Reliance on carers, recent changes in medication, communication problems, and problems in follow through were also commonly identified.

Given the difficulty in predicting suicide in people whose expressions of suicidal ideation change so rapidly, services may consider the use of strategies aimed at improving the individual, stressor, support, and care factors identified in this study.

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