Learning from prevented suicide in psychiatric inpatient care: An analysis of data from the National Patient Safety Agency

Background: Inpatient suicide is a tragedy, and removal of the means is only a partially effective strategy. Objectives: To identify the mechanisms by which attempted inpatient suicides are prevented, so that their use can become more widespread. Method: Analysis of one year of nationally reported suicide attempts on inpatient psychiatric wards from the National Patient Safety Agency. Results: Patients are discovered in the act by staff checks (medication rounds, meals, routine activities, and intermittent observation) and by staff being caringly vigilant and inquisitive (noticing the absence of patients, their psychological distress, physical state, responding to unusual noises, etc.). Conclusions: The use of intermittent observation and other patient checks should be increased, and particularly directed to private areas of the ward. All staff should act on any sense of unease or feeling that something about a patient, their behaviour, or noises on the ward, are not right. (C) 2011 Elsevier Ltd. All rights reserved.