Root Cause Analyses of Suicides of Mental Health Clients: Identifying Systematic Processes and Service-Level Prevention Strategies.
BACKGROUND
The ability to predict imminent risk of suicide is limited, particularly among mental health clients. Root cause analysis (RCA) can be used by health services to identify service-wide approaches to suicide prevention.


OBJECTIVE
To (a) develop a standardized taxonomy for RCAs; (b) to quantitate service-related factors associated with suicides; and (c) to identify service-related suicide prevention strategies.


METHODS
The RCAs of all people who died by suicide within 1 week of contact with the mental health service over 5 years were thematically analyzed using a data collection tool.


RESULTS
Data were derived from RCAs of all 64 people who died by suicide between 2008 and 2012. Major themes were categorized as individual, situational, and care-related factors. The most common factor was that clients had recently denied suicidality. Reliance on carers, recent changes in medication, communication problems, and problems in follow-through were also commonly identified.


CONCLUSIONS
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.
1 Mental Health Services, Western Sydney Local Health District, Cumberland Hospital, Parramatta CBD, NSW, Australia.
Donna
D
Gillies
1 Mental Health Services, Western Sydney Local Health District, Cumberland Hospital, Parramatta CBD, NSW, Australia.
David
D
Chicop
1 Mental Health Services, Western Sydney Local Health District, Cumberland Hospital, Parramatta CBD, NSW, Australia.
Paul
P
O'Halloran
D000328:Adult; D003142:Communication; D005260:Female; D006801:Humans; D008297:Male; D001523:Mental Disorders; D008605:Mental Health Services; D008875:Middle Aged; D011369:Professional-Patient Relations; D018570:Risk Assessment; D012307:Risk Factors; D060891:Root Cause Analysis; D059020:Suicidal Ideation; D013405:Suicide / Q000523:psychology; D000092864:Suicide Prevention
mental health services; root cause analysis; suicide prevention; systems change