title: Suicide by mental health in-patients under observation.
abstract: BACKGROUND
  Observations in psychiatric in-patient settings are used to reduce suicide, self-harm, violence and absconding risk. The study aims were to describe the characteristics of in-patients who died by suicide under observation and examine their service-related antecedents.
  
  
  METHODS
  A national consecutive case series in England and Wales (2006-2012) was examined.
  
  
  RESULTS
  There were 113 suicides by in-patients under observation, an average of 16 per year. Most were under intermittent observation. Five deaths occurred while patients were under constant observation. Patient deaths were linked with the use of less experienced staff or staff unfamiliar with the patient, deviation from procedures and absconding.
  
  
  CONCLUSIONS
  We identified key elements of observation that could improve safety, including only using experienced and skilled staff for the intervention and using observation levels determined by clinical need not resources.
authors.affiliation: The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness,Centre for Mental Health and Safety, University of Manchester,Jean McFarlane Building,Oxford Road,Manchester,UK.
authors.forename: S
authors.initials: S
authors.lastname: Flynn
authors.affiliation: The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness,Centre for Mental Health and Safety, University of Manchester,Jean McFarlane Building,Oxford Road,Manchester,UK.
authors.forename: T
authors.initials: T
authors.lastname: Nyathi
authors.affiliation: The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness,Centre for Mental Health and Safety, University of Manchester,Jean McFarlane Building,Oxford Road,Manchester,UK.
authors.forename: S-G
authors.initials: SG
authors.lastname: Tham
authors.affiliation: The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness,Centre for Mental Health and Safety, University of Manchester,Jean McFarlane Building,Oxford Road,Manchester,UK.
authors.forename: A
authors.initials: A
authors.lastname: Williams
authors.affiliation: The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness,Centre for Mental Health and Safety, University of Manchester,Jean McFarlane Building,Oxford Road,Manchester,UK.
authors.forename: K
authors.initials: K
authors.lastname: Windfuhr
authors.affiliation: The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness,Centre for Mental Health and Safety, University of Manchester,Jean McFarlane Building,Oxford Road,Manchester,UK.
authors.forename: N
authors.initials: N
authors.lastname: Kapur
authors.affiliation: The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness,Centre for Mental Health and Safety, University of Manchester,Jean McFarlane Building,Oxford Road,Manchester,UK.
authors.forename: L
authors.initials: L
authors.lastname: Appleby
authors.affiliation: The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness,Centre for Mental Health and Safety, University of Manchester,Jean McFarlane Building,Oxford Road,Manchester,UK.
authors.forename: J
authors.initials: J
authors.lastname: Shaw
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D004739:England / Q000453:epidemiology; D005260:Female; D006801:Humans; D007297:Inpatients / Q000706:statistics & numerical data*; D008297:Male; D008605:Mental Health Services / Q000706:statistics & numerical data*; D008875:Middle Aged; D061214:Patient Safety / Q000592:standards / Q000706:statistics & numerical data*; D013405:Suicide / Q000706:statistics & numerical data*; D014852:Wales / Q000453:epidemiology; D055815:Young Adult
keywords: Constant; In-patient; Intermittent; Observation; Suicide