we must continue to grow our knowledge base on the nature and circumstances of RRA to prevent harm to an increasing vulnerable population of nursing home residents and ensure a safe working environment for staff.

This is the first national study in Australia, and the largest internationally, to examine RRA deaths using medicolegal data. This generates hypotheses for future research on the effect of environmental and organizational factors on the frequency and preventability of RRA.

There is a paucity of research describing completed suicide among nursing home residents. More large-scale research is required using standardized methods for reporting information to better understand and prevent completed suicides in this setting.