Suicide as an incident of severe patient harm: a retrospective cohort study of investigations after suicide in Swedish healthcare in a 13-year perspective

Abstract

ObjectivesTo explore how mandatory reporting to the supervisory authority of suicides among recipients of healthcare services has influenced associated investigations conducted by the healthcare services, the lessons obtained and whether any suicide-prevention-related improvements in terms of patient safety had followed.Design and settingsRetrospective study of reports from Swedish primary and secondary healthcare to the supervisory authority after suicide.ParticipantsCohort 1: the cases reported to the supervisory authority in 2006, from the time the reporting of suicides became mandatory, to 2007 (n=279). Cohort 2: the cases reported in 2015, a period of well-established reporting (n=436). Cohort 3: the cases reported from September 2017, which was the time the law regarding reporting was removed, to November 2019 (n=316).Primary and secondary outcome measuresDemographic data and received treatment in the months preceding suicide were registered. Reported deficiencies in healthcare and actions were categorised by using a coding scheme, analysed per individual and aggregated per cohort. Separate notes were made when a deficiency or action was related to a healthcare-service routine.ResultsThe investigations largely adopted a microsystem perspective, focusing on final patient contact, throughout the overall study period. Updating existing or developing new routines as well as educational actions were increasingly proposed over time, while sharing conclusions across departments rarely was recommended.ConclusionsThe mandatory reporting of suicides as potential cases of patient harm was shown to be restricted to information transfer between healthcare providers and the supervisory authority, rather than fostering participative improvement of patient safety for suicidal patients.The similarity in outcomes across the cohorts, regardless of changes in legislation, suggests that the investigations were adapted to suit the structure of the authority’s reports rather than the specific incident type, and that no new service improvements or lessons are being identified.

Systemperspektiver på selvmordsforebygging i psykisk helsevern

“…Selvmord under og etter kontakt med spesialisthelsetjenestene er selvsagt en sterkt uønsket hendelse, og selvmord er langt fra alltid forårsaket av forhold i eller ved tjenestene. Enkelte har foreslått å forstå selvmord i spesialisthelsetjenestene som en sjelden ulykke eller uønsket hendelse (AjdacicGross et al, 2019;Fröding et al, 2021). Fordelen med en slik forståelse er at den kan åpne opp for å bruke etablerte risikoforståelsesmodeller, forholde seg mer offensivt til den sterkt forhøyede risikoen for selvmord pasien tene har, og ta høyde for at selvmord ikke nødvendig vis er knyttet til feil utført i tjenestene.…”

Coexisting service-related factors preceding suicide: a network analysis

“…The RCA procedure has been exhaustively described elsewhere,11 13 14 and the workflow of the Swedish RCA teams is identical to the steps listed there 12. A short summary of the history of incident reporting and patient safety legislation in Sweden can be found in Fröding et al 15…”

“…Besides highlighting the importance of providing treatment to underlying illness, it stresses the reduction of accessibility to lethal means,40–45 combining immediate and long-term multilevel interventions,42 43 46 47 building trustful staff–patient relationships and involving relatives,48–50 conducting regular assessments in outpatient settings,49 51 52 designing safer environments for inpatients,53–56 following up earlier and maintaining closer supervision in the post-discharge period 57–66. To reduce organisational risk factors, better communication among professionals, proper education and provision of adequate guidelines have been suggested 15 49 52…”

Shared understanding of resilient practices in the context of inpatient suicide prevention: a narrative synthesis

“…Retrospective reviews of suicide incidents have focused on deficiencies in the interface between healthcare professionals (HCPs) and patients [14,17,18]. In hindsight, suicide investigations have often concluded that an improved risk assessment could have led to a different outcome [14,17,18]. Nonetheless, suicidal outcomes cannot be predicted at the individual level [19][20][21].…”

“…Nonetheless, suicidal outcomes cannot be predicted at the individual level [19][20][21]. The fallacies of perceiving HCPs in the sharp end of the system as the main causes of the patient suicide are abundant; HCPs are the secondary victims of patient suicides; learning outcomes at the system level are limited; and the complexity of making the decisions regarding suicide risk, and the flexibility required for HCPs to adapt treatment to patients is ignored [14,17,18].…”