Root causes for suicide attempts and deaths by unit type 2017 and 2018
| Mental health units | Examples | Per cent (%) |
| Treatment for suicidal patient’s needs improvement | Specific treatment focused on reduction of suicidal behaviours and thoughts was lacking. | 17.27 |
| Environmental risk factors | Physical structures on the unit, such as blind spots contributed to the event. | 16.36 |
| Access to equipment or hazardous material | The patient had access to material on the unit, such as sheets or sharp objects. | 16.36 |
| Need for staff education on suicide interventions | Staff lacked knowledge of specific therapeutic interventions that reduce suicidal behaviours. | 10.91 |
| Poor communication of risk | Breakdowns in the communication of a patient’s risk of suicide. | 10.91 |
| Assessment of suicide risk need improvement | Specific assessment protocols to assess suicide risk were lacking. | 9.09 |
| Patient stressors or mental illness | Patient factors such as legal problems, family conflict or symptoms of mental illness such as depression and psychosis. | 6.36 |
| Problems with contraband search procedures | The protocol to search for hazardous items in patient clothing and belongings is lacking such that hazardous items have come onto the unit. | 5.45 |
| Pain management problems | The patient was in significant pain that contributed to suicidal thoughts or behaviours. | 2.73 |
| Other | Other root causes. | 2.73 |
| Short staffed | Not enough staff to cover the need to care safely for patients. | 1.82 |
| Total | 100.00 | |
| Emergency departments | ||
| Poor observation of suicidal patient in emergency department | The process of patient observation, usually one-to-one observation, was lacking such that patients were able to attempt suicide while under observation. | 18.75 |
| Poor communication of risk | Breakdowns in the communication of a patient’s risk of suicide. | 12.50 |
| Environmental risk factors | Physical structures on the unit, such as anchor points for hanging, contributed to the event. | 12.50 |
| Access to equipment or hazardous material | The patient had access to material on the unit, such as medical equipment used for self-harm. | 12.50 |
| Need for staff education on suicide interventions | Staff lacked knowledge of specific therapeutic interventions that reduce suicidal behaviours. | 12.50 |
| Assessment of suicide risk need improvement | Specific assessment protocols to assess suicide risk were lacking. | 12.50 |
| Problems with contraband search procedures | The protocol to search for hazardous items in patient clothing and belongings is lacking and hazardous items the patient brought into the emergency department were used for self-harm. | 9.38 |
| Lack of adequate holding area for suicidal patients | The area used to hold suicidal patients had hazards that can be used for self-harm or is not secure from elopement. | 6.25 |
| Treatment for suicidal patient’s needs improvement | Specific treatment focused on reduction of suicidal behaviours and thoughts was lacking. | 3.13 |
| Total | 100.00 | |
| Medical/Surgical units | ||
| Treatment for suicidal patient’s needs improvement | Specific treatment focused on reduction of suicidal behaviours and thoughts was lacking. | 26.09 |
| Environmental risk factors | Physical structures on the unit, such as anchor points for hanging, contributed to the event. | 17.39 |
| Problems with contraband search procedures | The protocol to search for hazardous items in patient clothing and belongings was lacking such that hazardous items have come onto the unit. | 13.04 |
| Poor communication of risk | Breakdowns in the communication of a patient’s risk of suicide. | 8.70 |
| Poor observation of suicidal patient | The process of patient observation, usually one-to-one observation, was lacking such that patients were able to attempt suicide while under observation. | 8.70 |
| Assessment of suicide risk need improvement | Specific assessment protocols to assess suicide risk were lacking. | 8.70 |
| Easy access to medications for self-harm | The patient was able to access medication to use for self-harm. | 8.70 |
| Treatment delays | Delays in medical or mental health treatment contributed to the suicide attempt | 4.35 |
| Short staffed | Not enough staff to cover the need to care safely for patients. | 4.35 |
| Total | 100.00 | |
| Community living centres | ||
| Treatment for suicidal patients’ needs improvement | Specific treatment focused on reduction of suicidal behaviours and thoughts was lacking. | 29.63 |
| Poor communication of risk | Breakdowns in the communication of a patient’s risk of suicide. | 18.52 |
| Assessment of suicide risk need improvement | Specific assessment protocols to assess suicide risk were lacking. | 14.81 |
| Patient room too far away | The patient’s room was not close enough to the nursing station to safety observe the patient. | 7.41 |
| Access to hazardous equipment | The patient had access to material on the unit, such as medical equipment used for self-harm. | 7.41 |
| Poor contraband check | The protocol to search for hazardous items in patient clothing and belongings was lacking such that hazardous items have come onto the unit. | 3.70 |
| Need for staff education on suicide risk factors | Staff lacked knowledge of specific risk factors for suicide. | 3.70 |
| Easy access to over-the-counter medication | The patient was able to access over-the-counter medication to use for self-harm. | 3.70 |
| Multiple providers of medications | More than one provider was prescribing medications allowing the patient access to medications that could be used for self-harm. | 3.70 |
| Patient in severe pain | The patient was in significant pain that contributes to suicidal thoughts or behaviours. | 3.70 |
| Code response delayed | A delay in the code response contributed to the level of harm experienced by the patient. | 3.70 |
| Total | 100.00 | |
| Residential units | ||
| Assessment of suicide risk need improvement | Specific assessment protocols to assess suicide risk were lacking. | 21.21 |
| Poor communication of risk | Breakdowns in the communication of a patient’s risk of suicide. | 15.15 |
| Poor service to service communication | Communication between referral sources and the residential unit was lacking. | 12.12 |
| Need for specific interventions for specific patients | Specific treatments, such as treatment for medically ill suicidal patients was needed. | 9.09 |
| Treatment for suicidal patients’ needs improvement | Specific treatment focused on reduction of suicidal behaviours and thoughts was lacking. | 9.09 |
| Problems with contraband search procedures | The protocol to search for hazardous items in patient clothing and belongings was lacking such that hazardous items have come onto the unit. | 6.06 |
| Need for staff education on suicide risk factors | Staff lacked knowledge of specific risk factors for suicide. | 6.06 |
| Short staffed | Not enough staff to cover the need to care safely for patients. | 6.06 |
| Easy access to medications for self-harm | Not enough staff to cover the need to care safely for patients. | 6.06 |
| Environmental risk factors | Physical structures on the unit, such as anchor points for hanging, contributed to the event. | 6.06 |
| Poor team coordination | The treatment team was not able to coordinate care among team members. | 3.03 |
| Total | 100.00 | |
| Hospital grounds | ||
| Poor communication of risk | Breakdowns in the communication of a patient’s risk of suicide. | 36.84 |
| Problems with assessment and treatment for suicidal patients | Specific treatment and assessment focused on reduction of suicidal behaviours was lacking. | 15.79 |
| Poor inpatient to outpatient communication | Communication between inpatient and outpatient providers was lacking. | 10.53 |
| Poor service to service communication | Communication between service caring for the patient was lacking. | 10.53 |
| Need for specific interventions for specific patients | Specific treatments, such as treatment for medically ill suicidal patients was needed. | 10.53 |
| Environmental risk factors | Physical structures on the hospital grounds, such as anchor points for hanging. | 5.26 |
| Short staffed | Not enough staff to cover the need to care safely for patients. | 5.26 |
| Severe medical diagnosis | The patient’s reaction to his medical diagnosis contributed to the suicide attempt. | 5.26 |
| Total | 100.00 | |
| Clinic areas | ||
| Inadequate controls on entrance to buildings | The outpatient clinic areas can be easily accessed. | 28.57 |
| Need for staff education on suicide risk factors | Staff lacked knowledge of specific risk factors for suicide. | 28.57 |
| Treatment for suicidal patients’ needs improvement | Specific treatment focused on reduction of suicidal behaviours and thoughts was lacking. | 14.29 |
| Poor tracking of emergency response | The system for tracking emergency response times was unreliable and may have contributed to the delay in responding to this attempt. | 14.29 |
| Environmental risk factors | Physical structures in the clinic, such as anchor points for hanging, contributed to the event. | 14.29 |
| Total | 100.00 |