Objectives: To describe the caseload of completed suicides at a single psychiatric facility and to review the perceived deficiencies in the care of those patients.
Method: Demographic and diagnostic data, clinical circumstances, and the deficiencies in care and documentation or both were extracted from medical records and post-suicide audit reports.
Results: There were 276 completed suicides over the period reviewed, yielding suicide rates of 206 per 100,000 registered patients and 123.5 per 100,000 inpatient discharges. The male to female ratio was 2:1, and patients with schizophrenia or depression accounted for 63.7% of the caseload. Only 18% of inpatients were involuntary, and only 10% were under individual observation at the time of suicide. Individual psychiatrists had up to 15 suicides in their caseloads. Deficiencies and recommendations pursuant to case audits are summarized.
Conclusion: This is the first report of the entire cumulative experience with completed suicide, including audited deficiencies in the care and documentation of that caseload, at a single Canadian psychiatric facility.