T2021-01 Three patient suicides in a psychiatric hospital in South Savo in the autumn of 2021

Three patients in South Savo Social and Health Care Authority’s Moisio Psychiatric Hospital in Mikkeli committed suicide in the space of 24 days in the autumn of 2021. All three were women aged between 50 and 75 years of age. In each case the patient had been routinely out of the sight of hospital staff immediately before the incident. Each patient’s absence from the ward was noticed relatively quickly, after which a search for the patient was initiated. All of the deaths occurred by drowning, two in a pond on the hospital grounds and one on the ward. The patients had been in the hospital for between one week and two months before their death.

The backgrounds and medical histories of the suicide victims were all different. One had a history of substance abuse and frequent interactions with health care services. Primary health care professionals had not been able to help the patient, and progress was only made when the patient’s case worker from social services began to push health care services to admit the patient. The second patient spiralled out of control relatively suddenly as a result of somatic problems and loneliness. The third patient had had their long-term medication deprescribed 18 months before her admission to the hospital, which had led to the patient’s deterioration and a suicide attempt. The escalation of a variety of problems led all three individuals to a situation where they needed psychiatric inpatient care. Hospitalisation did not bring the patients significant progress. All three suicides came as a surprise to health care personnel. The other two patients were already being treated in the hospital when the first suicide occurred. Suicidal persons are susceptible to mimicking the suicidal behaviour of someone else.

One of the conclusions of the investigation is that primary health care practices may not have the capacity to respond to the needs of multimorbid patients in a timely enough manner. The best outcome can be achieved when social services and health care services work together. Effective pharmacotherapy is a key element of the treatment of psychiatric patients, and changes in the drug regimen can have a significant impact on a patient’s health.

Information relating to a patient’s suicidal intent or behaviour is not necessarily flagged as a risk factor, which makes it more difficult to spot critical entries in patient records. The investigators also discovered that the structured methods described in the Current Care Guideline for suicide prevention are not always employed systematically.

There is a shortage of psychiatrists in the public health care system, which is in part due to not enough students wishing to specialise in psychiatry. Psychiatrists and other specialists play a critical role in ensuring the standard of psychiatric inpatient care and patient safety. The objective of inpatient care is to enable patients to cope with daily life, and achieving this objective requires patients to have as much freedom as possible. It is never possible to eliminate all risk, which makes patient-specific risk assessment all the more important.

The law does not make any authority responsible for the systematic investigation of inpatient suicides from the perspective of learning from previous incidents and suicide prevention. Any lessons that the authorities and service providers happen to learn are not put to systematic use.

The Safety Investigation Authority recommends that

• the Finnish Institute for Health and Welfare take it upon itself to ensure that entries relating to suicide risk are flagged as risk factors in its coding service. The recording of information about suicide risk needs to be promoted as part of the information strategy of the new well-being services counties and efforts to improve the recording practices of social and health care services in general in order to ensure that information relating to risks is easy to find and can be used to improve patient safety.

• the Ministry of Social Affairs and Health take it upon itself to ensure that each well-being services county has enough specialist competence and services to offer its clients and patients according to their myriad psychiatric needs. More specialist training is needed on the detection of psychiatric multimorbidity and the prevention of suicides, which must be provided in collaboration with education providers and labour market operators. More psychiatrists are needed in the public health care system.

• the Ministry of Social Affairs and Health take it upon itself to ensure that a harmonised operating model for the investigation of patient and client suicides and suicide attempts is introduced across the whole of the social welfare and health care system and kept up to date. Any lessons learned from investigations that could help to improve safety must be shared across and between well-being services counties as part of the efforts to continuously improve the standard of safety management and the implementation of the national patient and client safety strategy.