Patient-specific risk assessment is a critical element of psychiatric care

The Safety In­ves­ti­ga­tion Au­thor­ity, Fin­land (SIAF) es­tab­lished a new in­ves­tiga­tive branch fo­cus­ing on in­ci­dents in so­cial and health care set­tings ap­prox­i­mately one year ago. The new branch is re­spon­si­ble for in­ves­ti­gat­ing these kinds of in­ci­dents and for sys­tem­at­i­cally analysing the find­ings of the in­ves­ti­ga­tions in or­der to im­prove pub­lic safety.

The Safety Investigation Authority, Finland (SIAF) has completed its investigation into three psychiatric inpatient suicides that occurred in the South Savo Social and Health Care Authority’s Moisio Psychiatric Hospital in Mikkeli in the autumn of 2021. All of the suicides were committed by drowning, and all three victims were women. The backgrounds and medical histories of the suicide victims were all different.

Despite being in psychiatric inpatient care, the treatment that the women received failed to significantly improve their health.

It can be concluded based on the investigation 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.

The suicides came as a surprise to nursing staff. 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.

‘Our recommendations based on the investigation include always flagging suicidal tendencies as a risk factor in patient information systems. The fact that this is not standard practice at the moment makes it possible for information that would be critical for the patient’s care to get lost amid client and patient records. Furthermore, risk assessments are currently largely based on interviewing and other assessment of patients – more emphasis should be given to the use of the structured methods described in the Current Care Guideline for suicide prevention’, says Investigator-in-Charge Hanna Tiirinki.

‘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 nevertheless play a critical role in ensuring the standard of psychiatric inpatient care and patient safety. It is never possible to eliminate all risk, which makes patient-specific risk assessment all the more important’’, Tiirinki adds.

The investigation also revealed that 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. The lessons learned from past incidents therefore cannot be used systematically to anticipate and prevent similar incidents in the future. The Safety Investigation Authority’s recommendations also address this weakness.

Further information:

Investigator-in-Charge Hanna Tiirinki, tel. +358 (0) 29 515 0747

For ESSOTE, Mielenterveys- ja päihdepalvelujen palvelualuejohtaja Minna Mutanen, tel. +358 (0)44 794 4300