Table 2.
Proportions of cases with deficiencies, as reported in the post-suicide investigations of the healthcare services’ actions
| Cohort 1 (n=279) | Cohort 2 (n=436) | Cohort 3 (n=316) | |
| Cases with deficiencies, total | 136 (49) | 240 (55) | 248 (78) |
| Category | |||
| Communication and information | |||
| Communication with peers and family members | 8 (3) | 51 (12) | 39 (12) |
| Documentation | 57 (20) | 65 (15) | 68 (22) |
| External communication | 21 (8) | 74 (17) | 91 (29) |
| Internal communication | 18 (7) | 61 (14) | 68 (22) |
| Education and competence | |||
| Education and competence not specified | 12 (4) | 54 (11) | 50 (16) |
| Education and competence in suicide risk assessment | 5 (2) | 9 (2) | 13 (4) |
| Organisation and management | |||
| Human resources | 15 (5) | 60 (14) | 53 (17) |
| Number of beds | 2 (1) | 9 (2) | 5 (2) |
| Organisation/management | 2 (1) | 13 (3) | 13 (4) |
| Policies and procedures | |||
| Treatment | 26 (9) | 84 (19) | 92 (29) |
| Suicide risk assessment | 92 (33) | 86 (20) | 76 (24) |
| Work process | 20 (7) | 50 (11) | 51 (16) |
| Diagnostics | 16 (6) | 54 (12) | 41 (13) |
| Care plan and crisis plan | 10 (4) | 46 (11) | 53 (17) |
| Technics and equipment | 5 (2) | 13 (3) | 15 (5) |
| Other | 2 (1) | 11 (3) | 0 (0) |
The data in the table comprise numbers and percentages, n (%). Cohort 1: cases reported in 2006–2007, cohort 2: cases reported in 2015 and cohort 3: cases reported in 2017–2019.