Suicide in a hospital is known risk factor and recognized as sentinel event by JCI &NABH. Health care provider should know what to do in a post suicdide scenario.

1. Special Feature
Health Biz India July 201442
By: Dr. AK Khandelwal
M
edical literature
reveals that in-
patient suicide
rate among non psychiatric
patients is 5-15 per 1,00,000
admissions and 100-400
per 1,00,000 admissions in
psychiatric patient. Joint
Commission International on
accreditation of healthcare
organisations also reported
that in-patient suicide occupies
the second position among all
12 sentinel events.
However, there is a
paucity of studies on suicide
in non-psychiatric patients.
The problem of suicides in
such patients is less common
and hence physicians and
the hospital staff have less
experience in dealing with this
problem.
As per reports, around 51
per cent of psychiatrists report
of having had a patient who
committed suicide. However,
having similar predictability
becomes difficult in non-
psychiatric patients.
These days, post-suicide
lawsuits account for the
largest number of malpractice
suits against psychiatrists, a
psychiatrist’s risk of being sued
for malpractice is still quite
low though. Western literature
reveals that even when sued,
clinicians win up to 80 per cent
of the cases.
Suicidal methods
They can be non-violent or
violent. However, studies
suggest that non-psychiatric
patients often resort to violent
methods, like:
• Jumping from a height in
multi-storied hospitals or
wards
• Hanging inside the hospital
ward or in the premises
• Consumption of poisonous
substances/drugs or self
injection overdose
• Self-mutilation by easily-
available objects like fruit
cutting knife, glass or bottles
etc.
Risk factors for suicide
include: previously attempted
suicide; recent suicide
attempt; suicidal thoughts or
behaviors; family history of
suicide or psychiatric illness;
on antidepressants; physical
health problems, including
central nervous system
disorders such as traumatic
brain injury; diagnosis of
delirium or dementia; chronic
pain or intense acute pain;
poor prognosis or prospect
of certain death; social
stressors such as financial
strain, unemployment or loss
of financial independence;
disability; trauma; divorce or
other relationship problems;
hopelessness; substance abuse
Handling a Post-suicide
ScenarioHandling a post-suicide lawsuit is perhaps the worst nightmare
of a hospital administrator

2. Special Feature
www.healthbizindia.in
Health Biz India July 2014 43
like alcohol, drugs, etc.
Strategies for suicide
prevention
In order to effectively
reduce the risk of suicide
in the medical/surgical and
emergency department settings,
organisations need to identify
patients at risk of suicide and
then intervene to prevent
suicides in those patients
identified as ‘at risk’.
Recommendations:
• Regular (every three
years) staff training in risk
management
• In-patients with severe
mental illness and a history
of self-harm or violence
should receive the highest
level of care under the care
programme approach
• Individual care plans should
specify action to be taken
if a patient fails to adhere
to treatment or to attend
appointments
• Prompt access to services
for people in crisis and their
families
• Assertive outreach teams to
prevent loss of contact with
vulnerable and high-risk
patients
• Atypical antipsychotic
drugs to be available for all
patients with severe mental
illness prescribed typicals
who are non-adherent
because of drug side-effects
• Local strategies for dual
diagnosis that include
training in the management
of substance misuse services
and employment of staff
with specific responsibility
for developing the local
service
• Removal or covering of all
likely ligature points in in-
patient wards
• Local arrangements for
information-sharing with
criminal justice agencies
• Policy ensuring post-incident
multidisciplinary case review
and provision of information
to the patient’s family
Liability of a hospital
It is not uncommon to see a
few patients committing suicide
in hospital premises. Hence, a
hospital should be prepared for
such a scenario. Hence, what
would be the responsibility and
• Isolate the body (but do not
disturb it)
• Contact senior nursing and
medical staff
• Contact the family
• Contact the police
• Document the circumstances
of the suicide and all the
actions carried out
• Hold a brief staff meeting to
disseminate information
• Inform hospital management
• Meet with family
• Hold a brief meeting with
patients to disseminate
information
• Convey sympathies to the
family (e.g. card, letter,
attendance at funeral)
• Perform Root Cause Analysis
• Educate staff about findings
and corrective measures
taken
What to do
when a patient
commits
suicide
Myths about Suicide
Patients who repeatedly make suicide threats don’t really want to die
Discussing suicide may “give the patient ideas”
Depression is a normal reaction to medical illness
A history of prior attempts means that the patient is not serious
Suicidality and depression will simply fade away with time
Wanting to die is common in the seriously ill patient

3. Special Feature
Health Biz India July 201444
liability of a hospital manager
in such situations?
The hospital can be held
responsible only if it is proved
that the person was under
absolute care and protection of
hospital staff. It is absolutely
correct in cases where visitors
are prohibited and hospital
staff has the sole authority
over the patient. In situations
where a person in under dual
responsibility of hospital staff
as well as of relatives, it is very
difficult to decide the issue.
Where an in-patient’s
suicidal tendencies are known
and the risk of harm can be
identified through the exercise
of professional medical
judgment, the failure to take
measures to prevent the harm
may constitute malpractice.
The care taker duty to prevent
suicide is premised upon his
special training or experiences
and his consequence ability to
recognise suicidal tendencies in
person under his care.
Accordingly, many
jurisdictions have imposed
liability for suicide
attempts where a patient
has surrendered himself to
the custody and care of a
psychiatric hospital or mental
institution as an inpatient.
Conversely, courts are much
more hesitant to impose
liability upon a psychiatrist
for a suicide attempt on
an outpatient basis. Non-
psychiatric physicians are not
trained to identify suicidal
tendencies and cannot be
held liable.Therefore, this
comment proposes that liability
for causing suicide is rarely
appropriate, not only because
most suicides are not caused
by another person, but because
the act of suicide is usually
a voluntary one for which
another person cannot be held
liable; but, liability for failing
to prevent suicide is proper
when a person or entity in
a special relationship with a
suicidal person breaches its
duty to prevent a foreseeable
suicide.
In conclusion
Suicide in hospital premises
is relatively rare but clinically
quite common. It is therefore
important that clinicians are
up-to-date with suicide risk
assessment and prevention
strategies, the difficulties of
predicting and preventing
suicides, and their trust’s
responsibilities in relation
to their patients. Hospital
management should ensure
that strategies for suicide
prevention are integrated in
the hospital risk management
programme. Once a suicide
occurs, appropriate measures
should be taken as mentioned
to prevent both immediate and
long term complications.
Disclaimer: This article should
be treated only as a reading
material and readers are
advised to seek professional
assistance of a medico-legal
expert in case of being faced
with the above-mentioned
scenario.
About the author
Dr. Ashok Kumar
Khandelwal is the
Medical Director,
Anandaloke Hospital &
Neurosciences Centre,
West Bengal. He is
a trained Assessor
from the National
Accreditation Board for
Hospital and Health
Care Provider (NABH).
He carries around two
decades of experience
in the hospital industry
and 15 years of
experience as a hospital
administrator.