PRACTICE PARTNER
PATIENT SAFETY
We use this forum to regularly report on findings from patient safety organizations, expert review
committees of the Office of the Chief Coroner, and inquests.
Key Reminders When
Assessing Potential
Suicidality
Coroner’s Committee
makes recommendations
A
review into the suicide of a young
man has prompted several remind-
ers from a committee of the Chief
Coroner’s office.
The Patient Safety Death Review Committee
investigated the suicide of a 27-year-old Cana-
dian military veteran who was despondent over
the break up of a relationship. Concerns were
identified regarding the psychiatric services
received including assessment, treatment and
follow-up.
In August, 2014, the man’s former partner
called police after she received a text message
from him, indicating that he was thinking
of killing himself. Police arrived at the man’s
residence and transported him to hospital for
further assessment. His rifle was removed from
the residence by police.
The man, who had no history of known
mental health disorders, was assessed by a
physician in the hospital’s emergency depart-
ment (ED); the examining physician was
not a psychiatrist. The ED physician did
not record any indication of suicidality or
homicidality and the patient was discharged
home with a diagnosis of situational chal-
lenge. He was placed on "suicide watch" by
the military.
The next day, military personnel attended the
man’s residence to check on his wellbeing as per
the "suicide watch." When he did not come to
the door, the local police were notified. Upon
entry to the residence, the man was found with
a fatal self-inflicted gunshot wound.
It is believed that earlier that day, he had
legally purchased another gun and ammuni-
tion at a store.
The Patient Safety Death Review Commit-
tee was concerned by a number of different
issues raised in the course of its investigation.
It put forward recommendations to several
organizations including the CPSO. the College
of Nurses of Ontario, the Ontario Psychiatric
Association and the Department of National
ISSUE 3, 2019 DIALOGUE
49