Dialogue Volume 15, Issue 3 2019 - Page 49

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