The most significant problems were a lack of routine procedures for risk assessment, documentation and cooperation between different care units.
The report revealed that almost half of those who killed themselves had made one or more suicide attempts in the past. Almost 40 percent of the individuals had undergone no risk assessment and only in one third of the cases had an established care programme for high-risk patients been implemented.
“It is the responsibility of the care system to put this right because it is not satisfactory,” said Johan Carlson, head of the supervisory department at the Board of Health and Welfare.
Two out of three patients in the study had no documented care plan at all.
The board has proposed a series of measures to improve care of those at risk of committing suicide. At the top of the list of recommendations is routine risk assessments, while documentation of cases must be improved in order to make it simpler for new carers to see what treatment the patient has already received.
Another recommendation was improved cooperation and communication between the various care providers, staff and patients, and between carers and relatives.
But one of the authors of the report, Helena Silfverhielm, noted that the information that led to the recommendations was an important part of the process of improvement.
“It’s highly significant that the healthcare system has submitted such detailed material with all of these reports,” she said.
“Behind every report of suicide there is a traumatic sense of failure for relatives as well as for the care system. But every inquiry we can carry out becomes a lead in preventing new suicides.”