The Clarke Institute experience with completed suicide: 1966 to 1997

To describe the caseload of completed suicides at a single psychiatric facility and to review the perceived deficiencies in the care of those patients.

Demographic and diagnostic data, clinical circumstances, and the deficiencies in care and documentation or both were extracted from medical records and post-suicide audit reports.

There were 276 completed suicides over the period reviewed, yielding suicide rates of 206 per 100,000 registered patients and 123.5 per 100,000 inpatient discharges. The male to female ratio was 2:1, and patients with schizophrenia or depression accounted for 63.7% of the caseload. Only 18% of inpatients were involuntary, and only 10% were under individual observation at the time of suicide. Individual psychiatrists had up to 15 suicides in their caseloads. Deficiencies and recommendations pursuant to case audits are summarized.

This is the first report of the entire cumulative experience with completed suicide, including audited deficiencies in the care and documentation of that caseload, at a single Canadian psychiatric facility.