Implementation of a countywide adult suicide review commission: Development, lessons learned, and recommendations

Fatality review is a public health approach designed to inform efforts to prevent fatalities of a certain kind (e.g., suicide, homicide) or in a specific setting or population (e.g., hospitals, youth). Despite extensive literature on fatality review generally, the literature on suicide review teams specifically is scant. The aim of this paper is to: describe the implementation of a local adult suicide review commission, detail examples of initial outcomes and recommendations developed by the commission, and provide recommendations and/or best practices for how to develop and implement an adult suicide review team.

We utilize framing questions from the American Association of Suicidology's psychological autopsy framework. By using these guiding questions in the discussion, members are invited to explore not only the stressors that may have more immediately preceded the suicide event itself, but to situate those stressors in the context of the individual's life course.

Several recommendations proposed by our commission have resulted in tangible outcomes and are detailed using Haddon's Matrix as a guiding prevention planning tool.

We have highlighted the need to move beyond looking at individual-level help-seeking to focus on structural/systemic issues that result in stress or create unsafe environments for at-risk individuals.