285 © The Author(s) 2020. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com International Journal for Quality in Health Care, 2020, 32(5), 285–291 doi: 10.1093/intqhc/mzaa011 Review Article Review Article How health care systems let our patients down: a systematic review into suicide deaths MARIANNE WYDER 1,2 , MANAAN K. RAY 1 , HELENA ROENNFELDT 2,3 , MICHAEL DALY 1,4 , and DAVID CROMPTON 1,2 1 Metro South Health and Hospital Service, 2 Menzies Health Institute Queensland, Griffith University, 3 Centre for Psychiatric Nursing, University of Melbourne, School of Health Sciences, and 4 Queensland university of Technology Address reprint requests to: Marianne Wyder, Metro South Health - Addiction and Mental Health Services, PO Box 6046, Brisbane, Queensland 4122, Australia. E-mail: m.wyder@outlook.com Editorial Decision 23 December 2019; Accepted 0 Month 20xx Abstract Purpose: To synthesize the literature in relation to findings of system errors through reviews of suicide deaths in the public mental health system. Data sources: A systematic narrative meta-synthesis using the PRISMA methodology was con- ducted. Study selection: All English language articles published between 2000 and 2017 that reported on system errors identified through reviews of suicide deaths were included. Articles that reported on patient factors, contact with General Practitioners or individual cases were excluded. Data extraction: Results were extracted and summarized. An overarching coding framework was developed inductively. This coding framework was reapplied to the full data set. Results of data synthesis: Fourteen peer reviewed publications were identified. Nine focussed on suicide deaths that occurred in hospital or psychiatric inpatient units. Five studies focussed on suicide deaths while being treated in the community. Vulnerabilities were identified throughout the patient’s journey (i.e. point of entry, transitioning between teams, and point of exit with the service) and centred on information gathering (i.e. inadequate and incomplete risk assessments or lack of family involvement) and information flow (i.e. transitions between different teams). Beyond enhancing policy, guidelines, documentation and regular training for frontline staff there were very limited suggestions as to how systems can make it easier for staff to support their patients. Conclusions: There are currently limited studies that have investigated learnings and recommen- dations. Identifying critical vulnerabilities in systems and to be proactive about these could be one way to develop a highly reliable mental health care system. Key words: quality improvement, quality management, health system reform, health care system, adverse events, patient safety Introduction Despite a reduction in deaths due to suicide in most World Health Organization (WHO) regions, suicide still accounts for ∼1 million deaths per year and remains a leading cause of death among younger age groups. The 26% decline in suicide rates has not occurred in all regions with suicide disproportionately affecting those who are disadvantaged by education, employment and socioeconomic status with males continuing to be disproportionately represented in suicide data [1, 2]. Data indicate that factors such as access to mental health care, type of vocation, presence of mental illness, general health, social isolation and marital status inf luence the risk of suicide. [3–5]. The literature also highlights that countries with declining rates Downloaded from https://academic.oup.com/intqhc/article/32/5/285/5850236 by guest on 30 January 2023