ArticleBMJ open2021
Suicide as an incident of severe patient harm: a retrospective cohort study of investigations after suicide in Swedish healthcare in a 13-year perspective.
Article in BMJ open, 2021. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 9 papers, 1 of them a synthesis that pooled it.
What it found
Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.
The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.
The trial behind it
Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.
Who cites it
9 citing papers in PubMed, 1 synthesis or guideline pooled it, 17 citations in OpenAlex.
- Shared understanding of resilient practices in the context of inpatient suicide prevention: a narrative synthesis.BMC health services research · 2022Pooled it
- Reorienting the Way a Community Mental Health Service Responds to Suicide and Other Serious Incidents.Community mental health journal · 2026Article
- From Root Cause Analysis to Systems Thinking: A Comparative Content Analysis of Patient Safety Incident Investigation Reports in Mental Healthcare.Journal of evaluation in clinical practice · 2026Article
- Patient and care setting characteristics related to adverse events of self-harm, suicide attempt and suicide: a Danish nationwide study.BMC health services research · 2026Article
- Person-centred suicide prevention: key elements from the perspective of people living with suicidality.International journal of qualitative studies on health and well-being · 2025Article
- Suicide Risk Assessments Understood as Medical Rituals: Functions and Implications from Societal and Medico-Ethical Perspectives.Journal of bioethical inquiry · 2025Article
- Clinicians Perspectives on Effective Suicide Prevention in Secondary Care Adult Mental Health Services: An Appreciative Inquiry Approach.International journal of mental health nursing · 2025Article
- Requirements for effective investigation and learning after suicide: the views of persons with lived experience and professionals.Frontiers in health services · 2025Article
- Article
Corrections and comments
PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.
Authors and funding
4 authors at 2 institutions in 1 country.
Funding
No grant is acknowledged in the PubMed record.
Abstract
objectivesTo explore how mandatory reporting to the supervisory authority of suicides among recipients of healthcare services has influenced associated investigations conducted by the healthcare services, the lessons obtained and whether any suicide-prevention-related improvements in terms of patient safety had followed. DESIGN AND SETTINGS: Retrospective study of reports from Swedish primary and secondary healthcare to the supervisory authority after suicide.
participantsCohort 1: the cases reported to the supervisory authority in 2006, from the time the reporting of suicides became mandatory, to 2007 (n=279). Cohort 2: the cases reported in 2015, a period of well-established reporting (n=436). Cohort 3: the cases reported from September 2017, which was the time the law regarding reporting was removed, to November 2019 (n=316). PRIMARY AND SECONDARY OUTCOME MEASURES: Demographic data and received treatment in the months preceding suicide were registered. Reported deficiencies in healthcare and actions were categorised by using a coding scheme, analysed per individual and aggregated per cohort. Separate notes were made when a deficiency or action was related to a healthcare-service routine.
resultsThe investigations largely adopted a microsystem perspective, focusing on final patient contact, throughout the overall study period. Updating existing or developing new routines as well as educational actions were increasingly proposed over time, while sharing conclusions across departments rarely was recommended.
conclusionsThe mandatory reporting of suicides as potential cases of patient harm was shown to be restricted to information transfer between healthcare providers and the supervisory authority, rather than fostering participative improvement of patient safety for suicidal patients.The similarity in outcomes across the cohorts, regardless of changes in legislation, suggests that the investigations were adapted to suit the structure of the authority's reports rather than the specific incident type, and that no new service improvements or lessons are being identified.
Indexed as
Identifiers
What OpenQuestion holds
Registered trials
Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.