Deficiencies in healthcare prior to suicide and actions to deal with them: A retrospective study of investigations after suicide in Swedish healthcare

Research output: Contribution to journalArticle


Objectives The overall aim of this study was to aggregate the conclusions of all investigations conducted after suicides reported to the supervisory authority in Sweden in 2015, and to identify deficiencies in healthcare found in these investigations; the actions proposed to deal with the deficiencies; the level of the organisational hierarchy (micro-meso-macro) in which the deficiencies and actions were situated; and outcomes of the supervisory authority's decisions. Design and setting This is a retrospective study of all reports from Swedish primary and secondary healthcare after suicide to the regulatory authority in Sweden in 2015. Results In 55% (n=240) of cases, healthcare providers reported healthcare deficiencies that contributed to suicide; these deficiencies were primarily in 'suicide risk assessment' and 'treatment'. Actions aimed at preventing new suicides were proposed in 80% of cases (n=347). By far, the most frequent actions were 'education and competence', present in 52% of cases (n=227) and did not much correspond with identified deficiencies. Sixty-five per cent of the deficiencies and actions were at microlevel, while the remainders were at mesolevel. In 65% (n=284) of cases, the supervisory authority approved the investigation without further requirements. Conclusions The most common identified deficiencies were related to care in the immediate interface between patient and staff. Actions proposed to prevent new suicides were centred on single educational interventions without distinctive sustainable effects in the organisations and usually did not correspond with the identified deficiencies. Future research should examine if application of a framework based on knowledge of the suicide process, suicide prevention strategies and patient safety would enable more sophisticated investigations that could facilitate progress on suicide prevention.


  • Elin Roos Af Hjelmsäter
  • Axel Ros
  • Boel Andersson Gäre
  • Åsa Westrin
External organisations
  • Jönköping University
  • Region Skåne
  • Höglandssjukhuset
  • Ryhov County Hospital, Jönköping
  • Jönköping County Council
Research areas and keywords

Subject classification (UKÄ) – MANDATORY

  • Health Care Service and Management, Health Policy and Services and Health Economy
  • Psychiatry


  • adult psychiatry, health & safety, quality in health care, risk management, suicide & self-harm
Original languageEnglish
Article numbere032290
JournalBMJ Open
Issue number12
Publication statusPublished - 2019 Dec 11
Publication categoryResearch