Centre staff lacked suicide awareness

A proper assessment of patients of a mental health service where 13 people died by apparent suicide in less than two years would have made staff more alert to the risk of them taking their own lives, a report has found.

While a review of the patient safety culture and governance within Carlow/Kilkenny and South Tipperary mental health services concluded that the number of deaths by apparent suicide was not out of sync with figures in the UK, it also found staff training for risk assessment was either “insufficient, or else it wasn’t being carried out at all”.

Between January 2012 and March 2014, 13 patients died by apparent suicide, three in the Department of Psychiatry, St Luke’s Hospital, Kilkenny; two within 24 hours of discharge from the Department of Psychiatry; four while the patient was under the care of the home-based treatment team; one died while in a crisis house; and three died while under the care of the community mental health services.