Summary of a two-year study of suicides in the mental health service

During 2005 and 2006, the Norwegian Board of Health Supervision conducted a systematic registration of suicides committed by patients registered in the mental health care service and that were brought to the notice of the county branches of the Board of Health Supervision.

We found that the health enterprises did not comply with their statutory obligation to report to the supervisory authorities in nearly one of five cases, and that the events were only to a small extent used for quality improvement work. The health enterprises failed in preparing routines/procedures for suicide prevention work, in training their employees, in keeping records and in taking care of the bereaved, etc. We also found great differences in how the county branches of the Board of Health Supervision handled suicide cases.