Coexisting service-related factors preceding suicide: a network analysis

OBJECTIVES: The overall objective was to analyse service-related factors involved in the complex processes that precede suicide in order to identify potential targets for intervention. DESIGN AND SETTING: Explorative network analysis study of post-suicide root cause analysis data from Swedish primary and secondary healthcare. PARTICIPANTS: 217 suicide cases reported to the Swedish national root cause analysis database between 2012 and 2017. PRIMARY AND SECONDARY OUTCOME MEASURES: A total of 961 reported incidents were included. Demographic data and frequencies of reported deficiencies were registered. Topology, centrality indices and communities were explored for three networks. All networks have been tested for robustness and accuracy. RESULTS: Lack of follow-up, evaluations and insufficient documentation issues emerged as central in the network of major themes, as did the contributing factors representing organisational problems, failing procedures and miscommunication. When analysing the subthemes of deficiencies more closely, disrupted treatments and staffing issues emerged as prominent features. The network covering the subthemes of contributing factors also highlighted discontinuity, fragile work structures, inadequate routines, and lack of resources and relevant competence as potential triggers. However, as the correlation stability coefficients for this network were low, the results need further investigation. Four communities were detected covering nodes for follow-up, evaluation, cooperation, and procedures; communication, documentation and organisation; assessments of suicide risk and psychiatric status; and staffing, missed appointments and declined treatment. CONCLUSION: The results of this study suggest that healthcare providers may improve patient safety in suicide preventive pathways by taking active measures to provide regular follow-ups to patients with elevated suicide risk. In some cases, declined or cancelled appointments could be a warning sign. Tentative results show organisational instability, in terms of work structure, resources and staffing, as a potential target for intervention, although this must be more extensively explored in the future.