Recommendations from Coroner Following Hospital Suicides

An empty hospital bed

The Office of the Chief Coroner has asked CPSO to share recommendations for system changes with physicians and hospital leaders following the deaths of patients by suicide either while hospitalized as a psychiatric patient, or on a pass or shortly after being discharged from hospital.

The report’s recommendations were produced in collaboration with the patients’ families and the Office of the Chief Coroner with the aim of preventing similar deaths.

Dr. Reuven Jhirad, deputy chief coroner, stated in the report, “Families were concerned with the nature of the deaths and were hopeful that they could help to introduce changes to prevent similar deaths in the future [at St. Joseph’s Healthcare Hamilton and] all other institutions providing in-patient psychiatric care as well.”

During 2016-2018, St. Joseph’s Healthcare Hamilton (SJHH) had nine deaths involving patients in their institution or while on a pass, where the manner of death was classified as suicide. Over the last several years, SJHH has implemented several changes as a result of their own reviews, an external review, individual family comments, as well as the recommendations included in the report of the Office of the Chief Coroner and the Ontario Forensic Pathology Service.

The rating scale can be embedded in a hospital EMR and allow clinicians to create and document an individualized safety plan visible to all in the circle of care

The 17 recommendations touch on different issues, including monitoring, risks of seclusion, ensuring patients are protected from violent behaviour of other patients and notification of family prior to discharge. They were grouped under four categories:

  • In-Hospital Treatment and Assessment;
  • Hospital Passes;
  • Outpatient Treatment; and
  • Review Process for Deaths that Occur

Dr. Vivian Sapirman, a psychiatrist and CPSO Medical Advisor, urges hospital leaders to review this report and implement necessary changes. She encouraged hospitals to pay particular attention to the recommendation to adopt a formal, defined risk assessment for individuals assessed/admitted with depression and/or suicidal ideation. One such tool, adopted by SJHH in 2019, is the Columbia Suicide Severity Rating Scale (C-SSRS). The C-SSRS, which is to be used in concert with clinical judgment, is an evidence-based scale that assesses suicidality. An individual exhibiting even a single behaviour identified by the scale is 8 to 10 times more likely to die by suicide. The rating scale can be embedded in a hospital EMR and allow clinicians to create and document an individualized safety plan visible to all in the circle of care.

The SJHH families who participated in the Coroner review also recommended the hospital no longer use “contracting” as a means to keep patients safe. The intention and validity of “Contracts for Safety,” where a patient is asked to agree either verbally or in writing that they will not engage in self-harm, is not considered best practice and its use, at the time, appeared to mystify families. SJHH no longer supports the use of “contracting” given its lack of efficacy and effectiveness.

Another key recommendation was to involve families and caregivers in decisions made regarding their loved one’s care, when applicable.

“The goal of our hospital and all of our care providers is to work with patients and families on treatment and preventative measures,” said Dr. Maxine Lewis, Chief of Psychiatry at SJHH. “We believe that we have learned a great deal and have made many positive changes since the tragic circumstances which led to this report, but we also know that we have to continue to learn and adapt our practice as new evidence comes to light,” she said.

For more information about suicide prevention and awareness, please listen to our “In Dialogue” podcast, “How we talk about suicide matters.”