The current study aims to describe the patient and treatment characteristics of a sample of 505 suicides by mental health care patients, and to determine how clinicians view the care provided and what they learned. The results indicate that the quality of mental health care for suicidal patients could be improved by focusing on communication among clinicians, continuity of care, suicide risk assessment procedures, and the involvement of relatives.

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Journal Suicide and Life-Threatening Behavior
Huisman, A, Kerkhof, A.J.F.M, & Robben, P.B.M. (2011). Suicides in users of mental health care services: Treatment characteristics and hindsight reflections. Suicide and Life-Threatening Behavior, 41(1), 41–49. doi:10.1111/j.1943-278X.2010.00015.x