An examination of the Dutch Health Care Inspectorate's supervision system for suicides of mental health care users.

OBJECTIVE This study examined characteristics of suicides among mental health care users reported between 1996 and 2006 to the Dutch Health Care Inspectorate and the inspectorate's follow-up responses. The aims were to determine whether follow-up was associated with particular characteristics and whether the responses could be improved in accordance with guidelines for treatment of suicidal patients. METHODS Information about patient and treatment characteristics was collected from a sample of 505 of the 5,483 suicide notifications between 1996 and 2006. The 1996-2005 sample included an equal number of cases to which the inspectorate did and did not respond. The 2006 sample included the first 205 notifications in that year. RESULTS For 2006 notifications the response rate was 37%. The responses most frequently addressed how and whether the suicide was evaluated and the adequacy of treatment for the psychiatric disorder. A follow-up response was more likely when the suicide involved a young patient or a patient treated in a mental health care setting for less than a year or when the notification was accompanied by the mental health institution's plans for improving its policies. A response was less likely when the patient was discharged from inpatient care in the three months before the suicide. Since 2002 responses have more frequently emphasized the importance of suicide risk assessment, in accordance with guidelines. CONCLUSIONS The inspectorate might improve its supervision system by placing greater emphasis on addressing suicidal impulses and treating older and chronically suicidal patients and patients soon after inpatient discharge.