“Do we have a problem?” said the chief nursing officer. He had a list of 16 Exe Vale in-patients who had committed suicide in a period of 30 months. We looked at the list and then looked for something to compare it with in other hospitals; and that was where the trouble began. Such data as were available had been collected in diverse ways and often in the wake of special difficulties, e.g. the Warlingham Park Hospital enquiry (Croydon Area Health Authority, 1974/75). Comparisons were unrewarding, so we looked at our own 16 cases for indications of local problems. We also extended the study to the ten-year period 1972–81, during which there were 40 in-patient suicides. Since then more deaths have occurred—two in 1982 and four in 1983. These are referred to here only where special features warrant mention. Local monitoring of deaths continues; and certain deaths are notified to the Hospital Deaths Study of the Royal College of Psychiatrists.
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