Can all suicides be prevented in an inpatient facility like St. Joe's?
3 people died by suicide while they were inpatients at St. Joe's West 5th campus
As St. Joe's investigates an "extremely unusual" number of suicides among its inpatient psychiatric patients last year, it raises the question: Is it realistic to expect that no one admitted to hospital with suicidal thoughts will be able to kill themselves while they're there?
The hospital has said its goal is zero deaths, but also acknowledges the work of acute mental health treatment is complex and can be unpredictable. Like other disciplines in medicine, "bad outcomes" are possible, hospital officials say.
But at least one expert in suicide prevention, from Johns Hopkins University, argues it is possible to avoid all inpatient deaths.
In psychiatry we haven't yet figured out a standardized way of observing patients and keeping them safe in the inpatient unit.- Dr. Geetha Jayaram , Johns Hopkins Hospital
Dr. Geetha Jayaram said when she was physician advisor at Johns Hopkins Hospital, there were no suicides in 32 years.
She has published articles on suicide prevention in inpatient psych hospitals, and she said she hears two common responses from colleagues and peers.
One response she hears: "If you're in this profession you are bound to lose some patients despite your best efforts."
Or, sometimes: "Errors will happen and there's no way to avoid them."
Psychiatry lags in patient safety tools
But Jayaram says psychiatry has to catch up to surgery, anesthesia and other critical medical disciplines that have leaped forward in patient safety using tools like pre-operation checklists to cut down on rates of hospital-acquired infections, for example.
"In psychiatry we haven't yet figured out a standardized way of observing patients and keeping them safe in the inpatient unit," she said. "But if you're watching the patient at all times it cannot happen."
Because that "standardized way" doesn't exist, it's unclear how close the approaches St. Joe's has been using are to that ideal Jayaram describes.
'If you're watching the patient at all times it cannot happen.'- Dr. Geetha Jayaram,, Johns Hopkins Hospital
In a statement, St. Joseph's Healthcare Hamilton said staff does offer a level of care for some patients called "constant care" that assigns a staff member to be continuously with a patient. But it acknowledges that level of care can be "intrusive" for patients and its approach is to regularly reassess the level of treatment a patient needs, often with their input.
"There is no simple test or tool that can accurately predict how imminently a person may act on their thoughts with perfect accuracy," the hospital said.
The hospital has hired outside experts to conduct a comprehensive review of St. Joe's West 5th campus suicide prevention tools and practices.
- St. Joe's investigating 'extremely unusual' number of suicides at West 5th campus
- Families and friends of 3 people who died in psych hospital seek answers
'Eyes on the patient'
Jayaram is critical of a common practice of 15-minute checks on a patient with acute risk.
"That person needs to be on what we call 'eyes on the patient' at all times, including in the bathroom and the bedroom," she said.
It implies that the simple act of watching someone can avert a negative event. This is not the case.-Dr. Vicky Stergiopoulos, physician in chief, Centre for Addictions and Mental Health in Toronto
St. Joe's said staff does offer a "constant care" option for some patients, but it's unclear what the threshold is for a patient to be assigned to that.
Staff there don't use the term "suicide watch":
"It implies that the simple act of watching someone can avert a negative event. This is not the case."
Dr. Vicky Stergiopoulos, the physician in chief at the Centre for Addictions and Mental Health in Toronto, said there aren't enough "high-observation beds" for the need in that city. It's unclear how that compares to Hamilton.
"In Toronto it is routine that we need to admit patients to this high level observation and these beds are a scarce commodity," she said. "Mental health services have been under-funded. We don't always have the resources that we need to look after patients."
'Let's talk about how we can do this better'
In recent weeks, external investigators have visited St. Joseph's West Fifth hospital campus as they look into the deaths of the three psychiatric patients by suicide at that facility in 2016.
Their visit coincided with the recent "Let's Talk" campaign prompting Canadians to speak openly about mental illness.
"We exhort our patients and our families to be open, but it's important for us to be open – What is the best way to prevent this?" said Dr. Ian Preyra, deputy chief of staff for St. Joseph's Healthcare Hamilton.
"With the knowledge that sometimes just like in other aspects of medicine you're going to have bad outcomes, let's talk – about how we can do this better."
Preyra describes a hospital that remains open to the review by a suicidologist and a former regional coroner, and said he didn't know whether the findings of the review would be made public.
'We cannot predict all deaths'
Meanwhile, the institution offered some explanations about its care for people in mental crisis or instability that suggest it doesn't agree with Jayaram's assessment that it's possible to prevent all deaths by suicide in hospital.
"As in all serious medical conditions, like cancer or heart disease, while we understand signs, symptoms and risk, we cannot predict all deaths related to that illness," St. Joe's said. "Unlike other conditions, we don't have objective diagnostic tools or lab tests that can tell us what the suicidal person is thinking."
The hospital said the newly built West 5th campus was designed purposely to include "private patient bedrooms."
"We recognized that level of need for our patients, including suicidal risk, can fluctuate and ideally the care that is needed is brought to the bedside in an individualized way."
The hospital said the "constant care" level can be "intrusive" and "distressing" for some patients, and said its approach is to bring patients into the decision-making process about what level of supervision and care they require.