Understanding the true impact of suicide in inpatient mental health settings: reflections from a psychiatrist (22 April 2025)

Summary

*Trigger warning: content related to suicide

Rachel Gibbons is the Vice Chair of the Psychotherapy Faculty at the Royal College of Psychiatrists. In this opinion piece she draws on personal and professional experience to explore the complex relationship between patient safety and inpatient suicide. Rachel argues that fantasy-driven ideas of control and simplistic blame narratives do profound harm—both to clinicians and those bereaved.

Content

I'm a consultant psychiatrist whose professional trajectory was profoundly shaped by a harrowing experience early in my career. In 2009, during my first 18 months as a consultant, four of my patients died by suicide.

The intense aftermath—serious incident inquiries, coroner's court appearances, and the emotional fallout—fundamentally changed who I was, both personally and professionally. Before this, I was someone different; afterward, thoughts about suicide dominated my consciousness. Since then, I've dedicated my professional life to deeply understanding suicide, it’s devastating impact on those bereaved, and the complex interactions involved in patient safety.

Central to my work is the question of truth in patient safety—how to engage honestly and realistically with this complex subject. Too often, safety is driven by fantasies of control rather than by realistic expectations and honest acknowledgment of uncertainty. When our expectations are unrealistic, it harms clinicians and bereaved families alike.

The profound trauma of inpatient suicide

When suicide occurs within inpatient settings, its impact can be especially devastating. These tragedies unfold in two distinct scenarios: deaths occurring off the ward, and those taking place directly on the ward itself. Deaths on the ward can be especially traumatic—sometimes violent and occurring in the immediate presence of staff and other patients. I have personally been involved in such cases, witnessing first-hand the traumatic ripple effect across an entire organisation. The sudden, shocking nature of an inpatient death reverberates, intensifying every response, from the serious incident inquiry to appearances at the coroner’s court.

Unfortunately, we don’t often give sufficient attention to the profound trauma staff and patients experience when exposed to inpatient suicide. If not effectively addressed, this trauma can linger unresolved for years, manifesting repeatedly in patterns of care—a phenomenon Freud described as "repetition compulsion". Unprocessed trauma can harm staff and affect the safety and wellbeing of future patients.

The double-edged sword of patient safety investigations

It’s essential that every inpatient death prompts a thorough patient safety investigation. However, the issue isn’t the investigation itself; it’s how easily the concept of patient safety can become distorted following a traumatic death. When a suicide occurs, intense emotions and destructive forces are unleashed within an organisation. This often results in attempts to create a simplistic causal narrative for the tragedy—a narrative that can never truly capture the complexity of suicide.

In the aftermath of suicide, people’s ability to mentalise—to think clearly and compassionately—is severely compromised. The intense emotional turmoil often triggers a search for blame. As the deceased patient’s agency is often discounted, blame shifts rapidly towards clinicians. I've seen distressing examples where clinicians become scapegoats, absorbing an organisation’s collective anxiety and guilt. Organisations can behave almost like sentient beings, attempting self-preservation by shifting blame onto individual staff, often with devastating personal and professional consequences.

Improving support for bereaved families

The anxiety surrounding inpatient suicides can make it challenging for organisations to engage compassionately and openly with bereaved relatives. Defensive postures, though understandable given potential repercussions, ultimately harm those grieving. One proven way to mitigate confrontation and provide genuine support is appointing Family Liaison Officers. These dedicated individuals advocate for bereaved families, offering emotional support, clarity, and careful communication, thus alleviating confrontational dynamics.

Supporting staff in caring for the bereaved

Staff must not be left unsupported in their interactions with grieving families. Effective engagement with bereaved relatives requires thoughtful, organisational leadership and strategic planning. I've witnessed harmful situations where clinicians, driven by guilt, rush prematurely to communicate with bereaved families. Such impulsive actions, however well-intentioned, can cause unintended harm. Again, Family Liaison Officers are instrumental in mediating this delicate and emotionally charged communication, providing guidance and helping staff navigate difficult interactions more safely.

Creating reflective spaces for staff

Mental health work, particularly in inpatient environments, is intensely emotional and psychologically demanding. In the aftermath of a patient suicide, it becomes vital for organisations to provide reflective spaces—dedicated times and places where clinicians can safely process traumatic experiences. Without such spaces, unprocessed trauma can manifest as "acting out," leading to harmful patterns in care delivery and clinician burnout. Embedding regular reflective practice is essential, enabling staff to maintain their psychological wellbeing and enhancing patient safety through thoughtful, compassionate care.

Final thoughts: seeking truth and compassion in patient safety

Throughout my career, my core interest remains the truthful engagement with suicide and patient safety. We need honest, realistic frameworks that acknowledge limitations, complexity, and uncertainty. Fantasy-driven ideas of control and simplistic blame narratives do profound harm—both to clinicians and those bereaved. True safety comes from authentic, reflective practice, compassionate communication, and careful systemic support.

About the Author

Rachel Gibbons has held several leadership roles at the Royal College of Psychiatrists. She chaired the Patient Safety Group for four years until 2024, led the Working Group on the Effect of Suicide and Homicide on Clinicians until January2025, and currently serves as Vice Chair of the Psychotherapy Faculty.