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Assessments of patients' risk of suicide still not accordingly

April 19, 2014
by James M. Hunt, AIA
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The Joint Commission (TJC) recently released its Sentinel Event Data through 2013.  Suicides remain the fourth most frequently reviewed Sentinel Event for the second year in a row, with 90 reported last year.   The reporting of most sentinel events to the Joint Commission is voluntary and represents only a small proportion of the actual events.  Suicides were ahead of Falls and Medication Errors on this list as well as four other major categories.

There were 775 Root Cause Analyses of suicides studied by TJC from 2004 through 2013.  Of those, “Assessment” was a root cause in 624 (80%) of the cases and the “Physical Environment” was a root cause in 329 (42%) of the cases studied.

This is consistent with the Department of Veterans Affairs study conducted in 2012 titled “Suicide Risk Factors and Risk Assessment Tools: A Systematic Review”.  This was a very thorough evidence based study of all of the patient suicide assessment tools then being used in the entire VA hospital system.  It concluded that none of the tools studied should be relied upon.

I posted a blog on this website on August 16th of last year regarding how even one-to-one observation is not always successful in preventing inpatient suicides and  that other common steps taken for patients that are identified as at risk for suicide are even less successful.  I recently received a comment on that blog that was a beautifully written explanation by a patient of why the typical questions and interventions do not work for people with Bipolar I diagnoses.  The gist of this explanation was that once the decision was reached to commit suicide and how and when to proceed that the overwhelming feeling was “calm, almost peaceful”.  In many of the suicides with which I am familiar (others have told me of similar observations) the clinical staff comment that they had no idea that the patient was actively having suicidal ideations immediately before the event occurred.  This is not an indictment of the staff.  It is a statement that we have yet to identify ways of identifying all of the patients who are on the verge of ending their own life.

For this reason and the fact that TJC reports that the physical environment is a contributing factor in over 42% of inpatient suicides, I continue to emphasize that behavioral healthcare facilities and their designers need to provide the full level of suicide resistance deemed necessary for each facility’s patient population in all patient rooms and bathrooms as well as identified appropriate levels in other portions of the unit where patients have less privacy or alone time.  It is impartiive that we remove as many potential risks as possible from the patients' environment at the same time we are providing calming, relaxing spaces that will help them to be open to the treatment they will receive.




I am a clinician who had a very traumatic event, I watched my 4 yo son hit. And killed in the road, it was horrific, to say the least, but if that wasn't enough, my husband blamed ME because I was caring for him and my husband tried to kill me. I walked into ACTS mental Health in Benson, AZ in 2012, I stated I am suicidal and need help. I was told to get an appointment, I needed $275. I told them I had not worked in a year and they told me to go to a church I may be able to get help there. I wrote Will Humble, the director of ADHS, the governor and my congressman (barber) and my senator (mc Cain) and even went so far to write President Obama...none of them did anything. Oh wait, I take that back, will humbles office called the sheriffs department because my letter said I was having suicidal ideation, and OBAMAs office waited about 4 months and contacted a crisis worker in Maricopa County and SAMSHA, who of course wrote me a letter that said they could not do anything for me. I did get a gentleman at the state level who made some calls for me and got me in for a financial interview, where the manager of ACTS Benson (Theresa) sat in and poked every button I had, and I am not certain why. They had me bring my tax returns from the previous year in, I made $50, 000 but had not worked in a year....tough they said, no sliding fee for ME! When I wrote another letter to Will Humbles office, the state had someone call Francis Garcia, ACTS CFO) Francis denied the entire thing happened and assured the state that I was lying (I guess she didn't realize that I keep EVERYTHING and I just happened to have the form that gave proof to my allegations...later I came to find out that is the way Francis at ACTS responds to issues, (at least to my issues, as EVERY problem that has been brought to her, she has denied...again, good thing I keep everything) her first tack is to deny it. Funny though, the price changed from $275 to $250, still, unobtainable, I was about to be evicted from the home I had purchased, I had shut off notices for literally every single utility and really, I left that place worse off than I went in, all I wanted to do is die. I went home and crawled in a ball and just thought of suicide for months when my dad and mom finally begged me to get some help. I had worked in this system for 20 years and I had no idea how to get help, I called SEABHS in benson, AZ I(I didn't want to go there because I had been a high level manager there and didn't feel safe there) ITOLD THEM I WAS SUICIDAL and never received a phone call back (I did this twice) So I tried to file a complaint with Cenpatico...they REFUSED to take the complaint saying they could just help me without a complaint (and here I thought the complaint process was MY decision) that manger at ACTS literally told me, "you are a self pay client, Cenpatico can't help you." Several more months go by and the guy from the State did help me by demanding they see me, so they set me up with a doctor, over the TELEVISION. Ugh! There are no doctors that can see you in person here. Ok, well 2 years later, I am still suicidal, the ONLY help I have received from them is a lower dose of meds than I had been on before, that isn't helping and I was told point blank they don't care if 225 Effexor isn't enough that is all I am getting and they don't care how many times I say I am suicidal. (I really never asked for more, I just kept saying it wasn't working) I was told numerous times I would get counseling and Case Management, I never got anything except the PRIVILEGE of seeing a doctor who admits freely he doesn't like me. I really don't care if he likes me, but I sure wish he'd make an effort to HELP me. When I told him 4/20 is my dead sons birthday, 6/8 is the day he died, 6/11 is the day we buried him and Mother's Day, Father's Day Memorial Day and all the days in between are coming upon me and I was CERTAIN there was no way in HE double hockey sticks I would make it through this year, he simply rolled his eyes at me and told me he would see me next month. I left there in tears again, when I ran into a former colleague who used to work for me. She took 1 look at me, the shell of the dynamic, humorous person I was and literally started crying. Guess where she works now? You got it, ACTS. In 1 day ONE DAY, she did what EVERYONE ELSE in this godawful state refused to do...she helped me. The very next day, I was in counseling and saw a case manager. All the letters I wrote begging officials for help fell on deaf ears, the only reason I got any help at all wasn't because it is THE LAW, it turned out that I got the help because I was a good person that people liked and respected. Now I am a 20 year veteran as a clinician and director (I was in management most of my career but continued direct service bc I didn't want to be that manager that was so removed from reality they don't understand the troubles clinicians can have, because I have had a few too many of those supervisors)! 20 years I dedicated my life to the behavioral health system (14 years as high level management in AZ) and trust me, I know every Title 9 rule that applies to behavioral health and I couldn't get services for 2 FULL YEARS, HOW MANY PEOPLE DOES THE STATE OF ARIZONA KILL EVERY YEAR by this type of behaviors? How do people get services here? How many people quit the fight and just end it because there is very few ways to overcome bureaucracies this large! Several months ago, (February 2014), I am sitting home, minding my own business, having a fairly good day when I get a call from "justin" who I didn't know who says he is a peer support at ACTS and "justin" tells me because I have had suicidal ideation in the last year ACTS is going to discharge me because they can't help me (seriously, I can't even make this stuff up) When I asked him questions his response to EVERYTHING was "I don't know". I was stunned and attempted to call the secretary, who has been the only one to do anything to help me, she didn't answer my calls nor messages and that left me with no help or contact at that agency at all. When I saw her again, she told me that she was told by supervisors not to contact me because I hired a lawyer (my Social Security Disability lawyer had been trying to contact the doctor to get a statement from him for my SSDI court hearing coming up) and instead of calling me and asking me why a lawyer is calling, they assumed I was suing them and cut all contact off, again, leaving me horrified, thinking I am going to come off Effexor cold turkey again...NIGHTMARE!)


Still considering suicide in AZ,

I am terribly sorry for the ordeal you have undergone the last two years. Have you tried contacting NAMI? Their Arizona contact information for your location can be found at the following link:

If you click on the "Printable Arizona State and Affiliate Directory" below the blue box on the right side of the screen it will show you contact information for your area. I am told that they should be able to help you and it is my understanding that you do not need to be a NAMI Member to ask for assistance.

If you would email me ( your contact information, I have a few contacts in the Phoenix area that might be able to offer some other suggestions.

Do any other readers have suggestions?

James M. Hunt

Jim Hunt

Behavioral Healthcare Design Consultant

Jim Hunt

James M. Hunt, AIA, is a practicing architect and facility management professional with over 40...

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