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Table 3　Issues in the way in which the hospital staff handle information (Analysis 4)Issues in the Manner in which the Hospital Staff Handle Information (Analysis 4)Table 3 presents the major categories and sub- categories drawn from Analysis 4, along with examples. Our analysis yielded five major catego-ries: ‘omission in diagnostic records during admis-sion’, ‘omission in conference records’, ‘communica-, which described cases in which the patient was assumed to be isolated given that the family refused to let the patient live with them after being discharged.Major categoryOmission in diagnostic records during admissionOmission in conference recordsCommunication lapse during transferNeed for integrated informationSystemic issuesSub-categoryOmission in diagnostic records and treatment policyThe diagnostic record made for admission omitted the diagnosis and treatment policy.The patient was readmitted just four days after being discharged. The diagnosis record for readmission omitted any opinion on the recurrent symptoms and suicidal ideation. It also omitted the treatment plan. The diagnostic record for the original admission was in a separate document.In the record for admission, the doctor mentioned suicidal ideation despite the patient denying it. However, the record contained no opinion on the occurrence of suicidal ideation.Omission in patient information during readmissionAbridging report on suicide riskWhile delivering the medication, the nurse noticed that the patient was missing. The nurse knocked on the lavatory door and there was no response. The nurse finished delivering medication to the other patients and then looked for the missing patient, whom they discovered hanging in the lavatory. The nurse may have elected to leave the area (instead of searching for the patient immediately) because the severity of the suicide risk was not fully appreciated.Factors influencing ward staff’s judgements and behavioursOmission in treatment policyThe conference records omitted the treatment plan.The patient had been transferred from a seclusion room in an open ward to the general area of the closed ward for their protection following a suicide attempt. While bathing alone, the patient attempted suicide by swallowing shampoo and conditioner. The staff in the destination ward may have assumed that the patient no longer needed to be secluded because their psychiatric condition had improved, and they may have got this impression because the staff failed to share the intent of the principal doctor’s orders.Nine days before the event, the patient tried to hang themselves. Seven days before the event, the patient, in a seclusion room, banged their head against the wall and toilet out of a desire to kill themselves. One day before the event, the patient was transferred. The principal doctor’s transfer application did not mention the suicide attempts.Despite the nursing records having plenty of information on patient complaints and symptoms, the patient, during medical screenings, was judged as stable. Accordingly, the form of hospitalisation was changed and the patient was given more freedom. Decisions should be based on the information in both the nursing and diagnostic records.It is hard to share the records among the staff, as they comprised a single paper document.The patient died by suicide by swallowing detergent after their delusions worsened. This mirrored a previous suicide attempt (in which the patient had attempted suicide by swallowing detergent after their delusions worsened). An entry in the diagnostic record made nine days before the event mentioned the worsening delusions, and an entry in the nursing record mentioned that the patient had bought detergent. However, due to turnover in ward staff over time, it may have been difficult for them to piece the disparate information together and identify the suicidal pattern.Hard to relay complex information such as the principal doctor’s decision-making processOmission in transfer application recordsHard to view recordsHard to access past information↓Example267