tion lapse during transfer’, ‘need for integrated information’, and ‘systemic issues’.In the first category (‘omission in diagnostic records during admission’), the following three sub-categories pertained to the same patient: [omission in patient information during readmis-sion], [abridging report on suicide risk], and [factors influencing the ward staff’s judgements and behaviours]. The patient in question had been readmitted soon after being discharged, which may explain why the staff decided to cut corners and abridge the diagnostic records. Although the patient had evidently been readmitted because of severe suicidal ideation, there was just a brief, concise record stating that the patient had denied having such an ideation. On the second day after readmission, the ward received a report from the family referring to the patient’s suicidal ideation. However, the staff never discussed it with the patient. On the third day, the patient was absent from their room when the nurse came to deliver their medication. The nurse did not search for the patient right away; she first finished delivering medication to the other patients. Eventually, the nurse searched for the absconding patient and found them inside the ward lavatory. It was suicide by hanging. During Analysis 2, the professionals suggested that the omission of the diagnostic record may have prevented the hospital staff from appreciating the severity of the suicide risk, and that this complacency may explain why the nurse had delayed the initial response to the patient’s absence.One of the sub-categories of ‘communication lapse during transfer’ was [hard to relay complex information such as the principal doctor’s deci-sion-making process]. This sub-category pertained to a patient who had been transferred from a seclu-sion room in an open ward to the general area of the closed ward for the patient’s own protection following a suicide attempt. While bathing alone, the patient died by suicide by swallowing a substance. During Analysis 2, the professionals suggested that the staff at the closed ward, in whose care the patient had been transferred, may have mistakenly assumed that the patient no longer needed to be in seclusion because their symptoms had improved.268Assessing the suicide risk, which is non-constant and fluctuates over time, is essential in enabling timely intervention, and is therefore a top clinical priority. Of the cases we analysed, 61.1% of the patients died by suicide despite the absence of any verbalised references to suicidal ideation or exhibi-tions of suicidal behaviour in the 14 days leading up to the event. It is therefore crucial to look for signs of suicide other than explicit suicidal ideation state-ments or behaviour.In this study, we retrospectively analysed the signs of imminent suicide risk that were present in psychiatric patients during the 14 days before their fatal suicide attempt, using diagnostic and nursing records pertaining to that period. In Table 2, we listed the items that describe signs. However, not all these items imply imminent suicide risk in them-selves. Some of the items can be more accurately described as the lack of protective factors rather than imminent suicide risk. Three notable exam-ples are the major category ‘signs from response to treatment’, the sub-category [symptoms] (in ‘signs emanating from the patient’), and the sub-category [attitude inferred from integrated information] (in ‘signs inferred from multiple sources of informa-tion’). These items imply that the person’s psychi-atric condition has failed to improve sufficiently or has deteriorated, that the person is mentally unstable, or has a personality pathology. They do not directly imply imminent suicide risk to the extent that certain other items, such as
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