Underlying patterns and factors behind suicides of patients in treatment are still unclear
and there is a pressing need for more studies to address this knowledge gap. We analysed 278 cases of
suicide reported to The Norwegian System of Patient Injury Compensation, drawing on anonymised
data, i.e., age group, gender, diagnostic category, type of treatment provided, inpatient vs. outpatient
status, type of treatment facility, and expert assessments of medical errors. The data originated
from compensation claim forms, expert assessments, and medical records. Chi-square tests for
independence, multinominal logistic regression, and Bayes factors for independence were used to
analyse whether the age group, gender, diagnostic category, inpatient/outpatient status, type of
institution, and type of treatment received by patients that had died by suicide were associated with
different types of medical errors. Patients who received medication tended to be proportionally more
exposed to an insufficient level of observation. Those who received medication and psychotherapy
tended to be proportionally more exposed to inadequate treatment, including inadequate medication.
Inpatients were more likely to be exposed to inappropriate diagnostics and inadequate treatment
and follow up while outpatients to insufficient level of observation and inadequate suicide risk
assessment. We conclude that the patients who had received medication as their main treatment
tended to have been insufficiently observed, while patients who had received psychotherapy and
medication tended to have been provided insufficient treatment, including inadequate medication.
These observations may be used as learning points for the suicide prevention of patients in treatment
in Norwegian psychiatric services.
during software development. An extended (not free) version of the book is also available
(Margrave & Lamoureux, 2019). Finally, the book “Fourier Acoustics” by E.G. Williams
(Williams, 1999) was essential in developing the theory for cylindrical imaging geometries
