Deaths of patients under psychiatric care, especially if they are in-patients, have been the subject of a number of retrospective studies (Copas & Robin, 1982; Morgan & Priest, 1991; Modestin et al, 1992; Roy & Draper, 1995; Proulx et al, 1997). They have also been a particular focus of the National Confidential Inquiry (Appleby et al, 1999) as well as many individual inquiries. In contrast, little has been published on how individual psychiatric departments and trusts might best review and learn from local deaths or ‘near misses' of patients under their care. In particular, there is no well publicised or widely accepted model for routinely examining such occurrences.
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