Review of Knoll’s Inpatient Suicide: Identifying Vulnerability in the Hospital Setting

Safety is the number one concern of patients admitted into an inpatient mental health facility.  In theory, inpatient mental health facilities fulfill two goals: (1) to safeguard patients especially to patients at risk for suicide, and (2) to provide comprehensive services including, but not limited to medication management, individual/group psychotherapy, and effective diagnosis. The overall plan of care requires a collaborative effort consisting of psychologists, psychiatrists, social workers, nursing staff, the individual patient, and the patient’s family/primary support system. However, when an inpatient suicide takes place in a mental health facility, vulnerabilities must be carefully reviewed and addressed to help reduce and prevent the occurrence.



A study of Knoll’s (2008) article revealed frightening facts about the incidence of inpatient suicides. To support his findings, Knoll (as cited in the included information from the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) between 1995 -2005 (Knoll, 2008).  According to JCAHO, as cited from Knoll (2008) and Burgess, Pirkis, Morton, and Croke (2000),    “Suicides were the result of ineffective clinical assessment. The lack of risk management accounted for approximately 60% of suicides (Knoll, 2008;  p.1) .”


Specific to inpatient facilities, Knoll indicated that hanging was the most recurrent method to commit suicide.  Of particular interest, he indicated that approximately ¾ of inpatient deaths take place in the patient’s restroom, bedroom, or closet areas.  Knoll also reminds personnel that items such as shoelaces, belts, straps, razors, etc., can potentially be weapons used by patients wishing to attempt suicide. Furthermore, there is a pattern of concern that has emerged in recent literature which suggests that inpatient facilities are: (1) inadequately monitoring patients, and (2) inadequately protecting first admit patients with thoughts of self harm, either moderate or severe.  According to Knoll, these concerns have raised ethical concerns that question the efficacy of psychiatrists, psychologists, and the hospital staff to protect the patient from harm.


It is indeed a fact that hospitals face daily challenges.  Knoll emphasized that sharing information is a daily challenge and has become a critical issue to the point that it is of the utmost significance that staff communicate with one another to identify patients who are a suicide risk.  According to Knoll, communication or the lack thereof has contributed to a huge missing piece of the puzzle among the causes of suicide. He suggested ongoing staff education to focus on innovative suicide assessments and treatment. Knoll further stated that hospital staff should exercise caution when utilizing 15-minute checks with seriously suicidal patients who have been assessed as high risk or uncertain risk. He has also highlighted that inpatients can and do commit suicide while on 15-minute checks.


According to Knoll, too often will staff working in an inpatient environment get desensitized and no longer feel responsible for patient safety.  It is believed that staff may become stressed and oftentimes lose impartiality that they view patients as scheming, manipulative, over-dependent, or feigning. In other words, suicide rates tend to increase when there is a breakdown of empathy, genuineness, and a lack of unconditional positive regard. The bottom line is that Knoll stresses that the highest-risk times for suicide are the first week after admission to an inpatient mental treatment facility and shortly after discharge. In short, conventional therapy interventions may prove ineffective and in some instances may exacerbate the risk of suicidal ideation.  Therefore, mental health practitioners must implement out of the box thinking to approach patients who are at risk of suicide.


In summary, Knoll suggests that the mental health professional take a different point of view when caring for patients. Regardless of the mental health label, patient care should not be taken lightly. 1:1 close observation must be taken seriously. He states that the greatest risk of suicide is upon admission, especially when the patient being assessed is a first admit patient.



Knoll, J. L. (2008). Inpatient suicide: Identifying vulnerabilities in the hospital setting. Psychiatric Times, May 22, 2012. Retrieved from


Burgess, B., Pirkis, J., Morton, J., & Croke, E. (2000). Lessons from a comprehensive clinical audit of users of  psychiatric services who committed suicide. Psychiatric Services, 51, 1555-1560.


David Wright, MA, MSW
WKPIC Doctoral Intern



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