Suicides by mental health patients account for around a quarter of all suicides (Walby et al, 2018). Within services a range of approaches have been developed and implemented to reduce the risk of patient suicides. After every patient death by suicide, a review is carried out to identify recommendations which may assist in preventing future suicides. It is therefore important to identify the most effective methods for implementing these recommendations. The objective of this systematic review, completed in Northern Ireland, was to identify how recommendations from Serious Adverse Incident (SAI) reviews can be effectively implemented to contribute to reducing deaths by suicide within mental health services. Eleven electronic databases were searched for relevant work from 1 January 2005–30 November 2020. Quantitative, qualitative and mixed methods studies were included. A narrative synthesis was carried out of published and unpublished work on the effectiveness of implementing recommendations, after a death by suicide in mental health services. The review, which includes 41 published papers and reports, found that the literature is focused on producing recommendations to reduce future risk of suicide in mental health services. There is a lack of focus on the extent and effectiveness of the implementation of these. Recommendations have often not been tested or operationalised, limiting the translational value of these contributions. Leadership and culture are also identified as key drivers for change in mental health services. This review demonstrates that high quality research is being complete in this area, however, the majority of published research presents recommendations from reviews of mental health patient suicides. There is a lack of research focusing on implementing recommendations and evaluation of implementation, once recommendations have been made.

中文翻译：

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患者自杀后在心理健康服务中实施变革：系统评价

精神健康患者的自杀约占所有自杀的四分之一（Walby 等人，2018 年）。在服务范围内，已经开发和实施了一系列方法来降低患者自杀的风险。在每位患者死于自杀后，都会进行审查以确定可能有助于预防未来自杀的建议。因此，确定实施这些建议的最有效方法非常重要。这项在北爱尔兰完成的系统评价的目的是确定如何有效实施严重不良事件 (SAI) 评价中的建议，以帮助减少精神卫生服务中的自杀死亡。从 2005 年 1 月 1 日至 2020 年 11 月 30 日，对 11 个电子数据库进行了相关工作的检索。定量、包括定性和混合方法研究。在精神卫生服务自杀身亡后，对已发表和未发表的关于实施建议的有效性的研究进行了叙述性综合。该审查包括 41 篇已发表的论文和报告，发现文献的重点是提出建议，以降低未来在精神卫生服务中的自杀风险。缺乏对这些实施的程度和有效性的关注。建议通常没有经过测试或实施，限制了这些贡献的转化价值。领导力和文化也被确定为精神卫生服务变革的关键驱动力。这篇综述表明，该领域的高质量研究正在完成，但是，大多数已发表的研究都提出了对心理健康患者自杀的评论的建议。一旦提出建议，就缺乏关注实施建议和实施评估的研究。