External review of a death by suicide can open up blind spots for the organisation. This could be in the realms of practice, processes or patterns of patient care and flow.

At Progress Guide we take an appreciative enquiry approach. We attempt to establish:

• What’s working well?
• Even better if…

We give particular attention to hind sight bias. Practitioners do not have a crystal ball to look into the future. Life is lived forward and decisions are made in the moment with the information at hand. All decisions are made with good intentions and actions taken are a result of clinicians attempting to navigate the multiple goals that they have at any given time.

We are very aware that often external reviews focus on proximal causes, the last person to have made the decision feels the heat. But decisions are not made in isolation from the system that the person is working in. The system creates goal conflicts (I would like to admit the patient but that will be the last bed for this entire weekend) and these distal reasons are often not picked up by reviews. As an organisation if you are keen to ensure that professionals do not feel blamed and get deffensive, Progress Guide should be your choice. We work with teams and focus on learning make it clear that all such lessons are with the benefit of hindsight. 

Work as prescribed and work as done is another focus for us. There are many shortcuts that are custom and practice, and they have become so because suicide is a rare occurence. We use the advances tools from Protect like Creep – Crash – Crawl to helpteams understand how their risk taking often goes up gradually, almost imperceptible, till a critical incident and then their risk taking crashes and their practice becomes restrictive with minimal positive risk taking. We focus on giving practitoners the confidence to remain recovery focused and do what’s right for the patient and just for one’s own anxiety levels.