{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,7]],"date-time":"2026-08-07T17:25:34Z","timestamp":1786123534335,"version":"build-2736575974"},"reference-count":36,"publisher":"Springer Science and Business Media LLC","issue":"6","license":[{"start":{"date-parts":[[2026,3,21]],"date-time":"2026-03-21T00:00:00Z","timestamp":1774051200000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2026,3,21]],"date-time":"2026-03-21T00:00:00Z","timestamp":1774051200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"funder":[{"DOI":"10.13039\/501100001778","name":"Deakin University","doi-asserted-by":"crossref","id":[{"id":"10.13039\/501100001778","id-type":"DOI","asserted-by":"crossref"}]}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["Community Ment Health J"],"published-print":{"date-parts":[[2026,8]]},"DOI":"10.1007\/s10597-026-01604-x","type":"journal-article","created":{"date-parts":[[2026,3,21]],"date-time":"2026-03-21T06:10:46Z","timestamp":1774073446000},"page":"1187-1197","update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Reorienting the Way a Community Mental Health Service Responds to Suicide and Other Serious Incidents"],"prefix":"10.1007","volume":"62","author":[{"given":"Nandi","family":"Abdalla","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Richard","family":"Whitehead","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Liza","family":"Hopkins","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Paul","family":"Denborough","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rachel","family":"Barbara-May","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michelle","family":"Kehoe","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,3,21]]},"reference":[{"issue":"20","key":"1604_CR1","doi-asserted-by":"publisher","first-page":"79","DOI":"10.1007\/s10612-011-9151-y","volume":"20","author":"E Ahmed","year":"2012","unstructured":"Ahmed, E., & Braithwaite, V. (2012). Learning to manage shame in school bullying: Lessons for restorative justice interventions. Critical Criminology, 20(20), 79\u201397. https:\/\/doi.org\/10.1007\/s10612-011-9151-y","journal-title":"Critical Criminology"},{"key":"1604_CR2","unstructured":"Australian Institute of Health and Welfare (2025). Deaths in Australia. Retrieved from https:\/\/www.aihw.gov.au\/reports\/life-expectancy-deaths\/deaths-in-australia 22 May 2025."},{"issue":"4","key":"1604_CR3","doi-asserted-by":"publisher","first-page":"589","DOI":"10.1080\/2159676X.2019.1628806","volume":"11","author":"V Braun","year":"2019","unstructured":"Braun, V., & Clarke, V. (2019). Reflecting on reflexive thematic analysis. Qualitative Research in Sport, Exercise and Health, 11(4), 589\u2013597. https:\/\/doi.org\/10.1080\/2159676X.2019.1628806","journal-title":"Qualitative Research in Sport, Exercise and Health"},{"issue":"1","key":"1604_CR4","doi-asserted-by":"publisher","first-page":"245","DOI":"10.1111\/inm.13080","volume":"32","author":"A Croft","year":"2023","unstructured":"Croft, A., Lascelles, K., Brand, F., Carbonnier, A., Gibbons, R., Wolfart, G., & Hawton, K. (2023). Effects of patient deaths by suicide on clinicians working in mental health: A survey. International Journal of Mental Health Nursing, 32(1), 245\u2013276. https:\/\/doi.org\/10.1111\/inm.13080","journal-title":"International Journal of Mental Health Nursing"},{"issue":"4","key":"1604_CR5","doi-asserted-by":"publisher","first-page":"153","DOI":"10.1192\/bjp.2023.2","volume":"222","author":"M Deshpande","year":"2023","unstructured":"Deshpande, M., Sinclair, J. M. A., & Baldwin, D. S. (2023). Validity of root cause analysis in investigating adverse events in psychiatry. British Journal of Psychiatry, 222(4), 153\u2013156. https:\/\/doi.org\/10.1192\/bjp.2023.2","journal-title":"British Journal of Psychiatry"},{"issue":"3","key":"1604_CR6","doi-asserted-by":"publisher","DOI":"10.1136\/bmjopen-2020-044068","volume":"11","author":"E Fr\u00f6ding","year":"2021","unstructured":"Fr\u00f6ding, E., G\u00e4re, B. A., Westrin, \u00c5., & Ros, A. (2021). Suicide as an incident of severe patient harm: A retrospective cohort study of investigations after suicide in Swedish healthcare in a 13-year perspective. BMJ Open, 11(3), Article e044068. https:\/\/doi.org\/10.1136\/bmjopen-2020-044068","journal-title":"BMJ Open"},{"key":"1604_CR37","doi-asserted-by":"publisher","unstructured":"Fr\u00f6ding, E., Vincent, C., Andersson-G\u00e4re, B., Westrin, \u00c5., & Ros, A. (2024). Six Major Steps to Make Investigations of Suicide Valuable for Learning and Prevention. Archives of Suicide Research, 28(1), 1\u201319 https:\/\/doi.org\/10.1080\/13811118.2022.2133652","DOI":"10.1080\/13811118.2022.2133652"},{"key":"1604_CR7","doi-asserted-by":"publisher","unstructured":"Grealish, L. (2019). Using Learning Circles to Develop Intersubjectivity. In S. Billett, J. Newton, G. Rogers, & C. Noble (Eds.), Augmenting Health and Social Care Students\u2019 Clinical Learning Experiences. Professional and Practice-based Learning (Vol. 25). Springer. https:\/\/doi.org\/10.1007\/978-3-030-05560-8_8","DOI":"10.1007\/978-3-030-05560-8_8"},{"issue":"2","key":"1604_CR8","doi-asserted-by":"publisher","first-page":"157","DOI":"10.1007\/s40737-019-00145-9","volume":"6","author":"K Grim","year":"2019","unstructured":"Grim, K., Tistad, M., Sch\u00f6n, U. K., & Rosenberg, D. (2019). The legitimacy of user knowledge in decision-making processes in mental health care: An analysis of epistemic injustice. Journal of Psychosocial Rehabilitation and Mental Health, 6(2), 157\u2013173. https:\/\/doi.org\/10.1007\/s40737-019-00145-9","journal-title":"Journal of Psychosocial Rehabilitation and Mental Health"},{"issue":"4","key":"1604_CR9","doi-asserted-by":"publisher","first-page":"202","DOI":"10.1027\/0027-5910\/a000027","volume":"31","author":"A Gulfi","year":"2010","unstructured":"Gulfi, A., Dransart, D. A. C., Heeb, J. L., & Gutjahr, E. (2010). The impact of patient suicide on the professional reactions and practices of mental health caregivers and social workers. Crisis, 31(4), 202\u2013210. https:\/\/doi.org\/10.1027\/0027-5910\/a000027","journal-title":"Crisis"},{"key":"1604_CR10","doi-asserted-by":"publisher","DOI":"10.1136\/bmjoq-2019-000646","volume":"8","author":"G Hagley","year":"2019","unstructured":"Hagley, G., Mills, P. D., Watts, B. V., & Wu, A. W. (2019). Review of alternatives to root cause analysis: Developing a robust system for incident report analysis. BMJ Open Quality, 8, Article e000646. https:\/\/doi.org\/10.1136\/bmjoq-2019-000646","journal-title":"BMJ Open Quality"},{"issue":"465","key":"1604_CR11","first-page":"295","volume":"51","author":"P Halligan","year":"2001","unstructured":"Halligan, P., & Corcoran, P. (2001). The impact of patient suicide on rural general practitioners. British Journal of General Practice, 51(465), 295\u2013296.","journal-title":"British Journal of General Practice"},{"issue":"1","key":"1604_CR12","doi-asserted-by":"publisher","first-page":"23","DOI":"10.1192\/bjb.2023.98","volume":"49","author":"H Haylor","year":"2024","unstructured":"Haylor, H., Sparkes, T., Armitage, G., Dawson-Jones, M., Double, K., & Edwards, L. (2024). The process and perspective of serious incident investigations in adult community mental health services: Integrative review and synthesis. BJPsych Bulletin, 49(1), 23\u201335. https:\/\/doi.org\/10.1192\/bjb.2023.98","journal-title":"BJPsych Bulletin"},{"issue":"4","key":"1604_CR13","doi-asserted-by":"publisher","first-page":"166","DOI":"10.1177\/2516043519850914","volume":"24","author":"J Holden","year":"2019","unstructured":"Holden, J., & Card, A. J. (2019). Patient safety professionals as the third victims of adverse events. Journal of Patient Safety and Risk Management, 24(4), 166\u2013175. https:\/\/doi.org\/10.1177\/2516043519850914","journal-title":"Journal of Patient Safety and Risk Management"},{"key":"1604_CR14","doi-asserted-by":"publisher","first-page":"189","DOI":"10.1007\/s11218-017-9402-1","volume":"21","author":"M Kehoe","year":"2018","unstructured":"Kehoe, M., Bourke-Taylor, H., & Broderick, D. (2018). Developing student social skills using restorative practices: A new framework called HEART. Social Psychology of Education, 21, 189\u2013207. https:\/\/doi.org\/10.1007\/s11218-017-9402-1","journal-title":"Social Psychology of Education"},{"issue":"2","key":"1604_CR15","doi-asserted-by":"publisher","DOI":"10.1111\/jcap.70021","volume":"38","author":"M Kehoe","year":"2025","unstructured":"Kehoe, M., Hopkins, L., Whitehead, R., Meyer, D., & Nedeljkovic, M. (2025). Integrated aftercare support for parents and carers following a child\u2019s suicide attempt: A qualitative study. Journal of Child and Adolescent Psychiatric Nursing, 38(2), Article e70021. https:\/\/doi.org\/10.1111\/jcap.70021","journal-title":"Journal of Child and Adolescent Psychiatric Nursing"},{"issue":"1","key":"1604_CR16","doi-asserted-by":"publisher","first-page":"35","DOI":"10.1017\/S0790966700011952","volume":"28","author":"E Kelleher","year":"2011","unstructured":"Kelleher, E., & Campbell, A. (2011). A study of consultant psychiatrists\u2019 response to patients\u2019 suicide. Irish Journal of Psychological Medicine, 28(1), 35\u201337. https:\/\/doi.org\/10.1017\/S0790966700011952","journal-title":"Irish Journal of Psychological Medicine"},{"issue":"5","key":"1604_CR17","doi-asserted-by":"publisher","first-page":"381","DOI":"10.1136\/bmjqs-2016-005991","volume":"26","author":"KM Kellogg","year":"2017","unstructured":"Kellogg, K. M., Hettinger, Z., Shah, M., Wears, R. L., Sellers, C. R., Squires, M., & Fairbanks, R. J. (2017). Our current approach to root cause analysis: Is it contributing to our failure to improve patient safety? BMJ Quality & Safety, 26(5), 381\u2013387. https:\/\/doi.org\/10.1136\/bmjqs-2016-005991","journal-title":"BMJ Quality & Safety"},{"issue":"3","key":"1604_CR18","doi-asserted-by":"publisher","first-page":"254","DOI":"10.1007\/s10728-022-00447-3","volume":"30","author":"J Kok","year":"2022","unstructured":"Kok, J., de Kam, D., Leistikow, I., Grit, K., & Bal, R. (2022). Epistemic injustice in incident investigations: A qualitative study. Health Care Analysis, 30(3), 254\u2013274. https:\/\/doi.org\/10.1007\/s10728-022-00447-3","journal-title":"Health Care Analysis"},{"issue":"4","key":"1604_CR19","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pone.0251038","volume":"16","author":"RLD Lyra","year":"2021","unstructured":"Lyra, R. L. D., McKenzie, S. K., Every-Palmer, S., & Jenkin, G. (2021). Occupational exposure to suicide: A review of research on the experiences of mental health professionals and first responders. PLoS One, 16(4), Article E0251038. https:\/\/doi.org\/10.1371\/journal.pone.0251038","journal-title":"PLoS One"},{"key":"1604_CR20","doi-asserted-by":"publisher","first-page":"335","DOI":"10.1007\/s11115-005-5095-6","volume":"5","author":"B Morrison","year":"2005","unstructured":"Morrison, B., Blood, P., & Thorsborne, M. (2005). Practicing restorative justice in school communities: Addressing the challenge of culture change. Public Organization Review, 5, 335\u2013357. https:\/\/doi.org\/10.1007\/s11115-005-5095-6","journal-title":"Public Organization Review"},{"issue":"1","key":"1604_CR21","doi-asserted-by":"publisher","first-page":"74","DOI":"10.1017\/ipm.2019.4","volume":"39","author":"PT Murphy","year":"2022","unstructured":"Murphy, P. T., Clogher, L., Van Laar, A., O\u2019Regan, R., McManus, S., McIntyre, A., & Hallahan, B. (2022). The impact of service user\u2019s suicide on mental health professionals. Irish Journal of Psychological Medicine, 39(1), 74\u201384. https:\/\/doi.org\/10.1017\/ipm.2019.4","journal-title":"Irish Journal of Psychological Medicine"},{"key":"1604_CR22","unstructured":"National Confidential Inquiry into Suicide and Safety in Mental Health (2023). Annual Report: UK Patient and General Population Data, 2010\u20132020. University of Manchester, 2023 (https:\/\/sites.manchester.ac.uk\/ncish\/reports\/annual-report-2023\/)."},{"issue":"2","key":"1604_CR23","doi-asserted-by":"publisher","first-page":"217","DOI":"10.1016\/j.socscimed.2011.05.010","volume":"73","author":"D Nicolini","year":"2011","unstructured":"Nicolini, D., Waring, J., & Mengis, J. (2011). Policy and practice in the use of root cause analysis to investigate clinical adverse events: Mind the gap. Social Science & Medicine, 73(2), 217\u2013225. https:\/\/doi.org\/10.1016\/j.socscimed.2011.05.010","journal-title":"Social Science & Medicine"},{"issue":"4","key":"1604_CR24","doi-asserted-by":"publisher","first-page":"389","DOI":"10.1080\/01612840.2025.2475353","volume":"46","author":"N Nishii","year":"2025","unstructured":"Nishii, N., Endo, Y., & Shimizu, Y. (2025). Experiences of community mental health nurses who lost patients to suicide: A qualitative study. Issues in Mental Health Nursing, 46(4), 389\u2013396.","journal-title":"Issues in Mental Health Nursing"},{"key":"1604_CR25","unstructured":"Patel, R. H., & Boster, J. (2025). Medical error prevention and root cause analysis. In StatPearls. StatPearls Publishing. Retrieved December 19, 2025 from https:\/\/www.ncbi.nlm.nih.gov\/books\/NBK570638\/"},{"issue":"1","key":"1604_CR27","doi-asserted-by":"publisher","first-page":"54","DOI":"10.1016\/j.ijoa.2014.10.001","volume":"24","author":"SD Pratt","year":"2015","unstructured":"Pratt, S. D., & Jachna, B. R. (2015). Care of the clinician after an adverse event. International Journal of Obstetric Anesthesia, 24(1), 54\u201363. https:\/\/doi.org\/10.1016\/j.ijoa.2014.10.001","journal-title":"International Journal of Obstetric Anesthesia"},{"key":"1604_CR28","doi-asserted-by":"publisher","DOI":"10.3389\/frhs.2024.1473256","volume":"4","author":"L Ramsey","year":"2025","unstructured":"Ramsey, L., Sheard, L., Waring, J., McHugh, S., Simms-Ellis, R., Louch, G., & O\u2019Hara, J. K. (2025). Humanizing processes after harm part 1: Patient safety incident investigations, litigation and the experiences of those affected. Frontiers in Health Services, 4, Article 1473256. https:\/\/doi.org\/10.3389\/frhs.2024.1473256","journal-title":"Frontiers in Health Services"},{"key":"1604_CR29","doi-asserted-by":"publisher","first-page":"104","DOI":"10.1176\/appi.ap.28.2.104","volume":"28","author":"R Ruskin","year":"2004","unstructured":"Ruskin, R., Sakinofsky, I., Bagby, R. M., Dickens, S., & Sousa, G. (2004). Impact of patient suicide on psychiatrists and psychiatric trainees. Academic Psychiatry, 28, 104\u2013110. https:\/\/doi.org\/10.1176\/appi.ap.28.2.104","journal-title":"Academic Psychiatry"},{"issue":"5","key":"1604_CR30","doi-asserted-by":"publisher","first-page":"982","DOI":"10.1111\/inm.12738","volume":"29","author":"P Rytterstr\u00f6m","year":"2020","unstructured":"Rytterstr\u00f6m, P., Ovox, S. M., W\u00e4rdig, R., & Hultsj\u00f6, S. (2020). Impact of suicide on health professionals in psychiatric care mental healthcare professionals\u2019 perceptions of suicide during ongoing psychiatric care and its impacts on their continued care work. International Journal of Mental Health Nursing, 29(5), 982\u2013991. https:\/\/doi.org\/10.1111\/inm.12738","journal-title":"International Journal of Mental Health Nursing"},{"issue":"2","key":"1604_CR31","doi-asserted-by":"publisher","first-page":"261","DOI":"10.1002\/cpp.2515","volume":"28","author":"DM Sandford","year":"2020","unstructured":"Sandford, D. M., Kirtley, O. J., Thwaites, R., & O\u2019Connor, R. C. (2020). The impact on mental health practitioners of the death of a patient by suicide: A systematic review. Clinical Psychology & Psychotherapy, 28(2), 261\u2013294. https:\/\/doi.org\/10.1002\/cpp.2515","journal-title":"Clinical Psychology & Psychotherapy"},{"issue":"1","key":"1604_CR32","doi-asserted-by":"publisher","first-page":"41","DOI":"10.1097\/PTS.0000000000000169","volume":"14","author":"LP Vrklevski","year":"2018","unstructured":"Vrklevski, L. P., McKechnie, L., & O\u2019Connor, N. (2018). The causes of their death appear (unto our shame perpetual): Why root cause analysis is not the best model for error investigation in mental health services. Journal of Patient Safety, 14(1), 41\u201348. https:\/\/doi.org\/10.1097\/PTS.0000000000000169","journal-title":"Journal of Patient Safety"},{"issue":"8","key":"1604_CR33","doi-asserted-by":"publisher","first-page":"e1713","DOI":"10.1097\/PTS.0000000000000630","volume":"17","author":"S Wiig","year":"2021","unstructured":"Wiig, S., Haraldseid-Driftland, C., Zachrisen, R. T., Hannisdal, E., & Schibevaag, L. (2021a). Next of kin involvement in regulatory investigations of adverse events that caused patient death: A process evaluation (Part I - The next of kin\u2019s perspective). Journal of Patient Safety, 17(8), e1713\u2013e1718. https:\/\/doi.org\/10.1097\/PTS.0000000000000630","journal-title":"Journal of Patient Safety"},{"issue":"8","key":"1604_CR34","doi-asserted-by":"publisher","first-page":"e1707","DOI":"10.1097\/PTS.0000000000000634","volume":"17","author":"S Wiig","year":"2021","unstructured":"Wiig, S., Schibevaag, L., Zachrisen, R. T., Hannisdal, E., Anderson, J. E., & Haraldseid-Driftland, C. (2021b). Next-of-kin involvement in regulatory investigations of adverse events that caused patient death: A process evaluation (Part II - The inspectors\u2019 perspective). Journal of Patient Safety, 17(8), e1707\u2013e1712. https:\/\/doi.org\/10.1097\/PTS.0000000000000634","journal-title":"Journal of Patient Safety"},{"key":"1604_CR35","doi-asserted-by":"publisher","unstructured":"Wilschke, J., & Crepeau-Hobson, F. A.\u00a0(2024) Phenomenological analysis of mental health providers\u2019 experience of lient suicide.\u00a0 https:\/\/doi.org\/10.1007\/s10879-023-09611-9","DOI":"10.1007\/s10879-023-09611-9"},{"key":"1604_CR36","doi-asserted-by":"publisher","unstructured":"Wu A. W., Lipshutz, A. K., & Pronovost, P. J. (2008). Effectiveness and efficiency of root cause analysis in medicine. JAMA, 299(6), 685\u2013687. https:\/\/doi.org\/10.1001\/jama.299.6.685","DOI":"10.1001\/jama.299.6.685"}],"container-title":["Community Mental Health Journal"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1007\/s10597-026-01604-x.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/article\/10.1007\/s10597-026-01604-x","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1007\/s10597-026-01604-x.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,7]],"date-time":"2026-08-07T15:28:06Z","timestamp":1786116486000},"score":1,"resource":{"primary":{"URL":"https:\/\/link.springer.com\/10.1007\/s10597-026-01604-x"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,3,21]]},"references-count":36,"journal-issue":{"issue":"6","published-print":{"date-parts":[[2026,8]]}},"alternative-id":["1604"],"URL":"https:\/\/doi.org\/10.1007\/s10597-026-01604-x","relation":{},"ISSN":["0010-3853","1573-2789"],"issn-type":[{"value":"0010-3853","type":"print"},{"value":"1573-2789","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,3,21]]},"assertion":[{"value":"28 May 2025","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"16 February 2026","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"21 March 2026","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"The authors declare no competing interests.","order":1,"name":"Ethics","label":"Competing interests","group":{"name":"EthicsHeading","label":"Declarations"}}]}}