Mental health reforms in Europe: further evaluation of the Dutch supervision system for suicides of mental health care users.

Until recently, suicides of mental health care users in the Netherlands had to be reported to the Health Care Inspectorate by treating clinicians and medical directors. Interview data from 38 clinicians who reported a suicide and directors of the 28 facilities where they worked indicated ambivalence about the procedure's usefulness, especially about the blame implied by the required reporting procedure. No interviewee reported that a suicide could have been prevented. In May 2011 the national policy was changed so that most suicides can be reported in a blame-free manner within the facility and fewer suicides must be reported to the inspectorate.