Statement of purpose Utah began conducting comprehensive, multidisciplinary reviews of suicides in 2014 in order to:

1. Reduce the rate of suicide in Utah.

2. Identify and describe the prevalence of risk factors among those individuals who die by suicide by reviewing, studying and reporting trends and patterns.

3. Develop recommendations for system improvement and to improve continuity of care.

4. Cultivate discussion and action to establish a unified, multi-agency response to the severely mentally ill and/or suicidal individuals.

5. Develop or improve protocols and agreements to improve system response.

6. Promote effective prevention and intervention strategies to reduce suicide.

Methods/Approach The Utah Suicide Prevention Coalition developed a strategic, prevention plan for suicide in 2013 which is modelled after the National Strategy for Suicide Prevention. One of those strategies was to implement a suicide fatality review committee. The committee is modelled after the Child Fatality Review and Domestic Violence Fatality Review Committee’s and has implemented a multi-disciplinary review process. Behavioural Health data from local behavioural health authorities is linked with the suicide death data collected from the National Violent Death Reporting System (NVDRS) so that incident, diagnosis and treatment information can be shared with committee members.

Results Preliminary results of the reviews have been positive. System improvement and intervention recommendations have been made on the cases that have been reviewed and policies and protocols implemented to support those recommendations.

Conclusions Reviewing suicide deaths, using a public health approach, and partnering with behavioural health has the potential to reduce suicide deaths in Utah and is showing some promising results. As part of a larger strategic plan to reduce suicides, the data gleaned from reviewing these deaths will inform prevention, intervention and postvention efforts.

Significance and contribution to the field Reviewing suicide deaths leads to a better understanding of how and why people die from suicide and catalyses actions that will prevent other deaths.