Clearly, this is a tragedy to lose 20 of our brothers/sisters a day to suicide. And only 6 of those are seen at a VAC. Based on my research on clinical trauma dating back to WW Two, I understand some of the reasons for disengagement. I have released some of my findings to our local VAC, to no avail. And every suicide of someone being seen there is demoralizing and quite painful to all staff involved in their care. As the VAC does conduct psychosocial autopsies and root-cause analyses of these sentinel events, it should inform them in enhancing care. I have myself conducted these examinations at a large CMHC in my area to enhance our ability at predicting, and protecting, and preventing some of these tragedies.
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