Proper patient assessments would have made staff in one region of the country more aware of their suicide risk.
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That's a finding of a report carried out by the Inspector of the Mental Health Services in the Carlow/Kilkenny and South Tipperary area.
13 patients died by apparent suicide in the region in less than two years.
The report, requested by the Mental Health Commission, found staff training for risk assessment was either 'insufficient, or else it wasn't being carried out at all'.
Concerns with the safety of the services first coincided with the reconfiguration of services i the region, which saw some patients from Co. Tipperary treated in the psychiatric unit of Ennis General Hospital.
