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This story discusses failures related emergency psychiatric assessment, including premature discharge, implicit bias, patient management discontinuity and inappropriate physical restraint that contributed to the death of a patient at risk for suicide.

Patient suicide is a never event. This report analyzes the death of a veteran after presenting at an emergency room with suicidal ideation. The analysis found lack of both suicide prevention policy adherence and appropriate assessment, as well as a lack concern for the patient’s condition contributed to the failure.