When an inpatient takes his own life, it sparks myriad issues and concerns for any medical administrator. In this episode, Dr David Rankin and Dr Nick O'Connor explore the challenges of medical administration in this tragic scenario, through the lens of the restorative justice approach. Dr O’Connor is the Clinical Lead of the Mental Health Patient Safety Program for the NSW Clinical Excellence Commission. He is a psychiatrist with more than 25 years’ experience in clinical leadership and assessing medical practitioners for the NSW Medical Council. David and Nick discuss the hypothetical case of Ed, a psychiatric patient who experiences a devastating outcome. This episode emphasizes a shift from blame to systemic understanding, tackling issues like psychological safety and compounded harm. Disclaimer: The views, thoughts, and opinions expressed in the following Podcast are the speaker’s own and do not represent the views, thoughts, and opinions of the Royal Australasian College of Medical Administrators (RACMA). The material and information presented here is for general information purposes only, and should not be considered health, legal or financial advice. The cases discussed in the Podcast may be specific to the speaker’s organisation or location, and may not be applicable to other organisations, states, territories or countries. RACMA does not endorse, approve, recommend, or certify any information, product, process, service, or organisation presented or mentioned in this Podcast, and information from this Podcast should not be referenced in any way to imply such approval or endorsement. RACMA will not be held responsible for any losses, damages, or liabilities that may arise from the use of this Podcast. The Podcast may contain descriptions of health incidents that may be graphic and triggering for some people, so listener discretion is advised. See omnystudio.com/listener for privacy information.