Data from the National Institute of Statistics (INE) recorded 3,952 suicides in Spain in 2023. These figures prompt reflection on what lies behind suicidal behavior, whether it represents a collective social failure, and how medical professionals can approach and address this issue.

The Suicide Rate in Spain: Medical Responsibility and Legal Protocols

The suicide rate in Spain currently stands at 8.8 per 100,000 inhabitants (below the European and global average). In 2018, this rate was 7.2, so although the trend remains relatively stable, the current rate is the highest in history. Faced with these numbers, one must question what is failing, what can be legally reproached to those responsible for the safety of patients, and how, from a medical perspective, action can be taken, to the extent possible, to safeguard patients' rights.

This issue focuses on prevention and action, with healthcare services providing all necessary tools to ensure that this figure and percentage are as low as possible.

In legal practice, many cases and proceedings against public and private hospitals and medical professionals are based on what is considered a failure to adhere to suicide prevention protocols, which all autonomous communities should theoretically have in place, a failure often categorized as non-compliance with the lex artis ad hoc.

As specialized lawyers and through the cases we commonly encounter, we identify the controversial facts in civil or criminal actions as fundamentally stemming from:

• An incorrect diagnosis.
• An inadequate assessment of suicide risk.
• An inadequate evaluation of prior pathological decompensation.
• Overlooking psychotic behaviors.
• Previous suicidal or self-harming thoughts or attempts.
• Failing to properly evaluate delusional, aggressive, disorganized thinking.
• Errors in medication management or failure to implement containment measures based on the patient's severity.
• Lack of specialized training in certain hospital units for treating such patients.
• Breach of duty of care or the duty in vigilando that hospitals and their staff hold when a patient is under their care.
• Lack of immediate measures or failure to admit to specialized units.
• Failure to adhere to suicide prevention protocols, which, though not mandatory, are recommended for use and compliance.

Most lawsuits, complaints, or reports find their legal basis in the assertion that the suicidal person’s intellectual and volitional capacity was completely impaired, with altered reality judgment. Relevant behaviors or history were not adequately considered when evaluating the appropriate treatment.

Legal Framework for Public Health Services Liability

For public health services, several requirements must be met to declare administrative liability. According to extensive jurisprudence (including Supreme Court Rulings STS March 21, 2007, Rec. 276/2003 and STS February 5, 2007, Rec. 4067/2003), these are:

1. Existence of Actual Damage or Loss: This must be economically assessable and individualized in relation to a specific person or group.
2. Direct Causal Link: The injury or loss suffered by the claimant must directly result from the normal or abnormal (qualification irrelevant) functioning of public services, without intervention from external elements that might influence or alter the causal link.
3. Absence of Force Majeure: The event must not be due to uncontrollable or unforeseeable forces.
4. No Obligation for the Claimant to Endure the Damage: The claimant must not legally be required to bear damage caused by their own conduct.

It is worth noting that, although a causal link must exist between the damage and the functioning of the public service, the liability of the administration is objective, meaning the relevance lies in the unlawfulness of the result or injury rather than the administration's conduct. As noted in STS January 27, 2001 (Rec. 6360/96), this objective liability also extends to accidental events.

To legally assess potential liability of the health administration, several factors must be considered:

1. Foreseeability of Harm: Both STS February 5 and March 21, 2007, consider harm foreseeable if the facility is aware of the patient's abnormal conditions or previous psychiatric history.
2. Preventability of Harm.
3. Clear Causal Link between the omission of duty of care and the harm caused.

Undoubtedly, the duty of care lies with the hospital. The Superior Court of Galicia (Judgment 215/2021, April 14), in a case where a patient managed to jump out of a window, stated, “The Hospital was responsible for ensuring her safety, based on its duty of care.”

Regarding the causal link, STS rulings from February 5 and March 21, 2007, emphasize, “It must be concluded that the hospital did not take the necessary precautionary and care measures, and it is incorrect for the initial judgment to consider the plaintiff's behavior as a break in the causal link (...).”

Another requirement is that the patient should not be legally obligated to bear the harm caused by their own conduct. Referring again to STS February 5 and March 21, 2007, they note that “due to the patient’s mental disorder, which was the reason for their hospitalization, it was foreseeable that they might behave in a way that created a risk a person in normal conditions would avoid. Knowledge of these circumstances imposed on the health administration the duty to carefully monitor their behavior, which did not happen in this case, resulting in the plaintiff jumping from a window with the injurious consequences described.”

Thus, despite the multitude of circumstances and unknowns surrounding suicidal behavior, and the relative "lack of understanding" surrounding this critical issue, all possible measures should always be provided to the patient to reduce, as much as possible, the suicide figure of 3,952 to zero—if only in strictly utopian terms.