Greg - this is a major concern for all who work in the mental health field, and I too share your sorrow that someone has had to lose their life because of poor administration leading to shortages of staff, resources, proper care, etc. However, my comments may (or may not, depending on how good your team of staff are) offer some balance to your outlook.
I have worked in in-patient facilities on and off (more off than on, for reasons I'm about to illucidate)since the early 1980's. In all that time, I have to say that I've most commonly seen the most appalling treatment of people with psychiatric illness than I would ever dare to "nightmare" (as opposed to "dream") I would ever see any other patient receive.
Good mental health staff are few and far between (in my experience). I don't know why this is, either.
It is not the norm rather the exception (at least here in NZ) for the patients to be treated with
d) aroha (what the NZ Maori people call love, but it is professional rather than emotional and encompassess all of the above)
I guess my point is simply that I found for the majority of the "incidents" I have observed (as in the ones that require an "incident form" to be completed) the staff member involved in the incident played an active, and often highly provocational role in the conflict. I know this makes me sound highly critical of my colleagues, but sadly, I can only speak my truth. I have the utmost respect for some of mental health nursing colleagues, but as I am labouring the point, they are few and far between. These people know how to demonstrate key nursing skills (let's call them the "three P's of the Treaty of Waitangi)
As a baseline of care, these would be a good start. Maybe if the staff concerned are given the training they need, if the supervisory staff were given the skills they need to be able to confront shortfalls in nursing care, (but still using the three P's formula), if the management knew how difficult it was to work in these environments... if, if, if, if, if.
I guess you're probably hearing my message by now Greg? Let's hope that no-one else has to die, but I not putting any money on this gamble... Would you?
All the best Greg, and if you read to the end - good on you, for keeping on with my ramble!!!