摘要
the authors relate a case of suicide where experts concluded that there had been a medical error. a woman was seen by a physician and admitted to a psychiatric hospital. the doctor's notes described the patient as having a severe depressive episode, with ideas of helplessness and worthlessness and suicidal intention. the patient committed suicide. brazilian law dictated the opening of a police investigation. the experts responsible for the report concluded that a medical error had possibly been committed: the patient had been left unaccompanied and the therapeutic conduct was not incisive enough in relation to the severity of the episode, as described in the patient's record.