Mortality reviews conducted by the quality assurance committee in the Department of Psychiatry at the University of Rochester Medical Center during 1982-1984 disclosed a pattern of suicides by patients with a combination of major depression and either mixed or borderline personality disorder. This finding coincides with earlier published research on suicide risk for such patients. Data from the reviews led to the establishment of a suicide prevention task force and to changes in policies regarding patient transfers, family therapy, discharge planning, and suicide risk assessment. The data also suggest several hypotheses for further research on suicide risk assessment and case management for this patient population.