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Attendance at the Accident and Emergency Department in the Year BRITISH JOURNAL OF PSYCHIATRY (2003), 183, 28^33 Attendance at the accident and emergency detected by local mental health services and reported to the National Confidential department in the year before suicide: Inquiry.Inquiry. retrospective study METHOD ISAURA GAIRIN, ALLAN HOUSE and DAVID OWENS Every health district in England and Wales regularly sends a list of likely suicides to the National Confidential Inquiry into Sui- cides and Homicides by People with Mental Illness (Department of Health, 2001). The Background The National A key component of a suicide prevention list comprises all suicide verdicts and open Confidential Inquiry into suicides in strategy is the monitoring of suicides to de- verdicts, except where it is clear that suicide termine trends and to suggest further mea- was not considered at inquest. Unless speci- England and Wales found that a quarter of sures for reducing rates. In England and fied, findings presented here will refer to suicides are preceded by mentalhealth Wales a National Confidential Inquiry into the composite group as ‘suicides’ – in line service contactincontactinthe the year before death. suicides has been put in place, reporting with the practice in the National Confiden- However, visits to accident and recently that a quarter of suicides are tial Inquiry (Department of Health, 2001). emergency departments due to self-harm preceded by mental health service contact All local mental health services are required during the year before death (Appleby etet to determine whether or not each person on may notlead to a record of mentalhealth alal, 1999,1999aa; Department of Health, 2001). the list was in contact with their service in service contact. We have calculated that at least a quarter the year before death. of UK suicides are preceded by hospital at- We obtained the list of suicides for the Aims Todetermine the proportion of tendance as a result of self-harm (Owens & Leeds Health District for a 5-year period suicides preceded by accident and emer- House, 1994), an estimate that has been from 1994. It was our intention to identify, gencyattendance inthein the previous year. corroborated by research findings (Foster for each suicide on the list, whether the per- et aletal, 1997; Appleby et aletal, 1999,1999bb; Hawton;Hawton son had attended a local accident and MethodMethod We obtained the listoflist of et aletal, 1999). It seems to us unlikely that emergency department in the 12 months probable suicidesin Leeds for a 38-month all those people who were in contact with preceding suicide. Unfortunately, because of period, and examined the records from mental health services before suicide were the storage arrangements for old accident seen because they had undertaken an act and emergency records and consequent dif- thecity’saccidentandemergency of non-fatal self-harm. We suspect, there- ficulties with access to them, we were not departments for ayear before each death. fore, that the Inquiry methods overlook able to examine all the records for the rele- important contacts with health services that vant 6 years (5 years of suicides plus the ResultsResults Eighty-fiveEighty-five(39%)ofthe219 (39%) ofthe 219 point towards high suicidal risk. For a year before the first suicide on our list). people who later died by suicide had sample of suicides, we set out to determine We were, however, able to obtain accident attended an accident and emergency the number and nature of attendances at and emergency records for 50 consecutive departmentinthedepartmentin the year before death,15% the accident and emergency department months and we therefore used as our study in the preceding year, and we established sample the suicides that took place over 38 because of non-fatal self-harm.Finalvisits whether non-fatal self-harm was being consecutive months between 1994 and 1997; duetoself-harmwereoftenshortlybeforedueto self-harmwere often shortlybefore suicide (median 38 days), butthe National Confidential Inquiryrecordedabout afifth ofthemof them as‘notinas‘not in contact’withlocalmentalcontact’ with local mental Ta b l e 1 Relationship between suicide method, verdict and gender health services. Method Cases Proportion female Verdict Conclusions Although many suicides nn (%) Suicide ((Suicide nn)Open() Open (nn)) are preceded by recent attendance at accident and emergencydepartments due Ingested poisoning11 72 (33)(33)72 0.380.38 2626 4646 to non-fatal self-harm, localmentalhealth Hanging 63 (29)(29)63 0.03 58 55 service records may show no recent Toxic fumes 18 (8) 010 1771 contact.contact.Suicide Suicide preventionprevention might be Narcotic poisoning 12 (5.5) 0.17 2102 10 Multiple injuries 12 (5.5) 0.25 666 6 enhanced were accident and emergency Other methods 18 (8) 0.280.28 6126 12 departmentsdepartmentsandmentalhealthservicesto and mentalhealth services to Unascertained 24 (11) 0.25 7177 17 work together more closely. All methods 219 (100) 0.21 12297 Declaration of interest None. 1. Ingested poisons exclude narcotics, which constitute a separate category. 28 Downloaded from https://www.cambridge.org/core. 26 Sep 2021 at 03:02:21, subject to the Cambridge Core terms of use. HEALTH SERVICE CONTACT BEFORE SUICIDE Ta b l e 2 Contact with mental health services in the year before death and its relation to method of suicide accident and emergency record that was and verdict part of the final, fatal attendance at hospi- tal, we excluded it; all the episodes here therefore represent non-fatal hospital atten- Total sampleContact with mental health services in year before death dances. Our study had local research ethics nn No contact (nn) Contact nn (%) committee approval. We used two standard statistical proce- All casescasesAll 11 218127 91 (42) dures in our analyses: for categorical vari- Verdict ables we calculated the 95% confidence Open 96 4646 50 (52)50(52) intervals for the difference between propor- Suicide 122 81 41 (34)41(34)22 tions; and for the one comparison we made Method of suicide for a continuous variable, we used the Mann–Whitney UU test, because the data Ingested poisoning33 7272 35 37 (51)37(51) were not normally distributed. Hanging 63 41 22 (35)22(35) Toxic fumes 18 16 2(11)2 (11) Narcotic poisoning12 3 9(75)9 (75) RESULTSRESULTS Multiple injuries 12 111 111 (92)(92) Other methods 18 19 3(17)3 (17) There were 219 suicides (122 suicides and 97 open verdicts). The people who died Unascertained 23 16 7(30)7 (30) had an age range of 16–93 years, median 1, In one case, data on contact with mental health services were missing. 35 years, and the ratio of males to females 2. Difference in proportionsproportions18% 18% (95% CI 55^31). ^31). 3. Ingested poisons exclude narcotics, which constitute a separate category. was 3.8. Men were more likely to receive a suicide verdict rather than an open verdict accident and emergency records were ex- population of around 350 000. We thereby (105 of 174 men, 60%) compared with amined for 38 months plus the 12 months identified, for each suicide in the 38-month women (17 of 45 women, 38%) – a risk prior to the first suicide in the sample. period, all accident and emergency atten- ratio of 1.6 (95% CI 1.2–2.1). The gender Leeds has two large accident and dances in Leeds hospitals over the pre- difference in verdict may have much to do emergency departments, each serving a ceding 12 months. Where we found an with method: women were overrepresented in cases of drug poisonings but accounted for few hangings and no carbon monoxide poisoning (Table 1). The search of records by the local men- tal health service for the National Confi- dential Inquiry determined that 91 of the 219 persons who died by suicide (42%) were in contact with its service during the year before their death. Surprisingly, more of those receiving an open verdict than of those receiving a suicide verdict had made contact with local mental health services in the preceding year (Table 2). People whose death was due to multiple injuries or to poisoning by ingestion were particu- larly likely to have made contact with the mental health services in the last year, while few of those who died by toxic fumes or by unusual methods had been in contact (Table 2).(Table2). Attendance at accident and emergency departments Of the whole sample, 85 (39%) had at- tended an accident and emergency depart- ment in the year before death, 33 of them because of non-fatal self-harm – 39% (33/85) of all those who came to accident and emergency, 15% (33/219) of Fig. 11Fig. Accident and emergency department attendance in the year before suicide. suicides. The 85 people made 195 visits to 2929 Downloaded from https://www.cambridge.org/core. 26 Sep 2021 at 03:02:21, subject to the Cambridge Core terms of use. GAIRIN ET AL accident and emergency departments. Last attendance before death life 12 people (5% of all suicides in our Figure 1 sets out the reasons for attendance sample) paid a final visit to an accident and the clinical details. Table 3 shows that Of the 85 people who visited accident and and emergency department as a result of there was no striking difference in atten- emergency departments in the year before non-fatal self-harm. dance patterns between the genders or suicide, 26 (31%) did so on the last occa- The local mental health services according to the coroner’s verdict. Signifi- sion as a consequence of non-fatal self- searched their case records for contacts cantly more of those who had been in harm – 20 self-poisoning episodes and 6 with their service in the year before suicide. contact with mental health services in their self-injuries.
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