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 : 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 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 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 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 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.

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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 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

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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. These 26 patients were of the Of the 26 persons whose last attendance at last year had attended accident and emer- same age pattern as the total group of peo- a local accident and emergency department gency; this difference was almost entirely ple who had died by suicide. Equal propor- before death was a consequence of non- due to self-harm attendances. People who tions attended the city’s two accident and fatal self-harm, 5 were not found by this died from toxic fumes or whose cause of emergency departments. Clinical details search to have been in contact with mental death was unascertained had generally not and management of the cases by accident health services in the year before their sui- attended an accident and emergency de- and emergency staff are shown in Fig. 2. cide; consequently, they were notified to partment because of self-harm in the pre- The final attendance was shortly before sui- the National Confidential Inquiry as ‘not vious year. On the other hand, of those cide (median 38 days, interquartile range in contact’. Either these episodes of self- whose suicide was a result of ingested poi- 7–129) when the reason was self-harm, harm did not result in contact with a men- sons, nearly half had previously attended but not when it was for other reasons – tal health practitioner, or contact was made during the year – about a fifth because of median 114 days (44–228) (Mann–Whitney but did not find its way into mental health self-harm.self-harm. UU¼472,472, PP¼0.005). In their last month of service records.

DISCUSSION

Ta b l e 3 Accident and emergency attendance for any reason and specifically for self-harm, and its relation to Our main finding was the identification of other variables a high proportion of suicides preceded by accident and emergency attendance (39%) in the year before death, with over one- TotalTotal Accident and emergency department attendance third of these people (15% of all suicides) sample attending an accident and emergency nn Did notDidnot Attended for Attended because department because of a self-harm episode. attendattend any reason of self-harm A substantial proportion of these episodes nn nn (%) nn (%) were not known to local mental health ser- vices. Since it is not the National Confiden- All casescasesAll 219134 85 (39) 33 (15) tial Inquiry’s practice for accident and Gender emergency records to be searched as part FemaleFemale 4545 252520 (44) 6(13)6 (13) of the identification of recent contact with Male 174109 65 (37)11 27 (16)22 the mental health services, the Inquiry re- Verdict corded as ‘not in contact’ 5 out of 26 peo- Open97 55 42 (43) 18 (19) ple whose last visit to the accident and emergency department in the year before SuicideSuicide 12279 43 (35)33 15 (12)44 their suicide was a consequence of self- Contact with mental health services harm.harm. in the year before death55 Recorded91 42 49 (54) 28 (31)28(31) Not recorded 12791 36 (28)36(28)66 5(4)77 Accuracy of the study findings Method of suicide This study used two sources of data: the list Ingested poisoning88 7239 33 (46) 15 (21) of those dying by suicide, including their Hanging 6345 18 (29)(29)18 8(13)8 (13) contacts with local mental health services, Toxic fumes 1815 3 (17) 1(6)1 (6) sent to the National Confidential Inquiry; Narcotic poisoning 1248( 4 8(67)67) 4(33)4(33) and data on attendances drawn from clini- cal records at the two local accident and Multiple injuries 126 6 (50)6(50) 2(17)2 (17) emergency departments. The suicide data Other methods 189 9(50)9 (50) 2(11) will not perfectly represent all suicides Unascertained 2416 8(33)8 (33) 1(4)1 (4) and mental health service contacts in 1. Difference in proportions 7% (95% CI 778 to 23).23).8to the period of our sample, but they are the 2. Difference in proportions 2% (95% CI 7712 to 12).12).12to identical data that were received by the 3.Differenceinproportions8%(95%CI3. Difference in proportions 8% (95% CI 775to21). 4. Difference in proportions 6% (95% CI 773 to16).3to16). National Confidential Inquiry and are 5. In one case, data on contact with mental health services were missing. included in the Inquiry’s findings. Data 6. Difference in proportions 26% (95% CICI12 12 to 38). 7. Difference in proportions 27% (95% CI 17 to 37). drawn from accident and emergency re- 8. Ingested poisons exclude narcotics, which constitute a separate category. cords, on the other hand, will contain

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What are the shortcomings of present arrangements for care after self-harm?

Our retrospective study demonstrates a strong link between non-fatal self-harm and suicide. Published cohort studies have also shown a huge excess of suicidal risk in the year following self-harm: it seems likely that between 0.5% and 2% of those treated for self-harm will die by suicide in the following year (Hawton & Fagg, 1988; Owens et aletal, 2002). It was estimated in 1997, from Oxford rates, that there are over 140 000 people attending hospital because of a self-harm episode each year in England (Hawton et aletal, 1997). Simple arithmetic therefore indicates that a sub- stantial proportion of the 5000 suicides each year in England – probably some- where between 700 and 2800 of them – are preceded by a self-harm episode in the preceding year. This close tie between non-fatal and fatal episodes points to the need for great care over the psychosocial assessment and after-care arrangements for people attend- ing hospital because of self-harm. Unfor- tunately, this connection has been largely disregarded by national policies. Governmental targets for suicide reduc- tion in England started a decade ago with thethe Health of programmeprogramme (Department of Health, 1992). They were renewed (Secretary of State for Health, 1999) and accompanied by standard Fig. 22Fig. Last attendance at an accident and emergency department in the year before suicide. All data have setting (standard 7 in the National been extracted from accident and emergency records. Service Framework for Mental Health) for local health and social care commu- inaccuracies and may therefore misrepre- they are, seem most likely to have resulted nities (Department of Health, 1999). sent the relation between accident and in underestimation of the number and The measures recommended for preven- emergency attendance and suicide. We proportion of suicides in Leeds that were tion of suicide have emphasised recogni- might have missed some attendances – preceded by hospital attendance due to tion and treatment of depression, better perhaps because of use of different patient non-fatal self-harm. care of those with severe and enduring names, or simply as a consequence of For two further reasons, we also sus- mental illness – whether as in-patients, searchingsearchingforfor a small number of episodes pect that our local data underestimate the soon after discharge or in community among more than half a million atten- national shortfall in notification. First, we follow-up – and attention to in-patient dances at these large accident and found that our local mental health services facilities (Department of Health, 1993, emergency departments. had identified a higher proportion of 1999). Self-harm has hardly been We might also have failed to identify contacts than was the national average mentioned.mentioned. correctly whether each accident and emer- (42% compared with 24% nationally); The findings of the National Confiden- gency attendance was due to self-harm. perhaps the local mental health service tial Inquiry, in much the same way as the Accident and emergency records are often was especially adept at tracing contacts. earlier policy documents, have been used brief and sometimes contain incomplete Second, Leeds practice might have shown to recommend suicide prevention measures clinical details. Where it seemed possible an above-average rate of psychosocial in mental health services – but say little or that self-harm had occurred but was not assessment of self-harm cases during this nothing about more than 150 000 patients recorded by the clinician or coded by the period (Kapur et aletal, 1998), which would across the UK who attend hospital clerical staff as such, we designated the render the mental health service records after self-harm each year (Appleby et aletal,, episode as ‘not self-harm’. These method- particularly likely to show a contact around 19991999aa; Department of Health, 2001). The ological shortcomings, inevitable though the time of a self-harm episode. omission is not surprising: our study shows

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how the Inquiry’s methods are not designed to identify self-harm as an antecedent to CLINICAL IMPLICATIONS suicide.suicide. Across the UK, present arrangements && More than a third of over 200 consecutive suicides were preceded by accident and for the psychosocial assessment and emergency attendance in the previous year. after-care of patients attending hospital as a result of self-harm are in disarray && Over one-third of those who attended an accident and emergency department in (Owens & House, 1994). There is great the year before suicide did so because of self-harm, although a substantial proportion geographical variation in the proportions of these episodes were unknown to local mental health services. of people who receive adequate psycho- social assessment: a large majority of && The National Confidential Inquiry fails to identify the scale of the connection patients are assessed in some hospitals between non-fatal and fatal self-harm. but only a minority in others (Kapur etet alal, 1998). Assessment usually falls well LIMITATIONS short of the levels of assessment and care && Accident and emergency records are not detailed enough to determine whether recommended by professional bodies some attendances were due to self-harm. (Royal College of Psychiatrists, 1994; Hawton & James, 1995; Hughes et aletal,, && In our sample those dying by suicide had higher than national average recorded 1998; Head et aletal, 1999). Effective inter- contact rate with mental health services, so other mental health services may miss vention after self-harm is difficult to even more self-harm episodes. establish because the evidence, largely derived from a few small studies, is && We have probably underestimated the shortfall in local mental health services’ too weak and inconclusive to provide records of accident and emergency attendance due to self-harm. pointers to best practice (Hawton et aletal,, 1998; NHS Centre for Reviews and Dissemination, 1998).

ISAURA GAIRIN, MRPsych,Yorkshire Centre for Forensic Psychiatry,Wakefield; ALLAN HOUSE, DM, DAVID What practical steps are suggested OWENS, MD, Academic Unit of Psychiatry and Behavioural Sciences,University of Leeds,UK by this study? CorrespCorrespondence:ondence:Dr Dr David Owens, Academic Unit of PsychPsychiatryiatry and Behavioural Sciences,University of Leeds,15 HydeTerrace, Leeds LS2 9LT,UK Once risk factors for an adverse outcome have been identified, it is common practice (First received 14 May 2002, final revision 11December 2002, accepted 6 January 2003) for policy-makers to propose alterations in practice – to be instituted with immediate effect. The findings of the National Confi- dential Inquiry into suicides have been criti- cised for this approach (Geddes, 1999) discharge from hospital, a psychosocial ACKNOWLEDGEMENTS because of the poor predictive validity of assessment from a member of staff specifi- the risk factors. How useful is identification cally trained for this task (Department of We thank Paul Newton for help with data collection of a self-harm episode likely to be? Even Health and Social Security, 1984). This and Judith Horrocks for comments on an earlier draft of the manuscript. though people who self-harm may be at a assessment, and the ensuing decisions about hundred times the baseline risk (Hawton after-care, should become part of the & Fagg, 1988; Owens et aletal, 2002), suicide patient’s clinical record – held by or made REFERENCES in the year following non-fatal self-harm available to the mental health service. is uncommon in absolute terms: most These contacts and assessments would Appleby, L., Shaw, J., Amos,Amos,T., T., et aletal (19(1999 9 9 aa)) Suicide within 12 months of contact with mental health services: people attending accident and emergency thereby become available to the process national clinical survey. BMJ,, 318318,1235^1239., 1235^1239. departments because of self-harm are un- of monitoring and audit of suicides by the likely to die by suicide in the year that National Confidential Inquiry. Second, __ ,Cooper,J.,Amos,T., et aletal (19(1999 9 9 bb)) Psychological because it is inevitable that a proportion autopsy study of suicides by people aged under 35. follows. Low specificity of the predictive British Journal of Psychiatry,, 175175,168^174.,168^174. factor and low prevalence of the outcome of patients will receive no such assessment, bring about a poor positive predictive the National Confidential Inquiry must Department of Health (1992) The Health of the Nation. A Strategy for Health in England. London: HMSO. value: interventions for all will be un- record the occurrence of hospital atten-

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