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National Confidential Inquiry into Suicide and Homicide

by People with Mental Illness

How health informatics helps

15th January 2008, ASSIST Meeting

Rebecca Lowe, Administration Manager

Pauline Turnbull, Research Associate

www.manchester.ac.uk/nci

Outline

• Background to Inquiry

• Aims

• Methodology

• Findings

• Limitations

Background

• Set up at University of Manchester in 1996

• Funded by the National Patient Safety Agency

Aims

• To collect detailed clinical information on people who die by suicide or commit homicide and who have been in contact with mental health services

• to make recommendations on clinical practice and policy that will reduce the risk of suicide and homicide by people under mental health care

Suicide Methodology

Obtain national data from the Office for National Statistics

(ONS)

Determine contact with MH services via trust contact

No contact within 12 months

Contact within 12 months

Send questionnaire toconsultant

ONS data

• Received quarterly

• Suicide and open verdict deaths

• Provided with SHA code of residence and death

Trust contacts

• Usually 1 per trust, within Medical Records

• Sent the data for the Strategic Health Authority their Trust covers

• Given a detailed checking protocol

Suicide: Questionnaire

• Demographic features• Diagnostic features• Cause of death• Behavioural features• Contact with services• Priority groups

– in-patients– post-discharge– non-compliance– missed contact

N o previous contact w ithm enta l health services

Send questionnaire to psychia trists

Inquiry case

Previous contact w ith m enta l health servicesidentified by N H S Trusts

Psychia tric reports co llected

N ational sam ple of hom icidesM u rde r, M a ns la u gh ter & In fa n tic ide

Homicide Methodology

Homicide Questionnaire data

• Demographic information

• Psychiatric/Forensic history

• Treatment and compliance

• Views on prevention

• Priority groups include:– in-patient homicides– recently discharged – patients under CPA– missed appointments– non-compliance

Results

Suicide (England/Wales 2000-2004)

• General population suicides: 23,477

• Around 4,500 per year

• Hanging most common method overall

• Self-poisoning most common for females

General population suicide: age and sex profile

0

500

1000

1500

2000

2500

3000

3500

4000

4500

< 25 25-34 35-44 45-54 55-64 65-74 75+

Age groups

Freq

uenc

yMale

Female

Suicide: Inquiry cases

• Inquiry cases: 6,367 (27%)• Questionnaires returned on 6,203 cases (97%) response rate

• 66% male

• 7% ethnic minority

• 69% unmarried, 44% lived alone

• 40% unemployed

• 14% were in-patients at the time of the suicide

• Affective disorder (bipolar disorder & depression) the most common diagnosis (46%)

Method of suicide used by Inquiry cases by sex

0

200

400

600

800

1000

1200

1400

1600

1800

2000

Hanging/strangulation Self-poisoning Carbon monoxidepoisoning

Jumping/multipleinjuries

Drowning Other

Cause of death

Freq

uenc

yMale Female

Homicide (England/Wales 1999-2003)

• General population homicides: 2,670

• Around 500 per year

• 90% Male, median age 28

• Over half of victims were male under 35

• One third killed a family member or

current/ex partner

Method of homicide by sex of perpetrator

0

100

200

300

400

500

600

700

800

900

Sharpinstrument

Bluntinstrument

Hitting orkicking

Strangulation Shooting Other

Freq

uenc

y

Male Female

Homicide: Inquiry cases• Inquiry cases:486 (18%)• Questionnaires returned on 451 cases

(93%) response rate

• 249 seen within the 12 months prior to

homicide

• 87% male

• 71% unmarried, 37% lived alone

• 62% unemployed

• Schizophrenia most common diagnosis

(30%)

Limitations

Missed contact with services

Clinical data based on casenotes and clinical judgements

Completers aware of outcome

The Sudden Unexplained Death Study

Pauline Turnbull

National Confidential Inquiry into Suicide and Homicide by People with Mental Illness

ASSIST PRESTWICH 2008

Outline

• Background

• Methodology

• Results

• Limitations

• Clinical Implications

Background

• Sudden Unexplained Death (SUD)

1. Death by cardiac cause

2. Death within 60 minutes of symptoms

3. NOT a Myocardial Infarction

(World Health Organisation, 1993)

Associations with SUD

• Treatment for mental illness

• Anti-psychotic drug use– Some drugs prolong the QT interval

• Non drug factors– poor physical health

– restraint

Aims of the study

• To determine the number and rate of SUD in psychiatric in-patients in England & Wales

• To examine the circumstances leading up to death

• to conduct a case-control study to identify risk factors for SUD

Methodology

• Data collection began in March 1999

• The SUD study is part of the wider Inquiry

• NPSA funded

• The study is a collaboration between:– The University of Manchester

– The University of Newcastle

– The University of Bristol

Data linked to NACS codes

2 Controls per case

Data collection

HES data

Information from Trusts

Data formatted by SUDS team

Eligibility sent

Non-case

Case

Questionnaire Questionnaire

Data linked to NACS codes

2 Controls per case

Data collection

HES data

Information from Trusts

Data formatted by SUDS team

Eligibility sent

Non-case

Case

Questionnaire Questionnaire

Hospital Episode Statistics (HES)

• NHS number

• Local patient ID

• Sex

• Date of birth

• Date of admission

• Date of discharge

• Mode of discharge

• Consultant GMC code

• Trust code

• Trust site code

Data linked to NACS codes

2 Controls per case

Data collection

HES data

Information from Trusts

Data formatted by SUDS team

Eligibility sent

Non-case

Case

Questionnaire Questionnaire

Data linked to NACS codes

2 Controls per case

Data collection

HES data

Information from Trusts

Data formatted by SUDS team

Eligibility sent

Non-case

Case

Questionnaire Questionnaire

Questionnaire Data

• Demographic information

• Psychiatric history

• Physical health

• Substances taken prior to death

• Last admission

• Circumstances of death

• Additional information

• Questionnaire information is held on an anonymised database

Validation study

• Are we capturing all SUDs?

• Validate all cases and some non-cases

• Clinical Research Fellows:– review case notes

– decide whether patient is a case

– blinded to Consultant Psychiatrist’s opinion

Data linked to NACS codes

2 Controls per case

Data collection

HES data

Information from Trusts

Data formatted by SUDS team

Eligibility sent

Non-case

Case

Questionnaire Questionnaire

Matching Controls

• Controls are matched from HES data – Date of admission same as case– Sex same as case– Date of birth same as case– Alive on the day of death of the case

• Data matched to NACS codes• Questionnaire sent

• Questionnaire information is held on an anonymised database

Results

Age and Sex

0

5

10

15

20

25

30

35

40

45

Fre

qu

ency

<20 20-29 30-39 40-49 50-59 60-69 70-75

Age Group

Male

Female

Physical features

Number (235)

%

(95% CI)

History of Cardiovascular Disease

106

46%

(40 - 53)

History of Respiratory Disease

97

31%

(35 - 48)

Physical examination during final admission

216

93%

(89 - 96)

Clinical featuresNumber

(235) % (95% CI)

Speciality admitted to:

General Adult Psychiatry 97 41% (35 - 48)

Old Age Psychiatry 92 39% (33 - 46)

Primary Diagnosis: Schizophrenia 79 34% (28 - 40)

Affective Disorder 66 28% (23 - 34)

More than 5 previousadmissions 84 37% (30 - 43)

Prescribed Psychotropic Drug 182 78% (72 - 83)

Prescribed two or morePsychotropic drugs

113 49% (42 - 55)

Clinical features

Number(235) % (95% CI)

Patient died on the ward 198 85% (80 - 89)

CPR attempted 126 57% (50 - 64)

Staff trained in CPR 116 87% (80 - 92)

CPR equipment on the ward 131 68% (61 - 75)

Study limitations

• We rely on Consultant Psychiatrists accurately applying SUD criterion

• We may be missing some SUD cases

• Patient records are often missing important information

Clinical Implications

• QT prolonging medication should be used with caution

• Physical health care is important– assess physical health on admission

– follow up evidence of poor physical health

– include physical health care in care plan

– training opportunities for mental health nurses in physical health care

• CPR equipment and CPR trained staff could be more accessible

Contact Details

The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness

Centre for Suicide Prevention

The University of Manchester

Williamson Building

Oxford Road, Manchester

M13 9PL, UK

Telephone: (+44) 161-275-0700

Email: rebecca.lowe@manchester.ac.uk pauline.turnbull@manchester.ac.uk

http://www.medicine.manchester.ac.uk/suicideprevention/