Suicide Verdicts Research Articles

Apropos suicide verdicts: Lord Clifford strangled himself with his cravat in 1673? Beyond reasonable doubt versus the balance of probabilities - Psychiatry in the arts.

Apropos suicide verdicts: Lord Clifford strangled himself with his cravat in 1673? Beyond reasonable doubt versus the balance of probabilities - Psychiatry in the arts.

Coronial determination of suicide: insights from inquests

ABSTRACT The purpose of this article is to extend previous discussion of the relationship between coronial verdicts of suicide and suicide statistics, through a detailed examination of coronial decision-making during 130 inquests in Queensland, Australia between 2004 and 2018. This research suggests that the official category of suicide does not have the same meaning for different coroners, and it is unlikely that coroners follow the same rules in assigning particular cases to given categories. This is complicated by several factors: the feedback loops between researchers and coroners, where researchers rely on coronial data and coroners rely on research findings; beliefs about ‘suicide prone’ populations; and the role of coroners in offering closure for families and meaning for society. Suicide is a social fact, and how it is counted depends upon the norms, protocols and concepts operating within any given coroner’s court. We conclude that administrative options beyond the binary of suicide/not suicide would have the most impact on enabling suicide findings to be more consistent and defensible.

Risk of Suicide After Dementia Diagnosis

Patients with dementia may be at an increased suicide risk. Identifying groups at greatest risk of suicide would support targeted risk reduction efforts by clinical dementia services. To examine the association between a dementia diagnosis and suicide risk in the general population and to identify high-risk subgroups. This was a population-based case-control study in England conducted from January 1, 2001, through December 31, 2019. Data were obtained from multiple linked electronic records from primary care, secondary care, and the Office for National Statistics. Included participants were all patients 15 years or older and registered in the Office for National Statistics in England with a death coded as suicide or open verdict from 2001 to 2019. Up to 40 live control participants per suicide case were randomly matched on primary care practice and suicide date. Patients with codes referring to a dementia diagnosis were identified in primary care and secondary care databases. Odds ratios (ORs) were estimated using conditional logistic regression and adjusted for sex and age at suicide/index date. From the total sample of 594 674 patients, 580 159 (97.6%) were controls (median [IQR] age at death, 81.6[72.0-88.4] years; 289 769 male patients [50.0%]), and 14 515 (2.4%) died by suicide (median [IQR] age at death, 47.4 [36.0-59.7] years; 10 850 male patients [74.8%]). Among those who died by suicide, 95 patients (1.9%) had a recorded dementia diagnosis (median [IQR] age at death, 79.5 [67.1-85.5] years; median [IQR] duration of follow-up, 2.3 [1.0-4.4] years). There was no overall significant association between a dementia diagnosis and suicide risk (adjusted OR, 1.05; 95% CI, 0.85-1.29). However, suicide risk was significantly increased in patients diagnosed with dementia before age 65 years (adjusted OR, 2.82; 95% CI, 1.84-4.33), in the first 3 months after diagnosis (adjusted OR, 2.47; 95% CI, 1.49-4.09), and in patients with dementia and psychiatric comorbidity (adjusted OR, 1.52; 95% CI, 1.21-1.93). In patients younger than 65 years and within 3 months of diagnosis, suicide risk was 6.69 times (95% CI, 1.49-30.12) higher than in patients without dementia. Diagnostic and management services for dementia, in both primary and secondary care settings, should target suicide risk assessment to the identified high-risk groups.

The development and validation of a dashboard prototype for real-time suicide mortality data.

Introduction/AimData visualisation is key to informing data-driven decision-making, yet this is an underexplored area of suicide surveillance. By way of enhancing a real-time suicide surveillance system model, an interactive dashboard prototype has been developed to facilitate emerging cluster detection, risk profiling and trend observation, as well as to establish a formal data sharing connection with key stakeholders via an intuitive interface.Materials and MethodsIndividual-level demographic and circumstantial data on cases of confirmed suicide and open verdicts meeting the criteria for suicide in County Cork 2008–2017 were analysed to validate the model. The retrospective and prospective space-time scan statistics based on a discrete Poisson model were employed via the R software environment using the “rsatscan” and “shiny” packages to conduct the space-time cluster analysis and deliver the mapping and graphic components encompassing the dashboard interface.ResultsUsing the best-fit parameters, the retrospective scan statistic returned several emerging non-significant clusters detected during the 10-year period, while the prospective approach demonstrated the predictive ability of the model. The outputs of the investigations are visually displayed using a geographical map of the identified clusters and a timeline of cluster occurrence.DiscussionThe challenges of designing and implementing visualizations for suspected suicide data are presented through a discussion of the development of the dashboard prototype and the potential it holds for supporting real-time decision-making.ConclusionsThe results demonstrate that integration of a cluster detection approach involving geo-visualisation techniques, space-time scan statistics and predictive modelling would facilitate prospective early detection of emerging clusters, at-risk populations, and locations of concern. The prototype demonstrates real-world applicability as a proactive monitoring tool for timely action in suicide prevention by facilitating informed planning and preparedness to respond to emerging suicide clusters and other concerning trends.

Profile of suicide within the northern part of Ghana: A decade under review.

BackgroundSeveral reports show that suicide is the second and third leading cause of untimely death in young people below the age of 30. Little, however, is known about the profile and trend of suicide in this country due to lack of systematic studies and a lack of national statistics on suicide. This study seeks to examine the profile and pattern of suicide cases recorded within northern Ghana for the past decade.AimThis study aimed to report the prevalence of suicide as an independent cause of death; the choice of suicide method and the alleged reasons for suicide within the northern part of Ghana.SettingRetrospective review of coroners’ reports within the northern part of Ghana.MethodIn this descriptive study, 309 completed suicides as archived by the office of the coroner were examined. The coroners’ reports of 309 individuals, whose deaths received a suicide verdict or an open verdict in which the cause of death was likely to be suicide from 2008 to 2017, were examined. Student’s t-test was used to ascertain significant age differences between the genders involved.ResultsAmongst the 309 decedents examined, approximately, 61% were male, with ages ranging from 5 to 81 years. Hanging and poisoning were the most commonly used methods to complete suicide accounting for 124 (40.1%) and 102 (33.0%) deaths, respectively. Regarding the reasons for completed suicide, 78 (25.2%) were because of unknown reasons and 66 (21.4%) were because of social stigma. There was a notable decline in the prevalence of suicide from 2014 to 2017 compared with the years from 2010 to 2013.ConclusionSuicide was highest in the 30–39 year age group with hanging and poisoning being the most common method employed. Stigmatisation and psychosocial problems arising from chronic illness and economic hardship were significant triggers of suicide amongst the suicide decedents in the northern part of Ghana.

Risk of Suicide After Cancer Diagnosis in England

A diagnosis of cancer carries a substantial risk of psychological distress. There has not yet been a national population-based study in England of the risk of suicide after cancer diagnosis. To quantify suicide risk in patients with cancers in England and identify risk factors that may assist in needs-based psychological assessment. Population-based study using data from the National Cancer Registration and Analysis Service in England linked to death certification data of 4 722 099 individuals (22 million person-years at risk). Patients (aged 18-99 years) with cancer diagnosed from January 1, 1995, to December 31, 2015, with follow-up until August 31, 2017, were included. Diagnosis of malignant tumors, excluding nonmelanoma skin cancer. All deaths in patients that received a verdict of suicide or an open verdict at the inquest. Standardized mortality ratios (SMRs) and absolute excess risks (AERs) were calculated. Of the 4 722 099 patients with cancer, 50.3% were men and 49.7% were women. A total of 3 509 392 patients in the cohort (74.3%) were aged 60 years or older when the diagnosis was made. A total of 2491 patients (1719 men and 772 women) with cancer died by suicide, representing 0.08% of all deaths during the follow-up period. The overall SMR for suicide was 1.20 (95% CI, 1.16-1.25) and the AER per 10 000 person-years was 0.19 (95% CI, 0.15-0.23). The risk was highest among patients with mesothelioma, with a 4.51-fold risk corresponding to 4.20 extra deaths per 10 000 person-years. This risk was followed by pancreatic (3.89-fold), esophageal (2.65-fold), lung (2.57-fold), and stomach (2.20-fold) cancer. Suicide risk was highest in the first 6 months following cancer diagnosis (SMR, 2.74; 95% CI, 2.52-2.98). Despite low absolute numbers, the elevated risk of suicide in patients with certain cancers is a concern, representing potentially preventable deaths. The increased risk in the first 6 months after diagnosis may indicate an unmet need for psychological support. The findings of this study suggest a need for improved psychological support for all patients with cancer, and attention to modifiable risk factors, such as pain, particularly in specific cancer groups.

Suicide prevention proposals

British Journal of Healthcare ManagementVol. 24, No. 10 CommentSuicide prevention proposalsKate Harmond AllanKate Harmond AllanSearch for more papers by this authorKate Harmond AllanPublished Online:13 Oct 2018https://doi.org/10.12968/bjhc.2018.24.10.479AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Fiore V. 2017. GPs report ‘85% increase’ in patients with mental health conditions. http://www.pulsetoday.co.uk/clinical/clinical-specialties/mental-health/gps-report-85-increase-in-patients-with-mental-health-conditions/20035612.article (accessed 1 October 2018) Google ScholarHealthcare Conferences UK. 2018. The wounded healer. https://www.healthcareconferencesuk.co.uk/practitioner-health-summit (accessed 1 October 2018) Google ScholarMind. 2018. 40 per cent of GP appointments about mental health. https://www.mind.org.uk/news-campaigns/news/40-per-cent-of-all-gp-appointments-about-mental-health/#.W6JV8yOZNjR (accessed 1 October 2018) Google ScholarMinistry of Defence. 2018. Suicide and open verdict deaths in the UK regular armed forces. https://data.gov.uk/dataset/b7c1ef47-3374-4322-925a-d82132cff6b0/suicide-and-open-verdict-deaths-in-the-uk-regular-armed-forces (accessed 1 October 2018) Google ScholarNHS Digital. 2016. Adult Psychiatric Morbidity Survey: Survey of mental health and wellbeing. https://digital.nhs.uk/data-and-information/publications/statistical/adult-psychiatric-morbidity-survey/adult-psychiatric-morbidity-survey-survey-of-mental-health-and-wellbeing-england-2014 (accessed 1 October 2018) Google ScholarNICE. 2018. Depression in adults: recognition and management. https://www.nice.org.uk/guidance/cg90 (accessed 1 October 2018) Google ScholarONS. 2017. Suicides in the UK: 2016 registrations. https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/suicidesintheunitedkingdom/2016registrations (accessed 1 October 2018) Google ScholarRoyal Foundation. 2018. The Duchess of Cambridge announces plans to support early intervention for young children and families. https://www.royalfoundation.com/duchess-cambridge-announces-plans-support-early-intervention-young-children-families/ (accessed June 2018) Google ScholarThe Festival of Higher Education. 2018. http://www.hefestival.com (accessed 1 October 2018) Google ScholarThe Times. 2018. Do Less Harm. https://www.thetimes.co.uk/article/do-less-harm-tnpcq67gw (accessed 1 October 2018) Google ScholarWeale S. 2018. Seventh Bristol university student takes his own life. https://www.theguardian.com/education/2018/jan/22/seventh-bristol-university-student-takes-his-own-life (accessed 1 October 2018) Google ScholarWoolcock N, Joiner S, Watts R. 2018. Schools buckle under 70,000 self-harm cases. https://www.thetimes.co.uk/article/schools-buckle-under-70-000-self-harm-cases-nbfxpg5h7 (accessed 24 September 2018) Google Scholar FiguresReferencesRelatedDetails 2 October 2018Volume 24Issue 10ISSN (print): 1358-0574ISSN (online): 1759-7382 Metrics History Published online 13 October 2018 Published in print 2 October 2018 Information© MA Healthcare LimitedPDF download

Risk of Suicide After a Cancer Diagnosis in England: A Population-Based Study

Background: Previous research has identified an increased risk of suicide among cancer patients, however this has not been investigated at a population level in England. Those subgroups of patients most at risk need to be identified to ensure appropriate access to psychological support. Aim: To examine the variation in suicide risk among individuals diagnosed with cancer in England. Methods: We identified 4,453,547 individuals (21 million person-years at risk) aged 18 to 99 years at diagnosis of cancer during 1995 to 2015 from the national cancer registry, and followed them up until 31 August 2017. The outcomes of interest were both suicide and open verdicts (ICD-10 X60-X84, Y87.0, Y10-Y34 [excluding Y33.9, Y87.2]). Population-based expected deaths were as published by ONS [2]. We calculated standardized mortality ratios (SMRs) and absolute excess risks (AERs), and explored variation in suicide risk by cancer type, age at death, sex, deprivation, ethnicity, and years since cancer diagnosis. Results: 2352 cancer patients died by suicide. This was 0.08% of all deaths. The overall SMR for suicide was 1.19 (95% CI 1.14-1.24) and AER per 10,000 person-years was 0.18 (0.13-0.22). The risk was highest among individuals diagnosed with mesothelioma, with a 4.34-fold risk corresponding to 4.00 extra deaths per 10,000 person-years. This was followed by pancreatic (3.94-fold), esophageal (2.53-fold), lung (2.52-fold), and stomach (2.14-fold) cancer (all significantly elevated). Suicide risk was highest in the first 6 months following cancer diagnosis (SMR: 2.64 [2.42-2.89]), but a significantly increased risk persisted for 2 years (SMR: 1.21 [1.08-1.35]). Conclusion: Despite low numbers, the elevated risk of suicide in patients with certain cancers is a concern, representing potentially preventable deaths. The increased risk in the first 6 months after diagnosis, which is consistent with previous studies, highlights unmet needs for psychological support delivered alongside cancer diagnosis and treatment. Our findings suggest a need for improved risk stratification across cancer services, followed by targeted psychological support.

The influence of undetermined deaths on suicides in Shanghai, China.

In global forensic practice, some suicides were misclassified as undetermined deaths, leading to suicide underreporting. In this study, we aimed to explore the influence of undetermined deaths on suicides in Shanghai, China. The police records on suicide verdicts and undetermined deaths in Pudong, Shanghai, from 2004 to 2016 were used. In this study, undetermined deaths have been classified into three levels of suicide possibilities namely, probable, possible, and highly unlikely. Probable suicides were presumed as misclassified suicides. Poisson regression was used to calculate the rate ratio ("RR") of probable suicides compared to suicide verdicts. Poisson regression was also used to calculate the annual percentage change ("APC") of the original suicide rates (crude suicide rates based on the suicide verdicts) and adjusted suicide rates (crude suicide rates based on the suicide verdicts and probable suicides). Among the 1,318 underdetermine deaths, 560 (42.5%) were classified as probable suicides. The overall RR was 0.23 (95% CI 0.21-0.26): 0.15 (0.13-0.17) for the locals' RR and 0.22 (0.19-0.26) for the migrants' RR. The APCs of the original and adjusted suicide rates were - 2.0 (-3.1 to -0.9) and - 2.9 (-3.8 to -2.0), respectively, for the overall population. The number of suicides could be 23% higher than the reported cases. Suicides were more likely to be underreported in migrants than in the locals. Thus, it is important to improve suicide monitoring and the surveillance systems in China.

An analysis of international traveller deaths at the Cliffs of Moher in Ireland, 1993-2017.

Traumatic deaths, and more particularly suicides, during international travel receive a disproportionately low level of attention in the travel medicine literature. We describe the demographic profile of international travellers whose death occurred at the Cliffs of Moher along the Atlantic seaboard in Ireland. Coroners' files for the 25 years between 1993 and 2017 were interrogated. All cases of death on or at the cliffs were examined, and demographic data were extracted, including date of death, gender, age, nationality, whether the victims were alone at the cliffs prior to their death, whether the fall was witnessed, prevailing weather conditions, post-mortem examinations, toxicology reports and inquest verdicts. Overall, 66 deaths occurred on or at the base of the Cliffs of Moher during the period 1993 through August 2017. In total, 18 (27.3%) of the victims were international visitors to Ireland, including 11 males (61.1%). The mean age of travellers (n = 17) was 34.2 years. Victims were nationals of 12 different countries, with 13 being European nationals. Most deaths occurred in summer (n = 7) or spring (n = 6), with eight deaths (44%) reported at weekends. In total, 15 victims (83.3%) had walked along the cliff path alone. A jump or fall from the cliffs was witnessed in only two cases (11.1%). Post-mortem examinations revealed multiple traumatic injuries consistent with a fall from a height. Four cases had evidence of alcohol intoxication. Suicide or open verdicts were returned in 50% (n = 9) of the cases. Travelling alone to the site, purchasing one-way tickets, or depositing belongings on the clifftop support the possibility of suicidal intent, while being intoxicated could be a co-factor in suicidal jumps or support the possibility of an accidental fall. This knowledge could help to identify travellers at the greatest risk of death at cliffs.

The Iraqi national study of suicide: Report on suicide data in Iraq in 2015 and 2016

BackgroundVery little is known regarding the epidemiology of suicides in Iraq, given the lack of a national surveillance system. Therefore, the government initiated this project “The Iraqi National Study of Suicide MethodsThe study covered 13 (out of 18) provinces in Iraq. A data collection form was designed by the researchers. The forms were completed by police stations in the 13 provinces. Data were extracted from the legal investigation (which include police investigation, family reports and postmortem reports) of cases of when there was no clear cause of death and where there was final verdict of suicide made by judge after examining these reports. ResultsThere were 647 cases of suicide. The crude rate of suicide per 100 000 population was 1.09 (1.21 for males, 0.97 for females) in 2015 and 1.31 (1.54 for males and 1.07 for females) in 2016. The majority of cases (67.9%) were aged 29 years or below. The most common method was hanging (41%) followed by firearms (31.4%) and self-burning (19.2%). 24.1% of cases were reported to have psychiatric disorders, of which the most common diagnosis was depression (53.9%). In the majority of cases (82.1%) there were no previous attempts. Only a small minority were reported to have had psychological trauma (15.5%), financial problems (12.4%) or childhood abuse (2.2%). LimitationsThe study covered only 13 provinces in Iraq. We were able to calculate age-standardized rates for year 2016 only. Data are based on official police records and under-reporting and under-recognition of psychiatric disorders are possible. ConclusionOn the basis of data available to this study, the suicide rate in Iraq is lower than the global rate. Suicide is more common in young people, where the gender distribution is almost equal. Social and cultural factors might have played a role in these patterns. The findings underscore the need of a national registry with a comprehensive and multipronged surveillance approach to correctly identify suicide events. This study aims to be the first step in this process.

Mental health profile of suicide victims in an Irish urban population

ObjectivesTo describe demographic and psychiatric characteristics of suicide victim cases.MethodRetrospective, case file psychological autopsy of deaths registered at the coroner's court, Dublin. Cases with a verdict of suicide and open verdicts registered in 2007, 2012 and 2013 were included.ResultsTwo hundred and five cases of suicide/open verdicts were registered the 3-year period. Seventy four percent (n = 152) were males. Mean age – 42.87 years old (STD = 15.44) with no significant difference between genders. Sixty-four percent (n = 132) were single at the time of death, while 32.2% had children. One hundred and ninety-eight had a stable accommodation; 37.5% (n = 77) living alone, and 36.6% (n = 75) actively employed.One hundred and twelve subjects (54.6%) suffered from mental illness; 53.6% – affective disorder; 15.2% – alcohol and substance misuse; 12.5% – psychotic disorder. Seventy-nine (70.5%) were not in contact with mental health services at the time of death; 32 (28.6%) were attending as outpatients. Illness onset was recorded for 68.7% cases (n = 77); 35.7% (n = 40) had a length of illness of more than 5 years. Psychiatric comorbidity was present in 29.5% (n = 33); 54.5% (n = 18) presented also alcohol/substance misuse.ConclusionSuicide victims were single, middle-aged male, suffered mental health difficulties, most frequently affective disorder. A small number of subjects an additional comorbid diagnosis. Few were in contact with outpatient services at the time of death. No significant differences in demographic characteristics were found between the group suffering from mental illness and the group with no mental illness.Disclosure of interestThe author has not supplied his/her declaration of competing interest.

Factors associated with suicides in Wolverhampton: Relevance of local audits exploring preventability.

Suicide rates and associated risk factors are known to change over time. The periodic evaluation of suicides in a particular locality may identify specific issues that may help in prevention efforts. The profile of 146 consecutive cases with suicide, open and narrative verdicts between January 2004 and July 2011 in Wolverhampton was studied in order to explore associated factors. Specific information about methods, mental health issues and stressors was collected. There was considerable variation in suicides in different wards of the city, with higher occurrences in inner-city areas. Male suicides were three times more common, and they were significantly younger than in female suicides. Common methods were hanging (52.7%) and poisoning (21.9%) involving a wide range of drugs. Life events were reported in 52.1% suicides, most frequently relational problems (28.1%), followed by physical illness and bereavement. Mental-health factors were associated with 63.0% of suicides, predominantly depression (45.9%) and alcohol and drug abuse (6.8%). The majority of the suicide victims (63.0%) were not in contact with mental-health services, including: most men (68.8%), young suicides up to age 34 (78.6%), the elderly (69.2%) and Asians (70.0%). A considerable proportion of these suicides had mental-health issues, mainly depression (42.4%) and alcohol or drug abuse (6.5%). Significantly more of them (69.6% vs. 22.2%) had stressors compared with suicides known to mental-health services. The findings of the study highlighted risk factors that may help prioritising intervention initiatives. It appears that local suicide audits may complement national information on suicide in designing appropriate local suicide-prevention strategies.

착화탄 연소에 의한 일산화탄소 중독사에서 자살입증에 관한 사례연구

Carbon monoxide (CO) intoxication, arising from CO from an ignited charcoal briquette (ICB), is a popular means of committing suicide in Korea. Most CO intoxications are related to suicide attempts; however, the possibility of a homicide disguised as a suicide cannot be ruled out. Therefore, forensic investigation of the deceased and the crime scene is crucial to confirm that the deceased committed suicide. Detection of the components of an ICB on the objects suspected of being contacted by the deceased, such as the hands, nostrils, and doorknobs, is essential for linking the crime scene to the victim in the case of suicides by ignited ICBs. The traces from an ICB were analyzed by investigating the morphological characteristics and obtaining elemental compositions. The ICBs were completely different from blackened wood, as detected by discriminant analysis with the elements of carbon and oxygen. We analyzed one case of CO intoxication to demonstrate an excellent procedure for verifying whether a suicide occurred with an ICB. We employed SEM-EDX for the analysis of an ICB, microscope-FT/IR and pyrolysis-GC/MS for a partly burnt resin-type substance, GC/MS for diphenhydramine (a sleeping drug), and GC/TCD for the CO-Hb level. We detected traces of an ICB on the hands, nostrils, and doorknobs, which were all discriminated into an ICB group. Detection of ICB traces from the nostrils could indicate that the deceased started the fire themselves to commit suicide. The partially burnt black material was analyzed as an acrylronitrilestyrene polymer, which is normally used to make bags for carrying or wrapping and could be assumed to have been used to transport the ICB. Diphenhydramine, a sleeping drug, was detected at a level of 2.3 mg/L in the blood, which was lower than that in fatal cases (8-31 mg/L; mean 16 mg/L). A CO-Hb level of 79% was found in the blood, which means that the cause of death was CO intoxication. The steps shown here could represent an ideal method for reaching a verdict of suicide by CO intoxication produced by burning an ICB in a sealed room or a car.

The accuracy of suicide statistics: are true suicide deaths misclassified?

Official suicide statistics often produce an inaccurate view of suicide populations, since some deaths endorsed as being of uncertain manner are in fact suicides; it is common, therefore, in suicide research, to account for these deaths. We aimed to test the hypothesis that non-suicide death categories contain a large potential reservoir of misclassified suicides. Data on undetermined intent and ill-defined death causes, and official suicide deaths recorded in the district of Tel Aviv for the years 2005 and 2008 were extracted. Based on supplementary data, cases regarded as probable suicides ("suicide probable") were then compared with official suicides ("suicide verdicts") on a number of socio-demographic variables, and also in relation to the mechanism of death. Suicide rates were 42 % higher than those officially reported after accounting for 75 probable suicides (erroneously certified under other cause-of-death categories). Both death classifications ("suicide probable" and "suicide verdicts") had many similarities, significantly differing only with respect to method used. Logistic regression confirmed that the most powerful discriminator was whether the mechanism of death was considered "less active" or "more active" (p < 0.001). Indeed, deaths among the less active group were 4.9 times as likely to be classified as "suicide probable" than were deaths among the more active group. Caution is needed when interpreting local area data on suicide rates, and undetermined and ill-defined deaths should be included in suicide research after excluding cases unlikely to be suicides. Improving suicide case ascertainment, using multiple sources of information, and uniform reporting practices, is advised.

Creation of a Death by Suicide.

Background: Suicide research acknowledges the negotiated nature of a coroner's verdict of suicide. However, the process by which those who are bereaved come to determine that a death was a suicide has received little attention. Aims: To explore how young adults come to conceptualize their friends' deaths as suicides. Method: In-depth interviews were undertaken with 12 young people whose friends had died by apparent suicides. Interviews were analyzsed using interpretative phenomenological analysis. Results: Few of the participants attended the inquest, and most placed little value on the verdict given to the death by the coroner. However, participants used processes and definitions similar to the coroners' to explore and create meaning from their friend's final thoughts and actions in order to determine whether he/she meant to end their life. Conclusion: This research contributes to our understanding of the profound impact of death by suicide and the negotiated nature of participants' understandings of the death. The findings can assist in understanding how the bereaved may be supported.

Suicide following self-harm: Findings from the Multicentre Study of self-harm in England, 2000–2012

BackgroundSelf-harm is a key risk factor for suicide and it is important to have contemporary information on the extent of risk. MethodsMortality follow-up to 2012 of 40,346 self-harm patients identified in the three centres of the Multicentre Study of Self-harm in England between 2000 and 2010. ResultsNineteen per cent of deaths during the study period (N=2704) were by suicide, which occurred in 1.6% of patients (2.6% of males and 0.9% of females), during which time the risk was 49 times greater than the general population risk. Overall, 0.5% of individuals died by suicide in the first year, including 0.82% of males and 0.27% of females. While the absolute risk of suicide was greater in males, the risk relative to that in the general population was higher in females. Risk of suicide increased with age. While self-poisoning had been the most frequent method of self-harm, hanging was the most common method of subsequent suicide, particularly in males. The number of suicides was probably a considerable underestimate as there were also a large number of deaths recorded as accidents, the majority of which were poisonings, these often involving psychotropic drugs. LimitationsThe study was focussed entirely on hospital-presenting self-harm. ConclusionsThe findings underline the importance of prevention initiatives focused on the self-harm population, especially during the initial months following an episode of self-harm. Estimates using suicide and open verdicts may underestimate the true risk of suicide following self-harm; inclusion of accidental poisonings may be warranted in future risk estimates.

Factors influencing coroners' verdicts: an analysis of verdicts given in 12 coroners' districts to researcher-defined suicides in England in 2005.

To investigate the variation between coroners in the verdicts given to deaths thought by researchers to be probable suicides and analyse factors associated with the coroners' verdict. Data were collected from 12 English coroner districts on all deaths in 2005 given a suicide, open, accidental or narrative verdict where suicide was considered a possibility. The data were reviewed by three experienced suicide researchers. Regression models were used to investigate factors associated with the coroners' verdict. The researchers classified 593 deaths as suicide, of which 385 (65.4%) received a suicide verdict from the coroner. There was marked variation between coroner districts in the verdicts they gave. The suicide method was associated strongly with the coroners' verdict; deaths from poisoning and drowning were the least likely to be given suicide verdicts. The other factors strongly associated with a coroner's verdict of suicide were: whether a note was left, age over 60 years and being married or widowed compared with being single. Coroners vary considerably in the verdicts they give to individuals who probably died by suicide. This may compromise the usefulness of suicide statistics for assessing area differences in rates for public health surveillance.

A multicentre programme of clinical and public health research in support of the National Suicide Prevention Strategy for England

ObjectivesTo carry out a programme of linked research studies aimed at improving the management of self-harm, reducing the incidence of suicide and providing reliable data to evaluate the impact of theNational Suicide Prevention Strategy for England(2002).MethodsThere were four research streams: (1) we studied inquest records from 12 coroners and Ministry of Justice data to assess the accuracy of official suicide statistics; (2) we used Office for National Statistics mortality statistics, data from the Multicentre Study of Self-harm in England, national liver unit data, prescription data and patient interviews to assess (a) the impact of paracetamol (acetaminophen) pack size restrictions (1998), (b) the impact of withdrawal of co-proxamol in 2007 and (c) the relative toxicity in overdose of commonly used antidepressants; (3) we carried out 3-month audits of self-harm management in 32 hospitals to investigate variations between hospitals and the impact of management on repeat self-harm; and (4) we developed and piloted letter-based contact interventions aimed at reducing self-harm.Key findings(1) Between 1990 and 2005, the proportion of researcher-defined suicides given a verdict of suicide by the 12 coroners studied decreased by almost 7%, largely because of the increased use of misadventure/accident verdicts for deaths thought, on clinical review, to be suicides. Use of narrative verdicts increased markedly. Coroners who gave more narrative verdicts also gave fewer suicide verdicts, and geographical variations in the use of narrative verdicts appeared to distort reliable assessment of small-area differences in suicide rates. 2(a) UK legislation to reduce pack sizes of paracetamol was followed by a 43% reduction in number of deaths and a 61% reduction in registrations for liver transplantation over the next 11 years. Paracetamol overdoses were often impulsive and some were influenced by media (including the internet); sales outlets appeared mostly to be adhering to sales guidance. Smaller pack sizes of paracetamol for sale in Ireland compared with England did not result in a smaller number of tablets being taken in overdose. There was no clear evidence of an effect of the legislation on prescribing of non-steroidal anti-inflammatory drugs, nor on resulting gastrointestinal bleeds. 2(b) Withdrawal of co-proxamol from use in the UK resulted in approximately 600 fewer deaths than predicted between 2005 and 2010 based on previous trends, with no evidence of substitution by poisoning with other analgesics. 2(c) Of the tricyclic antidepressants, dosulepin and doxepin had the greatest toxicity. Citalopram was more toxic than other selective serotonin reuptake inhibitors. (3) There was marked variation between hospitals in the management of self-harm; effects of this variation on patient outcomes were unclear, although psychosocial assessment may have been associated with reduced repetition. Levels of specialist assessment remained static between 2001–2 and 2010–11, but service quality appeared to improve. (4) Findings of two pilot randomised controlled trials suggested that, although it would be feasible to scale up these interventions to full trials, these interventions might have low generalisability and be of limited benefit to patients.ConclusionWithin the context of the strengths and limitations of the individual studies, this research programme has made significant additions to the evidence base related to suicide and self-harm prevention in the UK.Study registrationA pilot study of a contact and information based intervention to reduce repeat self-harm; ISRCTN65171515.FundingThe National Institute for Health Research Programme Grants for Applied Research programme.

Suicide and accidental deaths in children and adolescents in England and Wales, 2001–2010

ObjectivesTo investigate the impact of narrative verdicts on suicide statistics among 10–19-year-olds; to identify the number and rate of suicide and accidental deaths, particularly in 10–14-year-olds.DesignNational cohort study.SettingEngland and Wales.MethodsMid-year...