1. © National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. All rights reserved. Not to be reproduced in whole or in part without the permission of the copyright holder. 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

2. Outline Background to Inquiry Aims Methodology Findings Limitations

3. Background Set up at University of Manchester in 1996 Funded by the National Patient Safety Agency

4. 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

5. 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 to consultant

6. ONS data Received quarterly Suicide and open verdict deaths Provided with SHA code of residence and death

8. 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

9. Suicide: Questionnaire Demographic features Diagnostic features Cause of death Behavioural features Contact with services Priority groups –in-patients –post-discharge –non-compliance –missed contact

10. Homicide Methodology

12. 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

13. Results

14. 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

15. General population suicide: age and sex profile

16. 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%)

17. Method of suicide used by Inquiry cases by sex

18. 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

19. Method of homicide by sex of perpetrator

20. 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%)

21. Limitations Missed contact with services Clinical data based on casenotes and clinical judgements Completers aware of outcome

22. The Sudden Unexplained Death Study Pauline Turnbull National Confidential Inquiry into Suicide and Homicide by People with Mental Illness ASSIST PRESTWICH 2008

23. Outline Background Methodology Results Limitations Clinical Implications

24. 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)

25. Associations with SUD Treatment for mental illness Anti-psychotic drug use –Some drugs prolong the QT interval Non drug factors –poor physical health –restraint

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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

37. Results

38. Age and Sex

39. Physical features

40. Clinical features

42. 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

43. 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

44. 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/