Impact of the growing use of narrative verdicts by coroners on geographic variations in suicide: analysis of coroners' inquest data

Preventable suicides involving medicines: A systematic case series of coroners' reports in England and Wales

Background

In England and Wales coroners have a duty to write a report, called a Prevention of Future Deaths report or PFD, when they believe that actions should be taken to prevent future deaths. Coroners send PFDs to individuals and organisations who are required to respond within 56 days. Despite the increase in mental health concerns and growing use of medicines, deaths reported by coroners that have involved medicine-related suicides had not yet been explored. Therefore, this study aimed to systematically assess coroners' PFD reports involving suicides in which a medicine caused or contributed to the death to identify lessons for suicide prevention.

Methods

Using the Preventable Deaths Tracker database (https://preventabledeathstracker.net/), 3037 coroners' PFD reports in England and Wales were screened for eligibility between July 2013 and December 2019. Reports were included if they involved suicide or intentional self-harm and prescribed or over-the-counter medication; illicit drugs were excluded. Following data extraction, descriptive statistics, document and content analysis were performed to assess coroners' concerns and the recipients of reports.

Results

There were 734 suicide-related coroner reports, with 100 (14%) reporting a medicine. Opioids (40%) were the most common class involved, followed by antidepressants (30%). There was wide geographical variation in the writing of reports; coroners in Manchester wrote the most (18%). Coroners expressed 237 concerns; the most common were procedural inadequacies (14%, n = 32), inadequate documentation and communication (10%, n = 22), and inappropriate prescription access (9%, n = 21). 203 recipients received the PFDs, with most sent to NHS trusts (31%), clinical commissioning groups (10%), and general practices (10%), of which only 58% responded to the coroner.

Conclusions

One in four coroner reports in England and Wales involved suicides, with one in seven suicide-related deaths involving a medicine. Concerns raised by coroners highlighted gaps in care that require action from the Government, health services, and prescribers to aid suicide prevention. Coroner reports should be routinely used and monitored to inform public health policy, disseminated nationally, and responses to coroners should be transparently enforced so that actions are taken to prevent future suicides.

Police-led real-time surveillance system for suspected suicides in Great Britain

It has become increasingly apparent that rapidly available information about the occurrence of suicides is needed, particularly to support suicide prevention efforts. Concerns about the potential impact of the COVID-19 pandemic on vulnerability to suicide highlighted the need for such early data internationally. Here, we set out the nature, current status and content of a real-time suicide monitoring system in Great Britain (England, Scotland and Wales), and explore its potential to contribute to timely and targeted suicide prevention initiatives. We also discuss the challenges to successful implementation.

Suicide Attempts in US Veterans with Chronic Headache Disorders: A 10-Year Retrospective Cohort Study

Objectives

A large-scale retrospective analysis of veterans with chronic pain was conducted to examine (1) the annual incidence of suicide attempts (SA) in veterans with chronic headache and other chronic pain conditions, and (2) the risk of SA in men and women with chronic headache and chronic headache concurrent with traumatic brain injury (TBI) as compared to non-headache chronic pain.

Methods

This retrospective study (N=3,247,621) analyzed National Veterans Affair Health Administrative data of patients diagnosed with chronic head, neck, back and other chronic pain from 2000 to 2010. Multivariable Poisson regression was used to explore the relative risks of SA in veterans with chronic headache and chronic headache concurrent with TBI as stratified by sex.

Results

Veterans with chronic headaches had the highest annual incidence of SA (329 to 491 per 100,000) each year among all identified types of chronic pain conditions. Compared to other non-headache chronic pain, chronic headache is associated with increased risk of SA [men RR (1.48), CI (1.37,1.59); women RR (1.64), CI (1.28,2.09)], after adjusting for demographic factors, TBI, and psychiatric comorbidities. The risk increased further when chronic headache is comorbid with TBI [men RR (2.82), CI (2.60, 3.05); women RR (2.16, CI (1.67-2.78)].

Conclusion

Veterans with chronic headache have a higher risk of SA than those with other chronic pain and women with chronic headache are at a higher risk than men with chronic headache. Chronic headache concurrent with TBI further heightened this risk, especially in men. Our data underscore the importance of identifying specific types of chronic pain in veterans with comorbid TBI and sex disparity associated with SA when targeting suicide prevention measures.

Continuity of care and mortality in people with schizophrenia

BACKGROUND

People with schizophrenia have shortened lives. This excess mortality seems to be related to physical health conditions that may be amenable to better primary and secondary prevention. Better continuity of care may enhance such interventions as well as help prevent death by self-injury.

AIMS

We set out to examine the relationship between the continuity of care of patients with schizophrenia, their mortality and cause of death.

METHOD

Pseudoanonymised community data from 5551 people with schizophrenia presenting over 11 years were examined for changes in continuity of care using the numbers of community teams caring for them and the Modified Modified Continuity Index. These and demographic variables were related to death certifications of physical illness from the Office of National Statistics and mortal self-injury from clinical data. Data were analysed using generalised estimating equations.

RESULTS

We found no independent relationship between levels of continuity of care and overall mortality. However, lower levels of relationship continuity were significantly and independently related to death by self-injury.

CONCLUSIONS

We found no evidence that continuity of care is important in the prevention of physical causes of death in schizophrenia. However, there is evidence that declining relationship continuity of care has an independent effect on deaths as a result of self-injury. We suggest that there should be more attention focused on the improvement of continuity of care for these patients.

Suicide risk in people with post-traumatic stress disorder: A cohort study of 3.1 million people in Sweden

BACKGROUND

It is unclear whether post-traumatic stress disorder [PTSD] is associated with suicide risk in the general population, whether this differs by sex, or what the population impact of PTSD is for suicide.

METHODS

We constructed a nationwide cohort of all people living in Sweden, born 1973-1997, followed from their 14th birthday (or immigration, if later) until suicide, other death, emigration or 31 December 2016. We used Cox proportional hazards regression to estimate hazard ratios [HR], and calculated the population impact of PTSD on suicide. We included sensitivity analyses to explore effects of outcome and exposure definitions, and to account for potential competing risks.

RESULTS

Of 3,177,706 participants, 22,361 (0•7%) were diagnosed with PTSD, and 6,319 (0•2%) died by suicide over 49•2 million person-years. Compared with women and men without PTSD, suicide rates were 6•74 (95%CI: 5•61-8•09) and 3•96 (95%CI: 3•12-5•03) times higher in those with PTSD, respectively, after sociodemographic adjustment. Suicide rates remained elevated in women (HR: 2•61; 95%CI: 2•16-3•14) and men (HR: 1•67; 95%CI: 1•31-2•12) after adjustment for previous psychiatric conditions; attenuation was driven by previous non-fatal suicide attempts. Findings were insensitive to definitions or competing risks. If causal, 1•6% (95%CI: 1•2-2•1) of general population suicides could be attributed to PTSD, and up to 53.7% (95%CI: 46.1-60.2) in people with PTSD.

LIMITATIONS

Residual confounding remains possible due to depressive and anxiety disorders diagnosed in primary care but unrecorded in these registers.

CONCLUSIONS

Clinical guidelines for the management of people with PTSD should recognise increased suicide risks.

Patterns of suicide mortality in England and Wales before and after the suicide of the actor Robin Williams

PURPOSE

There is international evidence supporting an association between sensational reporting of suicide and a subsequent increase in local suicide rates, particularly where reporting the death of a celebrity. We aimed to explore whether the observed increase in suicides in the United States, Canada and Australia in the 5 months following the 2014 suicide of the popular actor Robin Williams was also observed in England and Wales.

METHOD

We used interrupted time-series analysis and a seasonal autoregressive integrated moving averages (SARIMA) model to estimate the expected number of suicides during the 5 months following Williams' death using monthly suicide count data for England and Wales from the UK Office for National Statistics (ONS) 2013-2014.

RESULTS

Compared with the observed 2051 suicide deaths in all age groups from August to December 2014, we estimated that we would have expected 1949 suicides over the same period, representing no statistically significant excess.

CONCLUSIONS

This finding is an outlier among previous studies and contrasts with the approximately 10% increase in suicides found in similar analyses conducted in other high-income English-speaking countries with established media reporting guidelines.

Reform of the coroners' service in England and Wales: policy-making and politics

The Coroners and Justice Act 2009 promised an overhaul of the coroners' service, introducing much needed efficiencies to benefit people bereaved by suicide and other sudden deaths. Central to these reforms was the introduction of a Chief Coroner to coordinate the system and exercise wider public health responsibilities. The coalition government's proposal to abolish the Chief Coroner's office on grounds of cost, ignoring the potential efficiency gains, has delayed implementation of coronial reforms significantly. With this proposal now abandoned, ministers are expected to appoint an independent Chief Coroner in early 2012. This article describes the intended benefits of the reforms for bereaved relatives, coroners' staff, public sector budgets, and the public health, and explores the reasons behind the delays.

Railway suicide in England and Wales 2000-2013: a time-trends analysis

Background

In 2010, the “Tackling Suicide on the Railways” programme was launched as a joint initiative among Network Rail, the Samaritans and other key organisations such as the British Transport Police and train operators to achieve a 20 % reduction in railway suicides from 2010 to 2015 in Great Britain. We report the most recent age and sex specific trends in railway suicide in England and Wales from 2000 to 2013 and examine whether the initiative’s target reduction in railway suicides is likely to be achieved.

Methods

Population data and suicide mortality data (all methods combined and railway) for England and Wales were obtained from the Office for National Statistics (ONS) and used to calculate age and gender specific rates for deaths registered from 2000 to 2013. Data on railway suicides were also obtained from the Rail Safety and Standards Board (RSSB) and compared with ONS data. We used joinpoint regression to identify changes in suicide trends across the study period.

Results

The railway was used in 4.1 % of all suicides in England and Wales (RSSB data were similar to ONS data for most years). Suicides in all persons from all causes decreased from 2000 to 2007, with small increases from 2008 until 2013; this rise was entirely due to an increase in male suicides. Railway suicide rates increased over the entire study period; the proportion of railway suicides in all persons increased from 3.5 to 4.9 % during the study period. This trend was also mainly driven by increases in male suicides as female railway suicide rates remained steady over time. The highest age specific railway suicide rates were observed in middle aged men and women. Although there was no conclusive evidence of an increase in ONS railway suicides, RSSB data showed a statistically significant increase in railway suicides in males from 2009 onwards.

Conclusion

The continued rise in male railway suicide in England and Wales is concerning, particularly due to the high economic costs and psychological trauma associated with these deaths. The initiative’s target of a 20 % reduction in railway suicide is unlikely to be achieved.

'First, do no harm': are disability assessments associated with adverse trends in mental health? A longitudinal ecological study

Background

In England between 2010 and 2013, just over one million recipients of the main out-of-work disability benefit had their eligibility reassessed using a new functional checklist—the Work Capability Assessment. Doctors and disability rights organisations have raised concerns that this has had an adverse effect on the mental health of claimants, but there are no population level studies exploring the health effects of this or similar policies.

Method

We used multivariable regression to investigate whether variation in the trend in reassessments in each of 149 local authorities in England was associated with differences in local trends in suicides, self-reported mental health problems and antidepressant prescribing rates, while adjusting for baseline conditions and trends in other factors known to influence mental ill-health.

Results

Each additional 10 000 people reassessed in each area was associated with an additional 6 suicides (95% CI 2 to 9), 2700 cases of reported mental health problems (95% CI 548 to 4840), and the prescribing of an additional 7020 antidepressant items (95% CI 3930 to 10100). The reassessment process was associated with the greatest increases in these adverse mental health outcomes in the most deprived areas of the country, widening health inequalities.

Conclusions

The programme of reassessing people on disability benefits using the Work Capability Assessment was independently associated with an increase in suicides, self-reported mental health problems and antidepressant prescribing. This policy may have had serious adverse consequences for mental health in England, which could outweigh any benefits that arise from moving people off disability benefits.

Examining undetermined and accidental deaths as source of 'under-reported-suicide' by age and sex in twenty Western countries

OBJECTIVES

'Undetermined' (UnD) and accidental deaths (AccD) are explored as possible sources of 'under-reported-suicides' (URS) in 20 Western countries.

METHODS

WHO mortality rates per million of AccD, UnD and suicides analysed. UnD:suicides ratios of <1:5 calculated as likely URS versus ratios >1:10 unlikely URS and all correlated by sex and age.

RESULTS

Male URS likely in 7 countries and in 11 for females. URS in AccD likely in 5 countries for both sexes only UnD and suicide rates the elderly (75+) significantly correlated.

CONCLUSION

Strong indication of URS in the UK, Portugal, Switzerland, Sweden, Denmark and Germany with likely URS in AccD in Greece, Portugal, Switzerland and USA. These findings have important implications, indicating that, with the exception of France and Japan, official reported suicide rates contain a degree of under-reporting, and especially for women yet it is essential to have accurate suicide data to ensure adequate service provision.

Suicide Information Database-Cymru: a protocol for a population-based, routinely collected data linkage study to explore risks and patterns of healthcare contact prior to suicide to identify opportunities for intervention

INTRODUCTION

Prevention of suicide is a global public health challenge extending beyond mental health services. Linking routinely collected health and social care system data records for the same individual across different services and over time has enormous potential in suicide research. Most previous research linking suicide mortality data with routinely collected electronic health records involves only one or two domains of healthcare provision such as psychiatric inpatient care. This protocol paper describes the development of a population-based, routinely collected data linkage study: the Suicide Information Database Cymru (SID-Cymru). SID-Cymru aims to contribute to the information available on people who complete suicide.

METHODS AND ANALYSIS

SID-Cymru will facilitate a series of electronic case-control studies based in the Secure Anonymised Information Linkage (SAIL) Databank. We have identified 2664 cases of suicide in Wales between 2003 and 2011 from routinely collected mortality data using International Classification of Diseases, Tenth Revision, codes X60-X84 (intentional self-harm) and Y10-Y34 (undetermined intent). Each case will be matched by age and sex to at least five controls. Records will be collated and linked from routinely collected health and social data in Wales for each individual. Conditional logistic regression will be applied to produce crude and confounder (including general practice, socioeconomic status) adjusted ORs.

ETHICS AND DISSEMINATION

The SAIL Databank has the required ethical permissions in place to analyse anonymised data. Ethical approval has been granted by the Information Governance Review Panel (IGRP). Findings will be disseminated through peer-reviewed publications, consultations with stakeholders and national/international conference presentations. The improved understanding of the prior health, nature of previous contacts with services and wider social circumstances of those who complete suicide will assist in prevention policy, service organisation and delivery. SID-Cymru is funded through the National Institute for Social Care and Health Research, Welsh Government (RFS-12-25).

Characteristics of deaths by suicide in Northern Ireland from 2005 to 2011 and use of health services prior to death

BACKGROUND

Service presentation may offer an opportunity for intervention prior to suicide. The study aimed to examine the characteristics, disorders and service use profiles of those who had died by suicide in Northern Ireland (NI) from 2005 to 2011.

METHODS

An analysis of a database of deaths by suicide and undetermined intent based on data in the NI Coronial files from 2005 to 2011 (N=1667).

RESULTS

Males are three times as likely to die by suicide as females and suicide rates similar among those aged 20-60 years. Females have increased service use prior to suicide; males tend to disengage with services prior to death. Females are more likely to have recorded prior attempts, service use, diagnosis and referral. The most common health service used was primary care.

LIMITATIONS

Despite the inclusion of undetermined deaths (probable suicides) a proportion of deaths by suicide remain unrecorded as such. Data on marital status and mental and physical disorders were based on information recorded by police officers from relatives, other informants and medical records. The reliability of this data may therefore be questioned.

CONCLUSIONS

Primary care has an important role in suicide prevention. Gendered patterns in service use prior to death should be considered in suicide prevention programmes. It is important to strengthen clinicians׳ knowledge of the manifestations of suicidal ideation in males and ways of encouraging service use in males. The NI population who were exposed to the height of the violence of the conflict appear to be at increased risk of suicide as they age.

Suicide and the 2008 economic recession: who is most at risk? Trends in suicide rates in England and Wales 2001-2011

The negative impacts of previous economic recessions on suicide rates have largely been attributed to rapid rises in unemployment in the context of inadequate social and work protection programmes. We have investigated trends in indicators of the 2008 economic recession and trends in suicide rates in England and Wales in men and women of working age (16-64 years old) for the period 2001-2011, before, during and after the economic recession, our aim was to identify demographic groups whose suicide rates were most affected. We found no clear evidence of an association between trends in female suicide rates and indicators of economic recession. Evidence of a halt in the previous downward trend in suicide rates occurred for men aged 16-34 years in 2006 (95% CI Quarter 3 (Q3) 2004, Q3 2007 for 16-24 year olds & Q1 2005, Q4 2006 for 25-34 year olds), whilst suicide rates in 35-44 year old men reversed from a downward to upward trend in early 2010 (95% CI Q4 2008, Q2 2011). For the younger men (16-34 years) this change preceded the sharp increases in redundancy and unemployment rates of early 2008 and lagged behind rising trends in house repossessions and bankruptcy that began around 2003. An exception were the 35-44 year old men for whom a change in suicide rate trends from downwards to upwards coincided with peaks in redundancies, unemployment and rises in long-term unemployment. Suicide rates across the decade rose monotonically in men aged 45-64 years. Male suicide in the most-to-medium deprived areas showed evidence of decreasing rates across the decade, whilst in the least-deprived areas suicide rates were fairly static but remained much lower than those in the most-deprived areas. There were small post-recession increases in the proportion of suicides in men in higher management/professional, small employer/self-employed occupations and fulltime education. A halt in the downward trend in suicide rates amongst men aged 16-34 years, may have begun before the 2008 economic recession whilst for men aged 35-44 years old increased suicide rates mirrored recession related unemployment. This evidence suggests indicators of economic strain other than unemployment and redundancies, such as personal debt and house repossessions may contribute to increased suicide rates in younger-age men whilst for men aged 35-44 years old job loss and long-term unemployment is a key risk factor.

Trends in suicidal ideation in England: the national psychiatric morbidity surveys of 2000 and 2007

BACKGROUND

Recent falls in suicide rates should be accompanied by a decline in the prevalence of suicidal ideation.

METHOD

We used a pseudo-cohort analytic strategy to examine trends in suicidal ideation measured identically in 2000 and 2007, in nationally representative English probability samples of adults aged ≥ 16 years. Suicidal ideation included tiredness of life, death wishes and thoughts of suicide. Logistic regression models were fitted to estimate trends in age-specific prevalence of suicidal ideation in the past year and past week between 2000 and 2007.

RESULTS

There were 6799 participants aged 16-71 years in 2000, and 6815 participants aged 16-78 years in 2007. There was little evidence of trends in prevalence of suicidal ideation, with the exception of women aged 44-50 years in 2007, whose prevalence was unusually high. Prevalence of suicidal ideation in the past year followed a W-shaped profile with age, with peaks at the transition to adulthood, in the forties, and in the oldest participants.

CONCLUSIONS

Despite falling suicide rates, suicidal ideation did not decline overall between 2000 and 2007. This may indicate the success of the National Suicide Prevention Strategy. Women aged 44-50 years in 2007 were, however, particularly prone to suicidal ideation. As they also have the highest age-adjusted prevalence of common mental disorders and the highest female suicide rate, there are clear implications for treatment access, availability and delivery in primary care.

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

OBJECTIVES

To 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.

DESIGN

National cohort study.

SETTING

England and Wales.

METHODS

Mid-year population estimates from the Office for National Statistics (ONS) were used to calculate rates per 100,000 population for suicide (undetermined and suicide verdicts) and accidental deaths (poisoning, hanging) for those aged 10-14 and 15-19. Trends in rates over time (2001-2010) were investigated using Poisson regression. Interaction tests were carried out to determine differences in trends between the two time periods (2001-2005 and 2006-2010).

RESULTS

There were 1523 suicides (2.25/100,000). Suicide rates were highest in those aged 15-19 years (4.04/100,000) and in males (3.14/100,000). Between 2001 and 2010, rates significantly decreased among those aged 15-19 years (incidence rate-ratio (IRR): 0.95; 95% CI 0.93 to 0.97), with no change in rates of accidental deaths (IRR: 1.01, 95% CI 0.95 to 1.07). However, there was a significant interaction between the two time periods for accidental poisonings (2001-2005: IRR: 0.79 (95% CI 0.69 to 0.91); 2006-2010: IRR: 1.01 (95% CI 0.89 to 1.15), interaction p=0.012) and accidental hangings (2001-2005: IRR: 0.93 (95% CI 0.76 to 1.14); 2006-2010: IRR: 1.25 (95% CI 1.04 to 1.49), interaction=0.01) Undetermined deaths significantly decreased among females aged 15-19 yeras (IRR: 0.93; 95% CI 0.88 to 0.98). There were no significant trends among 10-14-year-olds.

CONCLUSIONS

Rates of suicide are higher among older adolescents and males. There was a significant fall in suicide rates in males aged 15-19 years that was not accounted for by changes in rates of accidental death. The absence of a significant trend in suicide or accidental deaths in those aged 10-14 years may have been the result of small numbers. However, monitoring should continue to identify longitudinal trends in all young people.

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

Objectives

To 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).

Methods

There 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.

Conclusion

Within 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 registration

A pilot study of a contact and information based intervention to reduce repeat self-harm; ISRCTN65171515.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

Identifying probable suicide clusters in wales using national mortality data

BACKGROUND

Up to 2% of suicides in young people may occur in clusters i.e., close together in time and space. In early 2008 unprecedented attention was given by national and international news media to a suspected suicide cluster among young people living in Bridgend, Wales. This paper investigates the strength of statistical evidence for this apparent cluster, its size, and temporal and geographical limits.

METHODS AND FINDINGS

The analysis is based on official mortality statistics for Wales for 2000-2009 provided by the UK's Office for National Statistics (ONS). Temporo-spatial analysis was performed using Space Time Permutation Scan Statistics with SaTScan v9.1 for suicide deaths aged 15 and over, with a sub-group analysis focussing on cases aged 15-34 years. These analyses were conducted for deaths coded by ONS as: (i) suicide or of undetermined intent (probable suicides) and (ii) for a combination of suicide, undetermined, and accidental poisoning and hanging (possible suicides). The temporo-spatial analysis did not identify any clusters of suicide or undetermined intent deaths (probable suicides). However, analysis of all deaths by suicide, undetermined intent, accidental poisoning and accidental hanging (possible suicides) identified a temporo-spatial cluster (p = 0.029) involving 10 deaths amongst 15-34 year olds centred on the County Borough of Bridgend for the period 27(th) December 2007 to 19(th) February 2008. Less than 1% of possible suicides in younger people in Wales in the ten year period were identified as being cluster-related.

CONCLUSIONS

There was a possible suicide cluster in young people in Bridgend between December 2007 and February 2008. This cluster was smaller, shorter in duration, and predominantly later than the phenomenon that was reported in national and international print media. Further investigation of factors leading to the onset and termination of this series of deaths, in particular the role of the media, is required.

Time trends in coroners' use of different verdicts for possible suicides and their impact on officially reported incidence of suicide in England: 1990-2005

BACKGROUND

Official suicide statistics for England are based on deaths given suicide verdicts and most cases given an open verdict following a coroner's inquest. Previous research indicates that some deaths given accidental verdicts are considered to be suicides by clinicians. Changes in coroners' use of different verdicts may bias suicide trend estimates. We investigated whether suicide trends may be over- or underestimated when they are based on deaths given suicide and open verdicts. Method Possible suicides assessed by 12 English coroners in 1990/91, 1998 and 2005 and assigned open, accident/misadventure or narrative verdicts were rated by three experienced suicide researchers according to the likelihood that they were suicides. Details of all suicide verdicts given by these coroners were also recorded.

RESULTS

In 1990/91, 72.0% of researcher-defined suicides received a suicide verdict from the coroner, this decreased to 65.4% in 2005 (p trend < 0.01); equivalent figures for combined suicide and open verdicts were 95.4% (1990/91) and 86.7% (2005). Researcher-defined suicides with a verdict of accident/misadventure doubled over that period, from 4.6% to 9.1% (p < 0.01). Narrative verdict cases rose from zero in 1990/91 to 25 in 2005 (4.2% of researcher-defined suicides that year). In 1998 and 2005, 50.0% of the medicine poisoning deaths given accidental/misadventure verdicts were rated as suicide by the researchers.

CONCLUSIONS

Between 1990/91 and 2005, the proportion of researcher-defined suicides given a suicide verdict by coroners decreased, largely due to an increased use of accident/misadventure verdicts, particularly for deaths involving poisoning. Consideration should be given to the inclusion of 'accidental' deaths by poisoning with medicines in the statistics available for monitoring suicides rates.

Suicides associated with the 2008-10 economic recession in England: time trend analysis

OBJECTIVE

To determine whether English regions worst affected by the economic recession in the United Kingdom in 2008-10 have had the greatest increases in suicides.

DESIGN

Time trend analysis comparing the actual number of suicides with those that would be expected if pre-recession trends had continued. Multivariate regression models quantified the association between changes in unemployment (based on claimant data) and suicides (based on data from the National Clinical Health Outcomes Database).

SETTING

93 English regions, based on the Nomenclature of Territorial Units Statistics level 3 groupings of local authorities at county level and groups of unitary local authorities.

PARTICIPANTS

Men and women with a record of death from suicide or injury of undetermined cause in 2000-10.

MAIN OUTCOME MEASURE

Number of excess suicides during the economic recession (2008-10).

RESULTS

Between 2008 and 2010, we found 846 (95% confidence interval 818 to 877) more suicides among men than would have been expected based on historical trends, and 155 (121 to 189) more suicides among women. Historically, short term yearly fluctuations in unemployment have been associated with annual changes in suicides among men but not among women. We estimated that each 10% increase in the number of unemployed men was significantly associated with a 1.4% (0.5% to 2.3%) increase in male suicides. These findings suggest that about two fifths of the recent increase in suicides among men (increase of 329 suicides, 126 to 532) during the 2008-10 recession can be attributed to rising unemployment.

CONCLUSION

The study provides evidence linking the recent increase in suicides in England with the financial crisis that began in 2008. English regions with the largest rises in unemployment have had the largest increases in suicides, particularly among men.