We have recently completed a study funded by the Department of Health to collect information to assist in evidence-based implementation of the National Suicide Prevention Strategy for England with regard to reducing deaths involving certain methods of suicide. The study was based on Coroners' inquest records, and was undertaken in collaboration with colleagues from Bristol and Manchester universities.
Aim of the study
Reducing availability and lethality of methods of suicide is a key goal in the National Suicide Prevention Strategy for England (2002). In order to determine how this might best be effected, and also how the danger of specific methods might be reduced, including through improved treatment following suicidal acts, it is necessary to have detailed information on suicides in which these methods have been used. This study was established in order to achieve this aim in relation to certain specific methods of suicide, namely:
3) Co-proxamol poisoning
4) Self-poisoning in which the individual reached hospital alive.
For each method of suicide, selective literature reviews were conducted to provide both background information for the empirical studies and to supplement the conclusions.
A further aim of the study was to determine the extent to which coroners' records are a satisfactory source of information for studies of this kind.
The study was conducted through a collaboration involving centres in Oxford (Keith Hawton, Lesley Sutton, Sue Simkin, Camilla Haw), Bristol (David Gunnell and Olive Bennewith) and Manchester (Navneet Kapur and Pauline Turnbull). It was co-ordinated by the Centre for Suicide Research.
The study was conducted by examining coroners' records of suicides in which the methods under investigation were used. Eight coroners' jurisdictions within reasonable travelling distance of each of the three research centres were randomly selected (i.e. 24 in all). The cases included in the study were those receiving a coroner's verdict of suicide, or an open verdict in which the research team judged there to have been a high or moderate probability of suicide.
Structured data-extraction forms were used to record the following broad areas of information (detailed items were used within each area): demographic characteristics of the deceased, circumstances of the act (method, timing, location, discovery), toxicology (alcohol and blood levels), contact with psychiatric services and general practitioner, and previous self-harm. Part of the Beck Suicide Intent Scale, based on the objective circumstances of the act, was also completed. More detailed information on each specific method under investigation was recorded on additional sections of the forms. For each case a brief vignette was compiled, including any other relevant details from the inquest records.
Data were analysed using SPSS and STATA.
Hangings: the majority occurred in the person's home or garden. A small minority occurred in prisons or psychiatric wards. Rope or cord was the most common ligature. In almost half the cases individuals were not fully suspended (i.e. feet off the ground).
Firearms: shotguns were used in over three-quarters of cases. A minority of individuals had had contact with psychiatric services and few had a history of previous self harm. Sport and occupational use were the main reasons for gun ownership.
Co-proxamol poisoning: More than 40% of individuals were aged 55 years and over. Nearly half had a history of self harm. Alcohol was involved in more than half the overdoses. These generally included fewer tablets. The co-proxamol was less often prescribed for the deceased in younger compared with older individuals. The number of tablets taken varied widely. Death occurred in most cases before the individual could reach hospital.
Self poisonings reaching hospital alive: Nearly a quarter of people who died from overdose reached hospital alive. Assistance was initially given by ambulance personnel in nearly three quarters of cases. Half the patients had a history of self harm. Cardiac monitoring occurred in at least one third of patients and approximately 4 out of 10 were ventilated and a similar proportion were admitted to an intensive care unit.
Use of coroners' records for the investigation of suicide: While coroners in general appear willing to assist with studies associated with suicide, there is considerable variation between coroners in the extent to which some information is included in their records. Some relatively important items are often not recorded, e.g. contact with psychiatric services, date of last contact with GP, blood levels for drug overdoses, source of drugs taken in overdoses, source of ligatures for hanging, and whether firearms used for suicide were licensed and whether they were kept in a locked cabinet.
Hanging: Since the most commonly used ligatures and ligature points are easily available, restriction of access to means is only possible in institutions such as hospitals and prisons. As death from hanging can often occur when an individual is not fully suspended, inspection of psychiatric wards and cells for potential ligature points should focus on fixtures and fittings at all heights.
Firearms: Use of firearms for suicide appears to have decreased following more restrictive firearm legislation (see Haw et al 2004 below)
Co-proxamol: Strategies to prevent co-proxamol poisoning should be based on safer prescribing and must take account of the fact that death can occur with relatively few tablets, especially if alcohol is consumed.
Self poisonings reaching hospital alive: Improved medical management could have the potential to prevent some poisoning suicides.
Use of coroners' records for the investigation of suicide: Standardisation of information recording by coroners could be valuable for investigations of suicide.
Bennewith, O., Gunnell, D., Kapur, N., Turnbull, P., Simkin, S., Sutton, L., Hawton, K. (2005) Suicide by hanging: a multicentre study based on coroners' records in England. British Journal of Psychiatry, 186, 260-261
Sutton, L., Hawton, K., Simkin, S., Turnbull, P., Kapur, N., Bennewith, O., Gunnell, D. (2005) Gunshot suicides in England: a multicentre study based on coroners' records. Social Psychiatry and Psychiatric Epidemiology, 40, 324-328
Haw, C., Sutton, L., Simkin, S., Gunnell, D., Kapur, N., Nowers, M., Hawton, K. (2004) Suicide by gunshot in the United Kingdom: a review of the literature. Medicine Science and the Law, 44, 295-310
Hawton K, Simkin S, Gunnell D, Sutton L, Bennewith O, Turnbull P, Kapur N. (2005) A multicentre study of co-proxamol poisoning suicides based on coroners' records in England. British Journal of Clinical Pharmacology, 59, 207-212
Simkin, S., Hawton, K., Sutton, L., Gunnell, D., Bennewith, O., Kapur, N. (2005) Co-proxamol and suicide: preventing the continuing toll of overdose deaths. Quarterly Journal of Medicine, 98, 159-170
Self poisonings reaching hospital alive
Kapur, N., Turnbull, P., Hawton, K., Simkin, S., Sutton, L., Mackway-Jones, K., Bennewith, O., Gunnell, D. (2005) Self-poisoning suicides in England: a multicentre study. Quarterly Journal of Medicine, 98, 589-597 doi:10.1093/qjmed/hci089
Kapur, N., Turnbull, P., Hawton, K., Simkin, S., Mackway-Jones, K., Gunnell, D. (2006) The hospital management of fatal self-poisoning in industrialised countries: an opportunity for suicide prevention? Suicide and Life-Threatening Behavior, 36, 302-312
Use of coroners' records for the investigation of suicideBennewith, O., Hawton, K., Simkin, S., Sutton, L., Kapur, N., Turnbull, P., Gunnell, D. (2005) The usefulness of coroners' data on suicides for providing information relevant to prevention. Suicide and Life-Threatening Behavior, 35, 607-614