Over the study period from January 1, 1997 until December 31, 2006, we received notifications of 50,352 cases of suicide, including 34,891 cases in which the coroner's verdict was suicide and 15,461 open verdicts or deaths from undetermined cause. Of these, 13,331 (26%) were confirmed as having been in contact with mental health services in the year prior to death. Completed questionnaires were received on 13,066 cases, a response rate of 98%.
There were 1,851 cases who were current in-patients at the time of suicide, representing 14% of all suicide cases (an average of 185 deaths per year). The number and proportion of in-patient suicides has significantly declined over the 10-year study period, from 221 (17%) cases in 1997 to 144 (12%) in 2006 (likelihood ratio χ2 test for linear trend 16.3 (1 df), p < 0.001). Thirty percent (546 cases) of in-patient suicides took place on the ward itself; 1,292 cases (70%) occurred away from the ward, and in 13 cases (0.7%) the place of death was unknown. Of those who died away from the ward, 469 (38%) had absconded, and 761 (62%) were either on authorised leave or off the ward with staff agreement when the suicide occurred (referred to as 'agreed leave' cases). Over the study period, whilst the number of suicides after absconding had fallen, the proportion showed no clear pattern, fluctuating from 40% (52 cases) in 1997, to 31% (40 cases) in 2003, and 38% in 2006 (35 cases). On average, these patient suicides occurred 50 times per year.
Type of ward
The majority of absconders were on a general psychiatry open ward (393 cases, 86%); 27 (6%) a rehabilitation unit; 11 (2%) a psychiatric intensive care ward, 5 (1%) a secure unit, and 21 (5%) were on 'other' specified wards (for example, women only crisis unit). In 12 (3%) cases, the type of ward was unknown.
Method of Suicide
Data on the cause of death are summarised in Table . Hanging and jumping from a height or in front of a moving vehicle were the main methods used for the sample as a whole. However, those who had absconded were proportionally less likely to die by hanging and self-poisoning compared to those who were on agreed leave, but more often died by jumping and drowning.
Method of suicide by leave status
Social and behavioural characteristics
Cases of suicide who had absconded were significantly younger than those who were on agreed leave (median age 39, range 17-78 vs. 46, range 15-95; p < 0.001). There was no difference between the two groups in terms of gender, ethnicity or living circumstances (Table ). However, those who had absconded were more likely to be unemployed, unmarried and homeless. Whilst three quarters of both in-patient groups had self-harmed, those who had absconded were more likely to have had a history of violence, alcohol misuse and drug misuse.
Socio-demographic and behavioural characteristics of in-patient suicide cases by leave status
The diagnostic profile differed between absconders and those on agreed leave (Table ). Forty percent of those who had absconded were suffering from schizophrenia, significantly more than other cases (26%). They were also more likely to have alcohol dependence but had lower rates of affective disorder. A co-morbid psychiatric condition was common, occurring in approximately half of both groups. A similar proportion of both groups had also been ill for longer than five years, and had multiple previous admissions to psychiatric in-patient care. There was no difference between absconders and those on agreed leave in terms of the number under enhanced levels of aftercare (the Care Programme Approach (CPA); a mechanism which provides supervision by a care co-ordinator and regular multi-disciplinary case reviews to patients with complex health and social care needs). However, non-compliance with medication was a particular feature of patients who had absconded compared to those on agreed leave.
Clinical characteristics of in-patient suicide cases by leave status
Contact with services
Those who had absconded were more likely than those on agreed leave to have been under a medium (checked every 5 to 25 minutes) or high (one-to-one) level of observation (Table ). However, clinicians had reported significantly more problems in observation of those who had absconded, through either ward design or other patients. Absconders were also more likely, at this final admission, to have been detained under the Mental Health Act (MHA; the legislation by which patients can be confined in hospital for assessment and treatment against their wishes), and to have died within a week of being admitted. Fewer absconders had died during the period when discharge from hospital was being planned.
Contact with services and risk characteristics of in-patient suicide cases by leave status
Proportionally more patients who had absconded had reported abnormalities of mental state at the last contact with the mental health team. These symptoms were most often emotional distress (166 cases, 36% vs. 138 cases, 18%; p < 0.001), hopelessness (94 cases, 21% vs. 76 cases, 10%; p < 0.001), delusions or hallucinations (87 cases, 19% vs. 59 cases, 8%; p < 0.001) and suicidal ideation (71 cases, 16% vs. 54 cases, 7%; p < 0.001). Estimates of both short- and long-term risk of suicide were more often considered as moderate or high in patients who had absconded. Clinicians were also more likely to view absconding cases as preventable. The most common suggested factors that could have made the suicide less likely were closer patient supervision (219 cases, 49%), better treatment compliance (118 cases, 26%), increased staff numbers (114 cases, 26%), improved staff communication (97 cases, 21%) and better staff training (93 cases, 21%).