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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%)
Limitations
Missed contact with services
Clinical data based on casenotes and clinical judgements
Completers aware of outcome
The Sudden Unexplained Death Study
Pauline Turnbull
National Confidential Inquiry into Suicide and Homicide by People with Mental Illness
ASSIST PRESTWICH 2008
Outline
• Background
• Methodology
• Results
• Limitations
• Clinical Implications
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)
Associations with SUD
• Treatment for mental illness
• Anti-psychotic drug use– Some drugs prolong the QT interval
• Non drug factors– poor physical health
– restraint
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
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
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 Questionnaire
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 Questionnaire
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
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 Questionnaire
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 Questionnaire
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
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
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 Questionnaire
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
Results
Age and Sex
0
5
10
15
20
25
30
35
40
45
Fre
qu
ency
<20 20-29 30-39 40-49 50-59 60-69 70-75
Age Group
Male
Female
Physical features
Number (235)
%
(95% CI)
History of Cardiovascular Disease
106
46%
(40 - 53)
History of Respiratory Disease
97
31%
(35 - 48)
Physical examination during final admission
216
93%
(89 - 96)
Clinical featuresNumber
(235) % (95% CI)
Speciality admitted to:
General Adult Psychiatry 97 41% (35 - 48)
Old Age Psychiatry 92 39% (33 - 46)
Primary Diagnosis: Schizophrenia 79 34% (28 - 40)
Affective Disorder 66 28% (23 - 34)
More than 5 previousadmissions 84 37% (30 - 43)
Prescribed Psychotropic Drug 182 78% (72 - 83)
Prescribed two or morePsychotropic drugs
113 49% (42 - 55)
Clinical features
Number(235) % (95% CI)
Patient died on the ward 198 85% (80 - 89)
CPR attempted 126 57% (50 - 64)
Staff trained in CPR 116 87% (80 - 92)
CPR equipment on the ward 131 68% (61 - 75)
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
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
Contact Details
The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness