Summary and Key findings
Summary
- This suicide audit for Hertfordshire is the second to include three years of data.
- It provides an overview of deaths in Hertfordshire given a Coroner’s conclusion of suicides at inquests held between 1st of January 2019 and the 31st of December 2021.
- The audit uses information from files held by the coroner service and has been carried out to a robust and repeatable methodology introduced in 2017.
- 203 deaths are included in the audit, with most deaths occurring in 2019 (39.4%), and 2020 (27.6%).
- 101 coroners inquests had a conclusion of suicide in 2019, 62 in 2020, and 40 in 2021. The Coroners Court closed for parts of 2020 and 2021 due to the COVID-19 pandemic, resulting in fewer inquests taking place in these years. The lower number of inquests with a conclusion of suicides in 2020 and 2021 should not be interpreted as a reduction in the number of suicides but rather is likely reflective of the lower number of inquests occurring in 2020 and 2021.
- Although each of the 203 deaths included represents a personal tragedy with potentially devastating consequences for others, statistically speaking these are small numbers.
- The 2018-2020 age standardised suicide rate in Hertfordshire is statistically significantly lower than the rate for England [1]. Whilst there has been no significant change in the rate for Hertfordshire over the last ten years, the rate has been increasing since 2011-13[1].
Key findings
- Men accounted for almost three quarters of all suicides.
- 41.4% of all people who died by suicide were aged 30-49.
- Mental health issues were the most common risk factor.
- 31.5% were known to a mental health service at the time of death.
- 24.6% were known to have discussed mental health issues with a member of their GP practice in the four weeks leading up to their death.
- Over a third of people who died by suicide were known to have made a previous suicide attempt.
- Almost two thirds (61.1%) of suicides were by hanging, strangulation or suffocation.
- Most suicides took place at the individual’s home (66%).
- One in ten suicides took place on the railway.
Key Recommendations
- An annual suicide audit should continue to be carried out as part of Hertfordshire’s commitment to suicide prevention.
- The findings of this audit and future audits will be shared with the suicide prevention network as part of the 2020-2025 Hertfordshire Suicide Prevention Strategy [4].
Background
The death of a person by suicide can have a devastating effect on families, friends, colleagues, first responders, medical staff, the wider community and beyond. It has been estimated that around 135 people may be affected by each person who dies by suicide[5]. There is also a considerable economic cost- estimated at around £1.7 million per death[5]. There has been a downward trend in suicide rates within England (and East of England), albeit with several statistically significant peaks including one in 2019[5]. However, there is no room for complacency: between 2018-20 there were 15,249 suicides registered in England, an age-standardised rate of 10.4 deaths per 100,000 population[1]. Over the latest three-year period (2018-20) 284 suicides were registered in Hertfordshire, an age-standardised rate of 9.2 per 100,000[1]. The suicide rate in Hertfordshire is statistically lower than the rate for England, and has been across all year since 2004-06 except for 2017-19[1]. As local authority level rates are based on relatively small numbers, changes can often be a result of fluctuations. The annual number of suicides registered in Hertfordshire has fluctuated between 52 and 105, over a 20-year period (2001 to 2020)[6].
National guidance recommends that every local authority carries out an annual suicide audit (though they are no longer a statutory requirement); develops a suicide prevention action plan; and establishes a multi-agency group to co-ordinate effective action within the local area [7]. Work was carried out by a multi-agency group, consisting of representatives from Hertfordshire County Council (Public Health, Coroner Service, Integrated Health and Care Commissioning Team), Hertfordshire Partnership University NHS Foundation Trust, Hertfordshire Police Constabulary and British Transport Police. The group agreed what information to capture from the coroner’s files for each individual, and a more robust, consistent and objective process was developed. The aim was to ensure the integrity of the audit results irrespective of who carried it out and ensure the comparability of results from audits in subsequent years.
This audit is the second audit report to include three years of data, covering suicides with a coroner’s conclusion reached in the calendar years from 2019-2021, the first being produced for 2017-2019. Apart from providing a more detailed insight into suicides within Hertfordshire, the key value of suicide audits is to identify trends and any areas where additional focus or emphasis is required locally, versus the national picture. This intelligence is used to inform the local strategy. Data for the 2019-21 suicide audit was collected in 2019, 2020 and 2021, and allows three years’ worth of directly comparable, consistent data to be used as part of the Hertfordshire Suicide Prevention Strategy 2020-2025. The report includes some recommendations for improving the process but does not include recommendations for action as there is a danger in drawing conclusions based on this data alone. Other data sources such as ONS death registrations, police, NHS and other service data are also considered by multi-agency working to reduce and prevent suicide. This audit is just one source of information and data.
Introduction
This audit uses the National Statistics definition of suicide, also used by Office of Health Improvement and Disparities (formally known as Public Health England); this includes all deaths from intentional self-harm for persons aged 10 years and over (where a coroner has given a suicide conclusion), and deaths from injury or poisoning where the intent was undetermined for those aged 15 years and over (mainly deaths where a coroner has given an open conclusion)[5].
203 deaths by suicide with a Hertfordshire Coroner Service inquest concluding in 2019, 2020 or 2021 were identified for the audit. 203 deaths were recorded as suicide (intentional self-harm) and 0 as an injury or poisoning of undetermined intent.
The 203 inquests concluding during 2019-21 included deaths occurring between June 2016 and December 2020 with 1% occurring in 2016, 2.5% in 2017, 29.6% in 2018, 39.4% in 2019, 27.6% occurring in 2020, and 0% occurring in 2021. The median number of days between the date of death and inquest conclusion was 210 (170 in 2019, 203.5 in 2020 and 378.5 in 2021) or approximately 30 weeks. For comparison, ONS recorded a median registration delay of 165 days (approximately 24 weeks) in England in 2020, however, provisional figures for January to June 2021 show an increase in median registration delay, as some suicides normally registered in 2020 have been registered in 2021 due to disruption caused by the COVID-19 pandemic [2]. Registration of a death typically occurs within a few days or weeks of the inquest conclusion.
Hertfordshire Coroner Service is primarily responsible for investigating deaths that occur within Hertfordshire. This means this audit, and future audits:- May not include all Hertfordshire residents, as some will have died outside of Hertfordshire and been investigated by another coroner’s office.
- May include people whose usual place of residence was not Hertfordshire.
- May use a different cohort to the annually published ONS and Public Health England Figures, as these are based on local authority of residence and the calendar year of the date the death was registered.
As coroners can transfer cases to each other, this may include deaths of Hertfordshire residents where the death took place outside the county, and vice versa.
Methodology (click to expand) ▼
Data collection involved staff visiting the coroner’s office to review records in detail. Significant time was required to sift through the paper files to pull out the items of interest. A standardised electronic questionnaire was developed in Microsoft Excel to collect the data from each record using a combination of free text and dropdowns wherever possible (see Appendix 1). This included:- coroner’s conclusion
- post-mortem and toxicology
- general Practitioner (GP) records
- reports from hospital doctors or other specialists including Mental Health Services
- police reports (including witness statements)
The questionnaire ensured that reporting was targeted to pertinent areas of the coroners’ records and that data was collected consistently by staff. The records were reviewed by local authority public health staff on-site at the coroner’s office on a number of occasions during 2019 to 2021. This data was then collated into one dataset.
Statistical analysis
Despite using three years of data, the number of suicides are small and many variables have incomplete data available. Due to rounding, numbers presented throughout this report may not add up precisely to the totals indicated and percentages may not precisely reflect the absolute Figures for the same reason. All findings reported are indicative. Due to the smaller number of women who died by suicide, breakdowns by sex may not always be provided.
Lower and upper confidence intervals are shown on figures to highlight the range of uncertainty (caused by sample size and random variation) around values. They appear as whiskers extending above and below the value. If the confidence interval around a value overlaps with the interval around another, we cannot say with certainty that there is more than a chance difference between the two values. Calculations based on small numbers of events are often subject to random fluctuations.Summary of the audit findings
The summary below is based on the 203 deaths with a Hertfordshire Coroner Service inquest conclusion of suicide from 1st January 2019 to 31st December 2021.
Demographics- 72.4% of deaths by suicide included in the audit were men.
- 41.4% of people who died by suicide were aged 30 to 49 years old.
- There were 7 (3.4%) suicides by people aged under 18, and 10 (4.9%) by people aged 80 years or over.
- 7.4% of people included in the audit resided outside of Hertfordshire.
- 87.2% were born in the UK (32% in Hertfordshire).
- 32% of people dying by suicide were married whilst 20.2% were widowed or divorced.
- 50.2% were employed, whilst 14.3% were unemployed and 15.3% were retired.
- Over half (61.1%) of suicides were by hanging, strangulation or suffocation. The second most common method of suicide was self-poisoning (14.8%), followed by deaths on the railway (10.8%).
- Most suicides took place at the individual’s home (66%). The next most common locations were woodland or park (10.8%) and the railway (10.8%).
- 41.9% of people left a suicide message.
- 69.5% of people who died by suicide had a mental health issue or condition recorded by their GP practice.
- 24.6% (50 suicides) of people who died by suicide discussed mental health issues with a member of their GP practice in the four weeks leading up to their death.
- Over one in ten (14.8%) were known to have contacted their GP practice in relation to their physical or mental health in the week prior to their death.
- 31.5% of people who died by suicide were known to a mental health service at the time of death.
- 37.5% (24 suicides) of those in contact with a mental health service had contact during the week leading up to their death, and 67.2% (43 suicides) were in touch within the four weeks prior to death.
- 14.3% of people who died by suicide were known to drug and alcohol services at their time of death.
- 16.7% of people who died by suicide had attended A&E due to self-harm, suicidal thoughts or suicide attempts in the 12 months prior to death.
- Mental ill health issues were the most commonly reported risk factor (75.9%).
- 39.4% of people who died by suicide were reported to have made a previous suicide attempt and 20.2% had a recorded history of self-harm.
- A fifth (20.2%) of people who died by suicide were known to have been involved with the criminal justice system.
Demographics
Age and sex
The average age of people who died by suicide over the audit period was 46 (47 for men and 45 for women).
Fig 1. Suicides by age group
The age band with the highest percentage of suicides was 40-49 where 21.7% of suicides occurred (Figure 1). 41.4% of people dying by suicide were aged 30 to 49 years old (Figure 1).
Fig 2. Suicides by age group and audit year
There were no significant changes in the proportion of suicides in each age band between the three audit years. Whilst there was variation in the 10-year age band with the highest percentage of suicides, the majority of suicides occurred in the 30-59-year age bands in all three audit years (Figure 2).
The average age was similar across the three audit years (47 in 2019, 46 in 2020 and 46 in 2021). There were 7 suicides by young people aged under 18 and 10 suicides by people aged 80 or over (Figure 2).
Fig 3. Suicides sex and audit year
Of the 203 suicides, 72.4% (147) were men and 27.6% (56) were women. This is in line with national findings where males make up three-quarters of suicides, a proportion which has been mostly consistent since the mid-1990s[5]. The proportion of suicides that were male remained statistically similar across the three audit years (70.3% in 2019, 74.2% in 2020, and 75% in 2021) (Figure 3).
Fig 4. Suicides by age group and sex
There were no statistically significant differences in proportion of suicides by males and females for any age group (Figure 4). The 30-39 age group had the highest proportion of suicides for women (23.2%). The 40-49 age group had the highest proportion of suicides for men (22.4%) (Figure 4).
42.9% (87 suicides) of all suicides were men aged 30-59.
A more in-depth analysis of suicides in children (under 18) and young persons (18-25) has been completed, due to the small numbers it has not been included in the published version of this audit.
Marital status
Fig 5. Suicides by marital status
46.8% of individuals were recorded as single, 32% married, 0.5% in a civil partnership, 14.8% divorced and 5.4% widowed (note ‘single’ includes people who are in a relationship, but not married) (Figure 5).
Fig 6. Suicides by marital status and audit year
There were no significant differences in marital status between any of the three audit years (Figure 6).
Fig 7. Suicides by marital status and sex
There was no significant difference in marital status between males and females (Figure 7).
Employment status
Fig 8. Suicides by employment status
50.2% of individuals were identified as in employment, with 14.3% unemployed, 15.3% retired and 2% unable to work due to illness or disability (Figure 8). The remainder were either full-time students (7.9%), homemakers (2%) or missing employment status (8.4%).
Fig 9. Suicides by employment status and audit year
There was no significant differences between employment status during any of the three audit years (Figure 9). Any effect on employment from the COVID-19 pandemic is unlikely to show up in this audit due to the limited number of inquest in 2020 and 2021 and the delay from time of death to inquest.
Fig 10. Suicides by Employment Status and Sex
There were no significant differences in employment status between males and females (Figure 10).
Place of birth
Fig 11. Suicides by place of birth
87.1% of people in the audit were born in the UK (32% in Hertfordshire, 24.1% in London, 24.6% in the rest of the UK) and 12.8% were born outside of the UK (Figure 11). For comparison purposes the 2011 Census recorded 12.3% of people (all ages) living in Hertfordshire as being born outside of the UK[8].
Place of residence
Addresses within Hertfordshire were recorded as the usual place of residence for 185 (91.1%) of the 203 suicides. 15 addresses (7.4%) were linked to a postcode outside of Hertfordshire and 3 suicides (1.5%) were recorded as no fixed abode.
Deprivation
Fig 12. Suicide by deprivation
Of the identified Hertfordshire residents (185), those living in Q5 (Least deprived quintile) areas of Hertfordshire based on local quintiles (fifths) of deprivation had the fewest suicides (17.8%) (Figure 12).
Fig 13. Suicide by deprivation and audit year
There were no significant changes in the percentage of people living in the IMD quintiles across the three audit years (Figure 13).
Fig 14. Suicide by deprivation and sex
There were no significant differences in the proportion of people in IMD quintiles between males and females (Figure 14).
District and CCG
Fig 15. Suicide rate by district
Crude rates of suicide, based on the usual place of residence, were calculated for Hertfordshire districts and Clinical Commissioning Groups (CCG). The rate of suicides across the three audit years in the 10 Hertfordshire districts ranged from 2.4 per 100,000 in Watford per 100,000 to 10.6 per 100,000 in Hertsmere (Figure 15). The rate was statistically significantly higher in Hertsmere than Watford, however there were no other statistically significant differences between any of the other districts or between the districts and Hertfordshire (5.9 per 100,000 population) (Figure 15).
Fig 16. Suicide rate by CCG
There were 76 suicides over the audit period with a postcode in NHS East and North Hertfordshire CCG boundary, a crude rate of 5 per 100,000 registered patients, and 104 in NHS Herts Valleys CCG boundary, a crude rate of 6.7 per 100,000 registered patients (Figure 16). The CCG rates were not statistically significantly different to each other. Nationally, rates for local authorities and CCGs are presented by aggregating three years of data and standardising for age, where numbers allow, for more meaningful comparisons[6, 7]. In the most recent national rates (2018-20) the suicide rate was 9.2 per 100,000 in Hertfordshire, 8.6 per 100,000 in NHS East and North Hertfordshire CCG, and 9.7 per 100,000 in NHS Herts Valley CCG [1].
Rates of suicide for Hertfordshire districts varied over the three years, however due to the small numbers at district level (an average of less than 7 per district per audit year), the confidence intervals are wide, and there were no statistically significant differences. Similarly, there were no statistically significant changes within the CCGs or Hertfordshire.
Equality data
All files were checked for details of ethnicity, religion, sexual orientation, gender identity, disability, and caring responsibilities. Sexual orientation was only recorded if explicitly stated in the coroners file (it was not assumed from marital or relationship status). Disability was only recorded if there was evidence of a registered disability. The Carers Trust definition was used to identify carers: “A carer is anyone who cares, unpaid, for a friend or family member who due to illness, disability, a mental health problem, or an addiction, cannot cope without their support”[9].
These equality characteristics were not routinely recorded and were missing from most files. Less than 6% of suicides had sexual orientation and 9% of suicides had religion recorded. Ethnicity was only recorded in 45.8% of suicides, and only 42% could be matched to 2011 Census categories[10]. As these equality characteristics are unavailable for most suicides, breakdowns are not provided.
Table 1. Availability of equality data
Equality characteristic | Data availability as percentage of all suicides |
Ethnicity (2011 census categories) | 42% |
Religion | 9% |
Sexual orientation | 6% |
Gender identity (reassignment or intent) | 3% |
Disability | 44% |
Carer | 52% |
Table 1: Data completeness, percentage of equality characteristics, Hertfordshire Suicide Audit, 2019-2021 | |
Circumstances of death
Method of suicide
Fig 17. Suicide by method
The most common method of suicide was hanging, strangulation, or suffocation, accounting for 124 (61.1%) suicides. Nationally, hanging, strangulation or suffocation, was the most common method used by both men and women in the UK (61.1% and 49.1% respectively)[5].
The second most common method of suicide was self-poisoning, accounting for 14.8% of all suicides (30 suicides), it was the second most common method in all three audit years (14.9% in 2019, 17.7% in 2020 and 10% in 2021) (Figure 17,18). Nationally this was the second most common method used by both men and women in the UK (15.8% and 32.4% respectively)[5].
Suicides on the railway was the third most common method accounting for 10.8% of suicides (22 suicides) (Figure 17). The suicides took place at, or near, eleven railway stations in Hertfordshire. Nationally, it is reported around 4.4% of suicides in the UK take place on the railway [12].
Fig 18. Suicide method by audit year
Hanging, strangulation, or suffocation was the most common method of suicide across all three years included in this audit (65.3% in 2019, 54.8% in 2020, and 60% in 2021) (Figure 18). There was no statistically significant differences in the method of suicide between the three audit years (Figure 18).
Fig 19. Suicide method by sex
Hanging, strangulation, or suffocation was the most common method for men (59.2%, 87 suicides) and women (66.1%, 37 suicides). For men, the second most common method was deaths on the railway (12.9%, 19 suicides), followed by self poisoning (10.2%, 15 suicides). For women, the second most common method was self-poisoning, (26.8%, 15 suicides), followed by deaths on the railway (5.4%, 3 suicides) (Figure 19).
- prescription drugs (20 suicides), at least 12 involved drugs prescribed for the person who died by suicide
- carbon monoxide (2 suicides)
- alcohol and/or recreational drugs (4 suicides)
- over the counter medication (2 suicides)
- morphine was listed as contributing to 5 deaths
A post-mortem is conducted in a case of suspected suicide. This includes a toxicology report to identify any substances present in the body that may have contributed to the death. For a small number of suicides there was no toxicology report, as toxicology was either not possible or inappropriate.
Location of suicide
Fig 20. Suicide location
Two thirds (66%) of people who died by suicide died at home (Figure 20). The next most common location was woodland or park (10.8%) and by the railway (10.8%) (Figure 20).
Fig 21. Suicide location by audit year
Across all three audit years, the location with the highest proportion of suicides was at home. There was no statistically significant differences between audit years for any other locations.
Fig 22. Suicide location by sex
The most common location of suicide was at home for both males and females, (61.2% of men and 78.6% of women) (Figure 22). There was no statistically significant differences between any other locations.
Suicide message
Fig 23. Suicide message
Of all the suicides audited in 2019-2021, there was evidence of a suicide message left by the deceased (using a variety of media such as a note or text) in two fifths (41.9%) of all suicides (48.2% of women and 39.5% of men).
Alcohol and drug use at time of death
Alcohol, of varying levels of concentration, was recorded in 34% of suicides. Several toxicology reports suggested low levels of alcohol may be as a result of post-mortem changes rather than ingestion of alcohol prior to death.
Drugs listed in the toxicology results were grouped according to the Sheffield Teaching Hospitals NHS Foundation Trust Forensic Toxicology Test screening groups (Appendix 2).- Opioids were recorded in the toxicology reports of 13.8% of suicides (28 suicides). Opiates include pain killers such as codeine and morphine, as well as heroin and methadone.
- Stimulants were recorded in 15.3% of suicides (31 suicides). Stimulants include amphetamine, cocaine, MDMA (ecstasy), etc.
- Cannabis was recorded in 4.4% of suicides (9 suicides).
Contact with health care services
Primary care
95.1% of people who died by suicide were registered with a GP practice (80.3% with a GP practice in Hertfordshire). 6 people (3%) were not registered with a practice and registration status was unknown for 4 people (2%).
Date of last contact with GP practice was missing for 28 (13.8%) of the 203 suicides. As shown in Figure 24, it was known that:- Nearly three-quarters contacted their practice within the 12 months prior to their death (73.9%, 150 suicides).
- Over a third contacted their practice within the four weeks prior to their death (34%, 69 suicides).
- Over one in ten contacted their practice within the week prior to their death (14.8%, 30 suicides).
There was no statistically significant difference across the audit period in the timing of last contact with GP and dying by suicide.
Fig 24. Last contact with primary care
Fig 25. Last contact with primary care by audit year
Fig 26. Last contact with primary care by Sex
Two fifths (40.4%, 82 suicides) of all people who died by suicide last contacted their GP for mental health issues; 39.5% (58 suicides) for men and 42.9% (24 suicides) for women. Details of the reason for last contact with the primary care team was missing for 25 suicides (12.3%) (some suicides had a known last contact reason, but an unknown last contact date).
For the 82 people whose last contact with their GP was related to their mental health issues, 28% (25% of females and 29.3% of males) had contact within the week prior to their death and 61% (62.5% of females and 60.3% of males) within the four weeks prior to their death.
GP recorded mental health issues and conditions
The GP had recorded mental health issues or conditions for 69.5 % (141 suicides) of people who died by suicide, 83.9% (47 suicides) for women and 63.9% (94 suicides) for men. Of these, 73.8% (104 suicides) had a treatment plan in place through primary care (74.5% for women and 73.4% for men). The most commonly recorded mental health issues and conditions were depression, anxiety, psychotic disorders and stress.
One quarter (24.6%, 50 suicides) of all people who died by suicide were known to have discussed mental health issues with a member of the primary care team within the four weeks leading up to their death (26.8% of women and 23.8% of men). 23 people (11.3%) had discussed mental health issues with their primary care team in the week leading up to their death.
Mental health services
Mental health services include the local NHS Trust (Hertfordshire Partnership University NHS Foundation Trust), out of area NHS trusts, and private mental health services. All information in this section was provided by the relevant mental health service in response to a request from the coroner.
Almost a third (31.5%, 64 suicides) of people who died by suicide were known to a mental health service at the time of death, with more women (44.6%) than men (26.5%) known to mental health services.
The percentage of people known to mental health services at time of death varied across the three audit years (34.7% in 2019, 25.8% in 2020 and 32.5% in 2021). Of the 64 suicides known to mental health services, 56 (87.5%) were known to Hertfordshire Partnership University NHS Foundation Trust. As shown in Figure 27, of the 64 people known to a mental health service at the time of death:- the majority had been in contact within the 12 months prior to their death (84.4%, 54 suicides)
- 62.5% had been in contact in the 4 weeks prior to their death (40 suicides)
- over a third were in contact with services, in the week leading up to their death (37.5%, 24 suicides)
- the date of last contact with a mental health service was not recorded for 15.6% (10 suicides)
There was no statistically significant difference across the audit period for the number of weeks since last contact with mental health services and suicide.
Fig 27. Last contact with mental health services
Fig 28. Last contact with mental health services by audit year
Fig 29. Last contact with mental health services by sex
95 people (46.8%) who died by suicide had a history of contact with mental health services, with a higher proportion amoungst women (80.4%, 45 suicides) than men (45.6%, 67 suicides). 107 people (52.7%) were identified as having been known to a mental health service at some point in their life, either before or at time of death. It is possible for people to have been known to mental health services at some point in their life but not have a mental health history if, for example, they had been referred shortly before their death but had not yet been seen.
19.2% of people (26.8% of females and 20.4% of males) who died by suicide had been previously known to mental health services but were not known at the time of their death.
61 (57%) of the 107 people who died by suicide and who had contact with a mental health service had details of one or more diagnosis (by a Mental Health Professional) recorded in the coroner files. Of these, 35 (57.4%) had two or more diagnoses recorded and 11 (18%) had three or more diagnoses.
The most common mental health diagnoses or working diagnoses recorded by a mental health professional, either before or at time of death were:- depression (35.5%, 38 suicides)
- anxiety (20.6%, 22 suicides)
- schizophrenia and/or personality disorder (15%, 16 suicides)
Alcohol and drug services
14.3% (29 suicides) of people who died by suicide were known to a drug or alcohol service (females 16.1% and males 13.6%). 15.8% (16 suicides) of suicides audited in 2019, 11.3% (7 suicides) of suicides audited in 2020, and 15% (6 suicides) of suicides audited in 2021, were known to the Hertfordshire commissioned drug and alcohol service.
Accident and Emergency attendances
There were 34 people (16.7%) who died by suicide who had attended Accident and Emergency due to self-harm, suicidal thoughts or suicide attempts in the 12 months prior to death. The proportion was higher in women (28.6%, 16 suicides) than men (12.2%, 18 suicides).
Other risk factors
The factors that contribute to why people take their own lives can be complex and multi-faceted, and consequently, it can be difficult to establish from the coroners file. The risk factors most frequently mentioned in the coroners’ files are listed in Figure 30. In females, mental ill health problems was the most commonly cited (82.1%, 46 suicides), followed by family/relationship problems (53.6%, 30 suicides) and bereavement (42.9%, 24 suicides). In males, mental ill health problems was the most commonly cited (73.5%, 108 suicides), followed by family/relationship problems (51.7%, 76 suicides) and drug or alcohol problems (38.8%, 57 suicides) (Figure 31). The smaller number of women means their proportions are more prone to fluctuations, making conclusions hard to reach.
Although mental ill health is the most frequently mentioned risk factor, mental health issues may also be caused by life events such as bereavement or physical health problems, as well as being linked to employment and financial issues. Mental ill health was the most common risk factor mentioned in all three audit years (Figure 32).
Suicide Risk Factors
Fig 30. Suicide risk factors
Fig 31. Suicide risk factors by audit year
Fig 32. Suicide risk factors by sex
Differences between risk factors for men and women are shown in Figure 32. They are most pronounced for bereavement (42.9% of women, 22.4% of men), drug or alcohol problems (30.4% of women, 38.8% of men), and involvement with the criminal justice system (10.7% of women, 23.8% of men).
Over a fifth (20.2%, 41 suicides) of people who died by suicide were known to have been involved with the criminal justice system (this includes a history of prison, remand, arrest or chargeable offences). 9.9% of suicides were in contact with the criminal justice system at the time of their death.
There was evidence of either a history or current emotional, sexual, physical, or other type of abuse in 14.3% (29 suicides) of people who died by suicide. Of these, the largest proportion was physical abuse (6.9%, 14 suicides), followed by sexual abuse (5.9%, 12 suicides), and emotional abuse (5.4%, 11 suicides) abuse. Some people experienced more than one type of abuse.
Files were checked to determine whether people who died by suicide were working for, or had a history of working for, the armed forces. This was not routinely recorded, and the numbers are too small to report.
Almost two fifths (39.4%, 80 suicides) of people who died by suicide had a record of a previous suicide attempt. 53.6% (30 suicides) for women and 34% (50 suicides) for men. Of these, close to half (48.8%, 39 suicides) had evidence of attempting suicide more than once (53.3%, 16 suicides, for women, 46%, 23 suicides, for men). Over one fifth (20.2%, 41 suicides) of people who died by suicide had a history of self-harm recorded; 37.5% (21 suicides) for women and 13.6% (20 suicides) for men. Of those who self-harmed, over half (56.1%, 23 suicides) had reportedly done so on more than one occasion.
12 suicides have cited effects of the COVID-19 pandemic, such as self-isolating and furlough as a risk factor. Due to the considerable delay in coroners inquests attributed to the COVID-19 pandemic, we are unlikely to get an indication of the effect of the pandemic in this audit.
Conclusion and Recommendations
Each of the 203 deaths included within this audit represents a personal tragedy with potentially devastating effects on families, friends, colleagues, first responders, staff, the wider community and beyond. It should be noted that, statistically speaking, these are small numbers. Because of this there is a danger in drawing too many, or too definitive, conclusions on the basis of this data alone. In isolation this audit is, at best, indicative. As such the audit is intended to inform continued action on suicide prevention and, alongside the use of ONS data, data from agencies such as Police, services and other agencies, is one source of information which should be taken into account by agencies working to reduce and prevent suicide. This audit is the second using three years of data since the development in 2017 of a new methodology designed to be robust, repeatable, and as objective as possible. This new methodology has resulted in data which is directly comparable and consistent allowing trends to be identified. Data relating to suicides where the inquest was concluded in 2019, 2020 and 2021 have been collected using this methodology and included in this report. Continuing to apply this more rigorous process to future years’ data will allow further trends to be identified and more meaningful conclusions to be reached that will inform the work of the Hertfordshire suicide prevention programme.
Appendix 1: Data collection template
Appendix 2: Forensic toxicology groupings
References
- OHID Fingertips, Suicide Prevention Profile: https://fingertips.phe.org.uk/search/suicide#page/4/gid/1/pat/6/ati/402/are/E10000015/iid/41001/age/285/sex/4/cat/-1/ctp/-1/yrr/3/cid/4/tbm/1
- Suicides in England and Wales: 2020 registrations https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/suicidesintheunitedkingdom/2020registrations
- Hertfordshire Suicide Prevention Strategy 2020-2025: https://www.suicidepreventionherts.org.uk/media/hertfordshire-suicide-prevention-strategy-2020-25-final.pdf
- Cerel, J. et al. (2018). How Many People are Exposed to Suicide? Not Six. Suicide and Life-Threatening Behaviour https://onlinelibrary.wiley.com/doi/full/10.1111/sltb.12450
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