A Case Series Analysis of a Cluster of 25 Sudden Service User Deaths; Summary Data and Profiling of the Grouping of Risk Factors in Patients.

Abstract

Introduction

25 suspected cases of suicide occurred in a 20 month period. A literature review revealed some differences in this sample that merited further study.

Objectives

To summarise the demographics, risk factors and service contact history of a suicide cluster and identify specific risk profiles and to compare these findings with international data.

Aims

To produce a data set that informs suicide intervention and suicide prevention.

Methods

A case notes review of patients’ charts was carried out. Other variables were chosen because of their importance in the existing suicide literature. Recommendations from the UK National Confidential Inquiry (NCI) were also used to assess the data. Clinical perception of risk was also recorded.

Results

In grouping risk factors together 3 profiles emerged. A chaotic pattern, a masking pattern and a recovered group whose response to relapse was increased suicidality.

Conclusions

This cluster have similarities and differences from the risk profile for patient suicides described in the existing literature. There was a large amount of substance misuse. Risk recognition for immediate risk of suicide was just as challenging in this group as in much larger studies. Questions regarding service provision and hypotheses about cluster occurrence are also discussed.