Norfolk Suicide Audit 2024
Call Samaritans for free on 116 123, email them at jo@samaritans.org, or visit www.samaritans.org
Or visit Norfolk County Council’s Suicide Prevention webpage for more ideas of where you can get support.
Key findings
Suicides in Norfolk are largely consistent with national data regarding rates, cohorts and personal risk factors.
After a large increase in the early 2010s, suicide rates in Norfolk have reduced in the mid- to late 2010’s. In the 2021-2023 time period they were similar to the average values for England, where rates have increased in the last five to seven years.
Unlike similar counties, Norfolk has not seen a rise in suicide rates in the last eight years.
Norwich has consistently had the highest or second highest suicide rates among the Norfolk lower tier local authority areas.
Around three in four individuals who die by suicide are men.
The risk of suicide is highest in men in their 40s and over the age of 80.
Living in a relatively more deprived area is a key risk factor, as is living alone.
There was also some evidence that suicide rates in Norfolk were higher among those born in European Union (EU) countries.
Most suicides occur at home and by hanging.
Risk factors for suicide are diverse and often act in combination. Eighty percent of the individuals whose inquest files were reviewed had one or several diagnosed mental health conditions, most commonly depression or anxiety.
The most common predictor of suicides is previous self-harm including suicide attempts. For a minority of suicides, there had been prior attempts that were not known to support services.
Common issues experienced by those taking their own lives in Norfolk:
Poor physical health
Economic difficulties such as unemployment or employment in routine or semi-routine occupations
Living alone and/or feeling lonely
Substance misuse
Adverse experiences such as domestic abuse in childhood or by an intimate partner
Relationship breakdown
Contact with the Criminal Justice System
The national suicide prevention strategy further highlights neurodiversity and autism, pregnancy and maternity, gambling problems, and bereavement by suicide as important risk factors.
The majority of people had a primary care contact in the last year of their life, but many did not discuss mental health issues with their GP.
Around half had been seen in a hospital in the year before their death, and fewer than half had been in contact with mental health services in the year before their death.
Many of those who died by suicide had been prescribed one or more psychoactive substances, most commonly antidepressants.
People with a diagnosed severe mental illness had the most contacts with primary care as well as mental health services, more commonly had a psychiatric inpatient history, and had more psychoactive substances prescribed than those with any other or no mental health diagnosis.
Some people who died by suicide had recent contact with mental health services. A considerable proportion of people had no previous contact.
Financial hardship was a direct impact of Covid-19 for some, and for many has been compounded by the cost of living crisis. For around one in eight suicides that took place since the start of the pandemic, Covid-19 was specifically mentioned as part of risk factors around isolation and anxiety, and limiting access to services. There is no evidence that suicides have increased during the pandemic.
1 Introduction and definition
Suicide is a leading cause of years of life lost and has devastating impacts on families and communities. On average, around 135 people are exposed to each individual suicide (Cerel, et al., 2019)1, with strong effects on those close to the deceased (Pitman, Osborn, King, & Erlangsen, 2014)2. Complex histories of risk factors and distressing events lead to suicide, but significant social and gender inequalities in suicide risk persist. In September 2023, the Sunak Conservative government published it’s 5-year suicide prevention strategy for England. This local suicide audit has been undertaken to inform the suicide prevention plan for Norfolk which aims to reduce the number of suicides and tackle those inequalities.
The Office for National Statistics (ONS) defines suicide as “death from intentional self-harm in individuals aged 10 years and over”, or “death by injury of undetermined intent in people aged 15 years and over” (ONS, 2023)3. The former group includes deaths where a coroner has given a suicide conclusion or made it clear in the narrative conclusion that the deceased intended to take their own life (ICD10 codes X60-X84). The latter group includes deaths for which the coroner has given an open conclusion (ICD10 codes Y10-Y34). Official statistics by the ONS are based on the year in which a death was registered rather than on when the death occurred.
The standard of proof used by coroners to determine suicides was changed in 2018 from a criminal (beyond reasonable doubt) to a civil standard (more likely than not). There is no evidence that this has changed reported suicide rates (Office for National Statistics, 2020)4. Research pre-dating the change showed that the likelihood of a suicide conclusion varies between coroners in England, and deaths with certain characteristics, for example deaths by poisoning, were less likely to receive a suicide conclusion5. A study in Israel came to similar conclusions about the relationship between types of deaths and suicide conclusions6. To our knowledge, it is unknown how the relationship between death circumstances and coroner conclusions has changed following the adjustment to the standard of proof in the UK. However, official suicide statistics in the UK have long been including deaths of undetermined intent, so there are arguably fewer ‘hidden’ suicides in the UK than in other countries with different coding practices7.
2 Audit Methods
This document is an audit of 961 suicides in Norfolk registered in 2014 to 2023. The data was accessed through the Civil Registrations of Death (CRD) database. 904 of these were suicides by people with a registered address in Norfolk. Following official suicide statistics, numbers here are based on the year of registration rather than year of death. As it currently stands, there is a time delay from death to registration which has grown as a consequence of disruptions to the coronial process caused by the Covid-19 pandemic. The median registration delay for Norfolk has been similar to the England average in recent years. Nevertheless, it is important to bear in mind the impact such time delays have on official suicide statistics. Depending on whether the delay increases further or decreases in the future, changes in delays will contribute to potential changes in suicide rates reported for Norfolk.
The audit further included an in-depth review of coroner’s inquest files (Coroner Inquest Files) for 202 suicides that occurred between 2019 and 2023. Inquests are carried out by the coroner’s office and are a comprehensive investigation of deaths that are suspected suicides as identified by the coroner’s office (https://www.cps.gov.uk/legal-guidance/coroners). Because coronial jurisdiction follows county rather than Integrated Care System boundaries, data for the Waveney area is not included in this audit but is instead included in the suicide audit for Suffolk. Data was entered by two different Public Health analysts into a spreadsheet-based database which was comprised of a mixture of quantitative as well as qualitative (free-text) fields.
To identify risk factors in Norfolk, information was obtained on widely available key characteristics based on residential location as well as occupation. This was then combined with more detailed information available for a subset of suicides included in Coroner Inquest Files. Witness statements by relatives, friends, colleagues and first responders gave insight into the lives as well as the circumstances surrounding the death of people who died by suicide. The files also included reports from primary care and mental health services that detailed their interactions with the individuals who took their own lives. In some circumstances little information was available, such that some risk factors are based on limited information.
Some individual characteristics which are known to be associated with suicide risk are not systematically and/or reliably collected in the context of an inquest. Among those are ethnicity, gender identity, sexual orientation, and (undiagnosed) neurodiversity. There are important caveats associated with relying on Coroner Inquest Files, with national research suggesting a focus on explanations made after the event8, and on medical explanations with less attention given to social aspects9. Information recorded in Coroner Inquest Files may also highlight a subset of known risk factors. We selected a pre-defined list of 33 potential individual risk factors based on the suicide literature and previous suicide audits. We later grouped individual risk factors for further analyses. We assessed the presence or absence of these risk factors based on all available documentation. Further, we used a free-text field for recording any additional relevant risk factors, such as effects of the Covid-19 pandemic. Where a particular risk factor was not mentioned we assumed it was unlikely to have been present. This may have led to underestimations regarding the prevalence of some risk factors among suicides in Norfolk. Nevertheless, locally, the Coroner Inquest Files represent the best available source of information and a valuable opportunity for identifying factors thought to have contributed to individuals taking their own life.
Throughout this audit, where numbers or crude rates are shown, small numbers (1-7) have been suppressed (indicated by *) and all other numbers have been rounded to the nearest five when they are based on the Civil Registrations of Death database, in accordance with NHS Digital statistical disclosure control rules. Numbers based on Coroner Inquest Files are suppressed if they are smaller than five (1-4) and there was a statistical disclosure risk. Unless otherwise specified, error bars in figures represent 95% confidence intervals.
3 General overview
3.1 Suicide rates in Norfolk
The suicide rate in Norfolk was significantly higher than national and regional rates from 2013-2016. More recently, it has not been significantly higher than the suicide rate in England, for which there has been an increasing trend over the last 15 years. The Norfolk suicide rate was higher than the East of England regional average in the most recent period 2021-2023 (Figure 1), though not statistically significantly so.
Local and national suicide rates
Compared to CIPFA (Chartered Institute of Public Finance and Accountancy) statistical ‘nearest’ neighbours, other local authorities with demographic and economic characteristics similar to Norfolk, the suicide rate in the most recent time period in Norfolk was lower than in eight of the twelve most similar counties. Lancashire, Lincolnshire and Worcestershire had the highest rates. Unlike most of its statistical neighbours, Norfolk has not seen a rise in suicide rates in the last five years (Figure 2).
Suicide rates in Norfolk and similar counties
3.2 Male suicides
More men than women take their own lives in most countries including the UK10. In Norfolk, around three in four individuals who die by suicide are male. The highest suicide rates are seen in middle-aged and very old men (Figure 3 & Table 1). Women in their 40s and 50s have the highest suicide rate for their sex.
Age- and sex-specific suicide rates in Norfolk
Age group | Male Suicides 2014-2023 | Male Suicide rate | Female Suicides 2014-2023 | Female Suicide rate |
|---|---|---|---|---|
10-14 | 0 | 0 [0-1.6] | * | * |
15-19 | 20 | 8.3 [5.4-12.8] | 10 | 4.3 [2.4-8] |
20-24 | 35 | 13.2 [9.5-18.3] | 10 | 3.9 [2.1-7.1] |
25-29 | 60 | 22.7 [17.7-29.3] | * | * |
30-34 | 55 | 21.3 [16.4-27.7] | 10 | 3.9 [2.1-7.1] |
35-39 | 55 | 22.3 [17.1-29] | 15 | 6 [3.6-9.9] |
40-44 | 60 | 24.5 [19.1-31.6] | 10 | 4 [2.2-7.4] |
45-49 | 75 | 26.4 [21-33] | 25 | 8.5 [5.8-12.6] |
50-54 | 70 | 22.8 [18-28.8] | 30 | 9.5 [6.6-13.5] |
55-59 | 70 | 23.5 [18.6-29.7] | 20 | 6.4 [4.2-9.9] |
60-64 | 45 | 16.4 [12.3-21.9] | 20 | 6.8 [4.4-10.4] |
65-69 | 40 | 14.1 [10.3-19.2] | 10 | 3.3 [1.8-6] |
70-74 | 40 | 14.4 [10.6-19.6] | 15 | 5.1 [3.1-8.4] |
75-79 | 15 | 7.5 [4.6-12.4] | 10 | 4.6 [2.5-8.5] |
80-84 | 30 | 21.7 [15.2-30.9] | * | * |
85-89 | 25 | 32.1 [21.7-47.4] | * | * |
90+ | 15 | 42.5 [25.7-70.1] | * | * |
3.3 Age group trends
There have not been any significant changes in the suicide rates in Norfolk by age category in 2019-2023 compared to 2014-2018 (Figure 4). There has been a very minor increase in those aged under 25, and minor decreases in suicide rates in the three broad age groups over 35. Nevertheless, suicide rates are still the highest for individuals aged 35-64.
Change in age-specific suicide rates in Norfolk
3.4 Norfolk lower tier local authority areas
It is worth noting that there is statistical uncertainty in suicide rates at the geographical level of local authority areas (large confidence intervals in Figure 5). Since the early 2000s, Norwich has consistently had one of the highest suicide rates of residents among Norfolk lower tier local authorities. The suicide rates of other lower tier local authority areas vary substantially between time periods. However, North Norfolk has seen a sustained rise from 2010 to 2021, starting from a very low rate in 2010. In the most recent period with available data (2021-2023), Norwich and Great Yarmouth tended to have a higher suicide rate than other areas of Norfolk (Figure 5).
Lower Tier Local Authority suicide rates
3.5 Method and location of suicides
Hanging/suffocation was by far the most common suicide method overall, accounting for more than half (56%) of all suicides in Norfolk, as has been the case nationally in the last 20 years. Poisoning (20%), predominantly through medication overdoses, and drowning (6%) were the next most common methods. Although hanging/suffocation and poisoning were the most common methods in both sexes, there were some differences between men and women in the relative prevalence of suicide methods (Table 2).
Method | Male | Female | Total |
|---|---|---|---|
Hanging/Suffocation | 60% | 43% | 56% |
Poisoning | 17% | 33% | 20% |
Drowning | 5% | 10% | 6% |
Cutting/Stabbing | 5% | * | 4% |
Other | 4% | * | 4% |
Shooting | 5% | * | 4% |
Train collision | 3% | * | 3% |
Burning | 1% | * | 2% |
Jumping from height | * | * | 1% |
Not known | * | 0% | * |
Road vehicle collision | * | 0% | * |
Most notably, a third of women who took their own lives did so by poisoning, compared with fewer than one fifth of men (Figure 6). Drowning was also relatively more common in women (10%) than in men (5%). However, compared to hanging/suffocation and poisoning, drowning remains a relatively rare suicide method.
Suicide methods in Norfolk
For almost half of all individuals who died by poisoning, and for whom there was detailed information available through Coroner Inquest Files, the cause of death involved medication prescribed to them (Figure 7). Over-the-counter drugs or industrial products were the cause of death in one third of poisoning deaths. Illicit drugs were the cause of death in fewer than 10% of poisoning deaths. Of the files reviewed, there was a very small number of incidents where the individual had used medication prescribed to someone else to take their own life.
Poisoning suicides in Norfolk
Suicide by self-poisoning was not associated with being known to drug and alcohol services. For most individuals (90%) who died by self-poisoning suicide there was no known contact with the substance misuse service Change Grow Live (CGL). And out of 18 individuals who were known to CGL, only five died by self-poisoning suicide.
There was an association between being known to CGL and toxicology indicating drug and alcohol use near the time of death. Fourteen out of 18 (78%) of the individuals known to CGL had alcohol and/or non-prescribed drugs present in their body at the time of death, compared to 38% of people who were not known to CGL.
Three in five (59%) suicides in Norfolk occurred at home (Figure 8 & Table 3). The remaining suicides took place in locations such as woodlands and other outside areas (12%), institutions and residential homes (6%; e.g., prisons), roads (5%), bodies of water (4%), commercial buildings (3%; e.g., car parks), railway lines or stations (3%) and hotels (2%). For 7% of suicides the location was unknown, most likely because the person died in hospital after attempting suicide elsewhere. Suicide location was more often unknown for women, likely because poisoning is more common for women, and individuals who die by poisoning are more likely to die in hospital than those dying from other suicide methods.
Suicide locations in Norfolk
Location | Male | Female | Total |
|---|---|---|---|
Private residence | 57% | 62% | 59% |
Woodland and other outside areas | 13% | 7% | 12% |
Unknown | 6% | 12% | 7% |
Institution/Residential home | 6% | 5% | 6% |
Road | 5% | * | 5% |
River/lake | 3% | 5% | 4% |
Industrial/Commercial | 3% | * | 3% |
Railway line/station | 3% | * | 3% |
Hotel | 2% | * | 2% |
Other public inside area | * | 0% | * |
4 Suicide risk factors
While there are often many different and complex circumstances that lead to someone taking their own life, studies of suicides across large populations have shown that a range of characteristics are associated with elevated suicide risk11. More broadly, there are certain characteristics measured at a population level that are associated with rates of suicides as well as drug and alcohol related deaths, giving insight into risk factors. Such associations between factors such as living alone, unemployment and elementary occupations with deaths of despair — suicides and drug and alcohol related deaths — have been identified in a recent study.
Therefore, although all individuals’ circumstances are unique, identifying common risk factors can aid the development of targeted intervention measures. Outlined below are identified risk factors for Norfolk residents based on the data analysed for this suicide audit, as well as risk factors identified as priorities in national and local suicide prevention strategies.
Negative life events can have a strong impact on wellbeing and suicidal thoughts and actions. An alternative approach to considering risk factors is thinking about the absence of protective factors for wellbeing. Suicide may often arise from an absence of protective factors such as good quality relationships and support networks, access to work and meaningful employment, secure and comfortable housing, and good physical health or effective pain management.