Sudden Unexplained Death by Psychiatric In-patients

What is sudden unexplained death (SUD)?

  • There is no standard definition of SUD. However, it is commonly defined as a death in which a person dies:

o   within 1 hour of symptom onset

o   from an unknown or uncertain cause

o   from a cardiac arrhythmia if there is no identified underlying cause (e.g. myocardial infarction)1 


How often does SUD occur?

  • In England there are approximately 37 per year in England and Wales; 2 the rate is 2.33 per 10,000 mental health admissions (England, 1999-2005)1

What are the characteristics of individuals who die suddenly and unexpectedly?

  • SUD is more common in older patients and males; 25% are under 45 years of age1,2
  • 11% are from an ethnic minority and this does not appear to be changing over time2
  • Factors associated with SUD include:

o    physical illness is associated with an increased risk of SUD (i.e. cardiovascular disease, respiratory disease, cerebrovascular disease, epilepsy)1

o    individual and classes of drugs psychotropic drugs (i.e. clozapine, promazine, benzodiazepines)1

o    polypharmacy (i.e. the concurrent exposure of 2 or more antipsychotic drugs); however the number of patients who receive multiple antipsychotics appears to be low1, 2


What is the role of restraint?

  • Data is collected on all post-restraint deaths, irrespective of whether the patient met the criteria for SUD. Approximately 5% of in-patient deaths followed the use of restraint; some of these were also SUD. Less than 5 post-restraint deaths were among individuals from an ethnic minority background 2
  • We do not know whether the use of restraint caused these deaths 1, 2

Lessons for prevention?

  • Good physical health care for mental health in-patients; including good management of cardiac arrest or other collapse (i.e. appropriately trained staff; equipment on site)1
  • Careful prescribing of psychotropic drugs, particularly polypharmacy1


1. Windfuhr K, Turnbull P, While D, Swinson N, Mehta H, Hadfield K, Hiroeh U, Watkinson H, Dixon C, Flynn S, Thomas S, Lewis G, Ferrier IN, Amos T, Skapinakis P, Shaw J, Kapur N, Appleby L (2010) The incidence and associated risk factors for sudden unexplained death in psychiatric in-patients in England and Wales. Journal of Psychopharmacology, doi: 10.1177/0269881110379288 Pubmed id:20952453

2. National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. Annual Report 2011(