IntroductionFollow-up studies of spinal cord injury patients show a fourfold increase in the suicide rate. ! To examine this risk further we studied a consecutive series of 366 traumatic spinal cord injured patients from the time of their discharge from a spinal injuries unit, for a period of up to 8 years (mean 3.5 years). Attempted suicide had been the cause of the spinal injury in 11 patients (3%).The number of observed deaths was compared with the number expected. Expected deaths for all causes, suicide (E950 -959), and undetermined death (E980-989) (death from injury undetermined as accidentally or purposely inflicted) were calculated using cause specific death rates by sex for five-year age-groups and one-year calendar periods, for England and Wales, by the person-years method. 2 Statistical significance was assessed using the Poisson distribution.Thirteen deaths occurred after discharge, which was not significantly more than the 8.6 expected (SMR 151, 95% CI 81-259). We report the two violent deaths, one suicide and one undetermined death, which together exceeded the expected of 0.25. We also report the death from bronchitis of a woman who became tetraplegic after a suicide attempt. These three histories show how long-standing mental disorder and substance abuse prior to injury, which persisted post injury, contributed to their deaths. Case report 1A 57 year old married man sustained an incomplete paraplegia at Ll after deliberately jumping from the first floor window of his house trying to commit suicide. A few hours earlier he had electrocuted himself by holding a live cable and burning his hands. In hospital the psychiatrist diagnosed an endogenous

Where patients are living Living with relatives after discharge 79 Living independently after discharge 14 Living long term in residential care after 0 discharge Required interim residential care on discharge 9 Transferred to other hospital 9 Some patients appear in more than one category.