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Homicide followed by suicide: a

cross-sectional study
a a a
Sandra Flynn , Nicola Swinson , David While ,
a a a
Isabelle M. Hunt , Alison Roscoe , Cathryn Rodway
a a
, Kirsten Windfuhr , Navneet Kapur , Louis Appleby
a a
& Jenny Shaw
a
Centre for Suicide Prevention, University of
Manchester, UK

Available online: 30 Mar 2009

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Roscoe, Cathryn Rodway, Kirsten Windfuhr, Navneet Kapur, Louis Appleby & Jenny
Shaw (2009): Homicide followed by suicide: a cross-sectional study, Journal of Forensic
Psychiatry & Psychology, 20:2, 306-321

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 The Journal of Forensic Psychiatry & Psychology
Vol. 20, No. 2, April 2009, 306–321

Homicide followed by suicide: a cross-sectional study

Sandra Flynn*, Nicola Swinson, David While, Isabelle M. Hunt,
Alison Roscoe, Cathryn Rodway, Kirsten Windfuhr, Navneet Kapur,
Louis Appleby and Jenny Shaw

Centre for Suicide Prevention, University of Manchester, UK

(Received 14 March 2008; final version received 21 July 2008)

Background: Approximately 30 incidents of homicide followed by

suicide occur in England and Wales each year. Previous studies have
not examined mental health characteristics in any detail. Aims: This
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study aims to identify the social, clinical, and criminological

characteristics of a national sample of perpetrators, to identify any
previous contact with mental health services and to establish risk of
suicide after homicide. Method: A national cross-sectional study of
perpetrators in England and Wales 1996–2005. Results: 203 incidents
were recorded over 9 years. The median age of perpetrators was 41
years (range 18–88 years); most were male. Men more often killed a
spouse/partner, whilst women more commonly killed their children.
Eighty-four (42%) perpetrators died by suicide on the day of the
homicide. The most common method of homicide was sharp
instrument (44, 23%). Fifty-nine (29%) used hanging as a method of
suicide. Twenty (10%) had previous contact with mental health
services, 14 were seen within a year of the offence. The most common
diagnoses were personality disorder and affective disorder. The risk of
suicide increased the closer the relationship between the perpetrator
and the victim. Conclusions: Significantly fewer perpetrators of
homicide-suicide compared with homicide or suicide only were in
contact with mental health services. Prevention is discussed and
suggestions made for the use of psychological autopsy methodology to
study rates of mental disorder.
Keywords: homicide; suicide; mental illness; risk; psychiatry

Introduction
Homicide followed by suicide refers to an incident where an individual kills
someone and subsequently takes his or her own life (Marzuk, Tardiff, &
Hirsch, 1992). This is a rare event with a rate of 0.06 per 100,000 population

*Corresponding author. Email: sandra.m.flynn@manchester.ac.uk

ISSN 1478-9949 print/ISSN 1478-9957 online

Ó 2009 Taylor & Francis
DOI: 10.1080/14789940802364369
http://www.informaworld.com
 The Journal of Forensic Psychiatry & Psychology 307
in England and Wales, equating to 29 perpetrators per year (Barraclough
& Harris, 2002). As a proportion of the overall homicide rate, the
numbers are small and these rates are similar world-wide; ranging between
0.08 per 100,000 population in New Zealand (Moskowitz, Simpson,
McKenna, Skipworth, & Barry-Walsh, 2006) to 0.55 reported in Miami
(Milroy, 1995).
Previous studies in England and Wales (Barraclough & Harris, 2002)
have provided good descriptive information on perpetrator characteristics
but little insight into the mental health factors associated with these crimes
on a national scale. A large case series conducted by West (1965) provided
clinical data, and was the first study to describe the role of mental illness in
homicide followed by suicide cases. However, the diagnostic criteria used are
now outdated and not comparable with ICD-10 classification. More
recently, research undertaken outside the UK demonstrates a surprising
variation in the rate of mental disorder ranging between 18% and 91%
(Bourget & Gagne, 2002; Milroy et al., 1997), which exemplifies the difficulty
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in determining a diagnosis of mental illness post mortem and underlines the

diverse methodologies used to examine these incidents. As stated by
Moskowitz et al. (2006), a systematic analysis of mental illness would
provide a valuable addition to our understanding of these events.
This paper describes data from a 9-year study of all homicides followed
by suicide in England and Wales, using a unique national database of
homicides and collated by the National Confidential Inquiry into Suicide
and Homicide by People with Mental Illness (Appleby et al., 2006). The
aims of this study were to:

. describe the social, criminological, and clinical characteristics of

perpetrators of homicide followed by suicide;
. determine the extent of contact with mental health services before the
incident;
. examine the risk of suicide following homicide.

Method
Cases of homicide followed by suicide in England and Wales occurring
between April 1996 and March 2005 were identified. We determined three
groups of perpetrator, those who committed suicide immediately following
homicide (immediate group), those who committed suicide more than 3 days
after the homicide but before conviction (delayed group), and those who
committed suicide after conviction. The 3-day cut-off has been used
previously by Barraclough and Harris (2002), the rationale being that the
mental state at the time of the homicide and suicide are more likely to be the
same if the events occurred within a short period.
 308 S. Flynn et al.
There were three stages to data collection. The Home Office via the
Homicide Index notified the Inquiry of all perpetrators suspected of
homicide (murder, manslaughter, or infanticide). Cases recorded as
homicide followed by suicide were extracted. To verify the data set and
ensure all cases were captured, we were also notified of cases directly from
individual police forces. Both data sources provided demographic informa-
tion on the perpetrator and victims and details about the offence. In
addition, records of previous convictions were obtained from the Police
National Computer. The cases of homicide followed by suicide identified by
the Homicide Index and police were crosschecked with data on suicides and
open verdicts provided by the Office for National Statistics (ONS). Cases
that were neither recorded as suicide or open verdicts by ONS were excluded
from further analysis. For example, we excluded cases originally recorded as
homicide followed by suicide by the Homicide Index or police when the
cause of death was subsequently ruled ‘undetermined’ at Coroners Inquest.
Details on each case were submitted to NHS Trusts in each individual’s
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district of residence and adjacent districts, to identify if the perpetrator had a

history of mental health service contact at any time before the offence. Questi-
onnaires were sent to the supervising clinician responsible for the patients’ care
(usually a Consultant Psychiatrist) to complete in conjunction with other mem-
bers of the mental health team. The questionnaire consisted of sections covering
demographic characteristics, clinical history, details of final contact with
services, events leading to the suicide, and respondents’ views on prevention.

Statistical analysis
The main findings are presented as proportions with 95% confidence inter-
vals (CI). For comparative analyses results are reported using the Pearson’s
chi-square and two-sample t-test with significance levels set at 5%. Where
numbers in cells were below 5, Fisher’s exact test was used. A multivariate
model was also fitted for predictive purposes to identify risk of suicide
following homicide. The final regression model included only those variables
that were independently significant at the 5% level. Stata 8.0 software (Stata
Corporation, 2003) was used to calculate odds ratios (OR), 95% confidence
intervals, and associated p-values. Forward stepwise logistic regression was
selected as the analytical model. Univariate analyses were first performed to
assess the association between individual factors and risk of suicide, with a
multivariate model then fitted to identify independent predictors of homicide
followed by suicide. The final regression model included only those variables
that were independently significant at the 5% level.
In addition, the suicide-only cases are compared with the homicide-suicide
cases. A well-known property when applying the chi-squared test is that small
differences between two groups become increasingly more significant as the
sample size increases. Hence, to make further comparisons, the population of
 The Journal of Forensic Psychiatry & Psychology 309
suicide-only cases (dates of death April 1, 1996–March 31, 2005) have been
factored down to create a sample of equivalent size to the homicide-suicide
cases. This pseudo sample retains the features of the suicide-only population.
Chi-squared tests of association have therefore been provided using both the
suicide-only population and factored down pseudo-sample.

Ethical approval
The National Confidential Inquiry into Suicide and Homicide by People
with Mental Illness received MREC approval on October 1, 1996, and is
registered under the Data Protection Act. The Inquiry also obtained
exemption under Section 60 of the Health and Social Care Act 2001,
enabling access to confidential and identifiable information without
informed consent in the interest of improving patient care.
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Results
The National Confidential Inquiry into Suicide and Homicide by People
with Mental Illness was notified of 300 cases of homicide followed by suicide
during the study period. In 48 cases, the perpetrators’ cause of death was not
confirmed as a suicide or open verdict by a coroner. These cases were
excluded. Furthermore, 49 perpetrators died by suicide after being convicted
of homicide. These perpetrators were also excluded from the analysis. The
sample used in this study was based on the remaining 203 perpetrators
(Figure 1), a rate of 0.05 per 100,000 population.
Most perpetrators of homicide followed by suicide were male (175 cases,
86%; Table 1). In 39 cases (19%), more than one victim was killed. In 129
(65%) cases, the victims were current or former spouse/partners, 37 (19%)
were the perpetrators child, and 14 (7%) were other family members. The
few perpetrators who killed strangers (4, 2%) were all young men aged
under 35 years old (Figure 2). The highest number of victims in one incident
was five. Men were more likely to kill women, usually a current or former

Figure 1. Homicide followed by suicide sample.

 Downloaded by [ ] at 02:46 25 January 2012

310

Table 1. Characteristics of homicide followed by suicide perpetrators and victims{.

Male perpetrator Female perpetrator Total

Number Number Number
(175) % (95% CI) (28) % (95% CI) (203) % (95% CI) p-value
S. Flynn et al.

Demographic features:
Age of perpetrator: median 44 (18–88) 35 (23–78) 41 (18–88) 0.07
(range)
Ethnic minority 18 11 6–16 6 23 9–44 24 12 8–18 0.07
Victim details:
Age of victim: median (range) 37 (0–89) 7 (0–84) 22–61 36 (0–89) 50.01
Female victim 144 82 76–88 11 41 22–59 155 77 70–82 50.01
Two or more victims 28 16 11–22 11 39 39 19 14–25 50.01
Victim relationship to
perpetrator:
Son/daughter/stepchild 18 10 6–16 19 68 48–84 37 19 13–25 50.01
Spouse/partner/ex-partner 124 72 65–79 5 18 6–37 129 65 57–71 50.01
Other family member 13 8 4–13 1 4 0–18 14 7 4–11 0.39
Acquaintance 12 7 4–12 3 11 2–28 15 8 4–12 0.35
Stranger 4 2 0–6 0 0 0 4 2 0–5 0.54
Method of homicide:
Sharp instrument 43 26 19–33 1 4 0–18 44 23 17–29 50.01
Strangulation 40 24 18–31 1 4 0–18 41 21 16–28 0.01
Firearms 30 18 13–25 1 4 0–18 31 16 11–22 0.04

{The denominator in all cases is the number of valid cases in each item, all proportions are therefore valid percents.
 The Journal of Forensic Psychiatry & Psychology 311

Figure 2. Relationship between perpetrator and victim by age of perpetrator.

spouse/partner, whereas when women were the perpetrators, the victim was
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more often their own child. Women were significantly more likely to kill
more than one victim (11, 39% vs. 28, 16%; p 5 0.01). Perpetrators aged
25–34 years old more commonly killed their own child compared to
perpetrators in any other age group. Data on previous convictions were
available on cases from April 1996 to December 2002 (133, 66%). Of these,
less than a fifth of perpetrators had a history of previous offending. Of those
previously convicted, the most common offences were theft (14, 11%),
offences against the person (9, 7%), and offences against property (7, 5%).

Timing of suicide
Eighty-four (42%) suicides occurred on the same day as the homicide. One
hundred and fifty-two perpetrators (75%) died less than 3 days after of the
homicide (immediate group). Those in the immediate group were more likely
to be older and kill a female victim. Their victims were more likely to be a
current or former spouse/partner. In contrast, perpetrators who died by
suicide 3 days or more after the homicide (delayed group) were more likely
to have killed an acquaintance than those in the immediate group. Suicide
by hanging was significantly more likely in the delayed group (Table 2).

Method of homicide followed by suicide

The most common methods of homicide were sharp instrument, strangula-
tion, and firearms (Table 3). The most common methods of suicide were
hanging (59, 29%), firearm (32, 16%), jumping/multiple injuries (27, 13%),
carbon monoxide poisoning (21, 10%), and cutting or stabbing (20, 10%)
(Table 4). Ninety-nine (49%) perpetrators killed themselves using the same
method that was used in the homicide. Of the 31 perpetrators who used a
 312 S. Flynn et al.
Table 2. Characteristics of perpetrators with immediate compared to delayed
suicide{.

Immediate suicide Delayed suicide

Number (95% Number (95%
(152) % CI) (51) % CI) p-value
Demographic features:
Age of perpetrator: 43 (20–88) 37 (18–81) 0.01
median (range)
Male perpetrator 134 88 82–93 41 80 69–90 0.16
Ethnic minority 17 12 7–18 7 14 6–27 0.67
Victim details:
Female victim 121 80 73–86 34 67 52–80 0.05
Two or more victims 33 22 15–29 6 12 4–24 0.12
Victim relationship to
perpetrator:
Son/daughter/stepchild 29 19 13–26 8 16 7–30 0.65
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Spouse/partner/ 106 70 62–77 23 47 33–62 50.01

ex-partner
Other family member 8 5 2–10 6 12 5–25 0.10
Acquaintance 7 5 2–9 8 16 7–30 50.01
Stranger 1 1 0–4 3 6 1–17 0.05
Method of homicide:
Sharp instrument 32 22 16–30 12 24 13–39 0.73
Strangulation 33 23 16–30 8 16 7–30 0.23
Firearms 27 19 13–26 4 8 2–20 0.06
Method of suicide:
Hanging 35 23 17–31 24 47 33–62 50.01
Firearms 29 19 13–26 3 6 1–16 0.02
Carbon monoxide 17 11 7–17 4 8 2–19 0.35
poisoning
Cutting and stabbing 14 9 5–15 6 12 4–24 0.60
{
The denominator in all cases is the number of valid cases in each item, all proportions are
therefore valid percents.

firearm in the homicide, 28 (90%) also shot themselves. Likewise in 12

(86%) out of the 14 cases where perpetrators used exhaust fumes to kill their
victims, they also died from carbon monoxide poisoning. Women were
significantly more likely to kill using exhaust fumes (7, 25% vs. 7, 4%;
p 5 0.01), poisoning (6, 21% vs. 4, 2%; p 5 0.01), or arson (4, 14% vs. 4,
2%; p 5 0.01). Men were more likely to use sharp instruments, strangula-
tion, or firearms to kill their victim.

Homicide only compared to homicide followed by suicide

There were 5096 people convicted of homicide over the 9-year study period.
In addition, 203 perpetrators died by suicide before standing trial.
 The Journal of Forensic Psychiatry & Psychology 313
Table 3. Comparison of homicide perpetrators and homicide followed by suicide
perpetrators.

Homicide-suicide Homicide
Number valid (95% Number valid (95% p-
(203) % CI) (5096) % CI) value
Demographic features:
Age of perpetrator: 41 28 50.01
median (range) (18–88) (9–99)
Female perpetrator 28 14 (9–19) 500 10 (9–11) 0.06
Ethnic minority 24 13 (8–18) 1088 22 (21–23) 50.01
Victim relationship
to perpetrator:
Spouse/partner/ 129 65 (57–71) 922 22 21–23 50.01
ex-partner
Son/daughter/ 37 19 (13–25) 303 7 (0–5) 50.01
stepchild
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Other family 14 7 (3–10) 306 6 (5–7) 0.06

member
Acquaintance 15 8 (4–12) 1586 38 (37–40) 50.01
Stranger 4 2 (0–5) 935 22 (21–24) 50.01
Offence details:
Female victim 155 77 (70–82) 1467 29 (27–30) 50.01
Two or more 39 19 (14–25) 163 3 (3–4) 50.01
victims
Method of homicide:
Sharp instrument 44 23 (17–29) 1850 38 (36–39) 50.01
Strangulation 41 21 (16–28) 354 7 (7–8) 50.01
Firearms 31 16 (11–22) 321 7 (6–7) 50.01
Contact within 14 7 (4–11) 484 10 (9–10) 0.21
12 months:
1
Primary
diagnosis from
services
(all cases):
Schizophrenia 2 15 (2–45) 130 28 (24–33) 0.30
Affective disorder 3 23 (5–54) 59 13 (10–16) 0.29
Personality 5 38 (14–68) 101 22 (18–26) 0.16
disorder
Anxiety/phobia/ 2 15 (3–40) 16 4 (2–5) 0.03
panic/OCD
1
The denominator in these variables is the number of cases in recent contact with services
(n ¼ 13), all proportions are valid percents.

The majority of perpetrators in the homicide and homicide-suicide groups

were male, however a higher proportion of women died by suicide (Table 3).
The homicide followed by suicide group were significantly older and less
likely to be from an ethnic minority group. They were more likely to kill a
current of former spouse/partner, or their son or daughter. Females were
 Downloaded by [ ] at 02:46 25 January 2012

Table 4. Characteristics of homicide followed by suicide cases compared to suicide-only cases.

314

Homicide-suicide Proportion suicide-only

perpetrators Total suicide-only cases cases
p-value p-value
N¼ (95% N¼ (95% N¼ (95% total proportion
203 % CI) 46,358 % CI) 203 % CI) suicides suicides
Demographic features
S. Flynn et al.

Age of perpetrator: 41 (18–88) 42 (10–102) 42 (10–102) 0.50 0.50

median (range)
Male perpetrator 175 86 81–91 34,616 75 74–75 152 75 68–81 50.01 50.01
Cause of death (suicide):
Hanging 59 29 23–36 16,588 36 36–37 73 36 29–43 0.03 0.14
Self-poisoning 14 7 4–11 12,237 27 26–27 55 27 21–34 50.01 50.01
Jump/multiple 27 13 9–19 4283 9 9–10 18 9 5–14 0.06 0.15
injuries
Drowning 4 2 1–5 2411 5 5–5 10 5 2–9 0.04 0.10
Firearms 32 16 11–22 1057 2 2–2 4 2 0–5 50.01 50.01
Cutting/stabbing 20 10 6–15 965 2 2–2 4 2 0–5 50.01 50.01
Burning 15 7 4–12 736 2 2–2 4 2 0–5 50.01 50.01
Carbon monoxide 21 10 7–15 4092 9 9–9 18 9 5–14 0.50 0.61
poisoning
Contact within 14 7 4–11 11892 26 25–26 53 26 20–33 50.01 50.01
12 months:
Primary
diagnosis from
services (recent
contact cases):
Schizophrenia 2 15 2–45 2282 19 19–20 39 19 14–25 0.72 50.01
Affective disorder 3 23 5–54 5296 45 44–46 91 45 38–52 0.11 50.01
Personality disorder 5 38 14–68 1087 9 9–10 18 9 5–14 50.01 50.01
1
The denominator in these variables is the number of cases in recent contact with services (n ¼ 13), all proportions are valid percents.
 The Journal of Forensic Psychiatry & Psychology 315
more likely to be the victims in homicide followed by suicide cases. The
method of homicide used was more likely to be strangulation or shooting
than in cases of homicide alone. Perpetrators of homicide followed by
suicide were more likely to have killed multiple victims.

Suicide only compared to homicide followed by suicide

The most common cause of death in both suicide only cases and homicide-
suicides cases was hanging (Table 4). In suicide only cases, people were
significantly more likely to die by self-poisoning, whereas those who committed
homicide prior to suicide were more likely to have died by using a firearm,
cutting/stabbing, or burning. Suicide only cases were more likely to have been
in contact with mental health services, and were more likely to have a severe
mental illness (schizophrenia or affective disorder), whereas perpetrators of
homicide followed by suicide were more likely to have personality disorder.
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Risk of suicide
The risk of suicide was calculated by using univariate and multivariate
analysis to compare homicide only to homicide followed by suicide cases.
Data from the multivariate model showed that perpetrators were
significantly more likely to die by suicide after killing their son or daughter,
current intimate partner, or ex-intimate partner (Table 5). There was
increased risk of suicide if the homicide method involved a firearm or was by
strangulation. Killing multiple victims had increased the risk of suicide
6-fold. Univariate analysis showed there was no increased risk associated
with killing an acquaintance or stranger or being from an ethnic minority
group. Furthermore, perpetrators aged over 55 years old were at higher risk
of suicide compared to all other age groups.

Typology of homicide followed by suicide

The most common type of homicide-suicides occurred between current or
former intimate partners (129, 65%). The majority were perpetrated by men
(96%). Where data on previous convictions were available (n ¼ 133), only
seven perpetrators who killed a current or former partner had a history of
violence. Filicide (the killing of a child by a parent) was also prominent (37,
19%), and in seven cases (4%) the perpetrator killed an elderly parent.
Figure 3 shows the circumstances of the homicide by the relationship to the
victim. The Homicide Index provides information on the circumstances of
each homicide and classified case into a number of categories. In 34 cases
(18%) the homicide occurred under circumstances of rage, 27 (14%)
jealousy or revenge, 17 (9%) irrational or motiveless acts, and mercy killing
in 17 cases (9%). The motive was unknown in 71 cases (37%).
 316 S. Flynn et al.
Table 5. Risk of suicide following homicide.

Univariate analysis Multivariate model

OR (95% CI) p-value OR (95% CI) p-value
Victim:
Female victim 8 6–11 50.01 2 2–4 50.01
Victim aged 75þ 3 2–5 50.01 4 2–8 50.01
Multiple victims 7 5–11 50.01 6 4–10 50.01
Perpetrator:
Ethnic minority 0.5 0–1 50.01 0.6 0–1 0.02
Perpetrator aged 25–54þ 2 1–2 50.01 3 2–6 50.01
Perpetrator aged 55þ 9 5–11 50.01 8 4–16 50.01
Relationship to perpetrator:
Son/daughter 4 2–5 50.01 13 8–22 50.01
Intimate partner 6 4–8 50.01 7 4–11 50.01
Ex-intimate partner 4 3–6 50.01 7 4–14 50.01
Acquaintance 0.2 10–30 50.01 – – –
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Stranger 0.09 3–24 50.01 – – –

Method:
Strangulation 3 3–5 50.01 2 1–3 50.01
Firearms 3 2–4 50.01 6 4–10 50.01

Figure 3. Relationship/type of homicide-suicide.

Perpetrators previously in contact with mental health services

Twenty (10%) perpetrators had been in contact with mental health services
within their lifetime, before the offence. The majority were male (15, 75%),
white (16, 80%), and the median age was 36 years. Fourteen (78%) killed a
family member or current or former spouse/partner, in one case the victim
was a stranger, and in three cases an acquaintance. The most common
primary diagnoses were affective disorder (5, 26%), personality disorder
(6, 32%), and anxiety disorders (3, 16%). Two (11%) perpetrators were
diagnosed with schizophrenia or other delusional disorders by services
(Figure 4). Eighteen patients had a secondary diagnosis, including three with
 The Journal of Forensic Psychiatry & Psychology 317

Figure 4. Primary diagnoses of homicide-suicide perpetrators in contact with

mental health services (n ¼ 20).

drug dependence, two with personality disorder, and two with alcohol
dependence. Nine (50%) had a mental disorder of over 5-years duration. Five
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patients had previously been admitted as an in-patient to a general psy-

chiatric hospital. Three were under enhanced levels of the Care Programme
Approach, and eight had a care co-ordinator allocated. Seven missed their
last appointment with services and four were non-compliant with medication
in the month before the homicide. Fourteen perpetrators (7%) had been in
contact with psychiatric services in the 12 months before the homicide
followed by suicide. Of those in recent contact, two were diagnosed with
schizophrenia or other delusional disorders, two anxiety disorders, three
affective disorder, and five with personality disorder (Tables 3 and 4). Three
cases had their last service contact a week prior to the deaths, five were seen
1–4 weeks before the offence. Clinicians felt that the incident could have been
prevented in only four cases.

Discussion
This is the first study in England and Wales to attempt to determine contact
with mental health services in a national survey of perpetrators of homicide
followed by suicide. The socio-demographic and offence characteristics of
perpetrators are consistent with previous studies. Men committed the
majority of homicides followed by suicide (Carcach & Grabosky, 1998;
Lecomte & Fornes, 1998), perpetrators were significantly older than their
victims (Marzuk et al., 1992), and significantly older than homicide-only
perpetrators. The victims of male perpetrators tended to be current or
former spouse/partners, whereas women were more likely to kill their own
children (Milroy et al., 1997). Perpetrators with multiple victims were also
more likely to take their own life compared to homicide only offenders. The
degree of positive attachment is considered an important factor in these
incidents. In this study, multivariate analysis showed that the risk of suicide
 318 S. Flynn et al.
increased if the victim and perpetrator had a close personal relationship,
perhaps confirming that the level of nurturing or responsibility toward the
victim increases the risk of suicide (Stack, 1997).
Multivariate analysis showed the risk of suicide was 6 times greater when
firearms were involved in the homicide. Acquiring a firearm (particularly in
the UK) suggests premeditation. Dawson (2005) examined premeditation in
intimate femicide followed by suicide and reported that premeditation was
commonly found in those motivated by jealousy or victim ill health. The
degree to which premeditation was found was dependent on the relationship
status, and whether a gun was used.
In this study, 14% of perpetrators were female. This is significantly
higher than for homicide only, where the proportion of female offenders was
10%. It has been claimed that for women these incidents are more akin to
suicide rather than to homicide. For instance, where suicidal ideation
dominates, the homicide is considered to be an extension of the perpetrators’
suicide (Palermo, 1994). Altruism or ‘extended suicide’ is commonly
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reported when mothers kill their children (Hanzlick & Koponen, 1994).
Rescue fantasies have been described as another motivation for homicide
followed by suicide (Selkin, 1976), freeing children from the destructive
marital relationship. Other researchers have argued that the perpetrators
primary aim is to kill another person often motivated by jealousy or
occurring in a passionate rage, as frequently reported in intimate partner
homicide followed by suicide cases (Daly & Wilson, 1988; Milroy, 1995);
suicide, therefore, becomes a secondary outcome (Allen, 1983).
Determining the level of mental illness in perpetrators of homicide
followed by suicide is difficult. In most homicide cases, perpetrators undergo
a pre-trial psychiatric assessment to determine if they had experienced an
abnormal mental state prior to the homicide. However, when perpetrators
die by suicide (before arrest) there is often no record of mental state at the
time of the offence. Analysing previous contact with clinicians is a robust
method of measuring mental disorder in perpetrators. This method provides
reliable data on mental illness and diagnoses based on clinical judgement
prior to the incident. However, it is recognized that perpetrators with mental
illness could be missed. We found that perpetrators were significantly less
likely to have been under the care of mental health services before the
incident than in cases of suicide or homicide-only. Therefore, it is
inconclusive whether severe and enduring mental illness was less prevalent
in these incidents, or whether these perpetrators were simply not in contact
with services. A similar study in New Zealand (Moskowitz et al.,
2006) found a higher proportion of perpetrators (18%) were in contact
with services within 12 months of the offence, compared to 7% in our
sample.
Unfortunately, from our data we are unable to determine if perpetrators
were treated for mental disorder at a primary care level. Research using a
 The Journal of Forensic Psychiatry & Psychology 319
psychological autopsy method has found that depression is common in
homicide followed by suicide (Rosenbaum, 1990). An extensive review of
each case is arguably the best method to uncover the true rate of mental
illness in homicide followed by suicide perpetrators. This method involves
the examination of coroners’ reports and police files, interviewing relatives
of the deceased, and analysing medical records both from hospitals and
General Practitioners.
Health care professionals may have an important role in future
prevention strategies. It is evident from previous research that most
incidents of homicide followed by suicide occur between intimate partners
or within a domestic setting. Domestic violence accounts for 16% of all
violent crime in England and Wales. Such violence is common with 1 in 4
women, and 1 in 5 men reporting to have been a victim of domestic violence
in their lifetime (Finney, 2006). Identifying those most at risk of becoming a
victim of homicide is therefore problematic, as this is a relatively rare event.
Tackling domestic abuse is a major challenge for public health officials. The
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Department of Health have issued guidance outlining how to enquire about

domestic violence with patients (Department of Health, 2000). Health care
professionals are encouraged to undertake routine inquiry, provide
information and refer patients for further support if domestic abuse is
disclosed. GPs and A&E departments are often the victims first point of
contact with health services and are therefore in a unique position to provide
information and support.

Study limitations
The study has a number of limitations. It is descriptive and therefore we are
unable to infer causation. Undertaking subgroup analysis created small
numbers therefore caution should be taken when generalizing the results.
The inclusion of perpetrators, whose suicide occurred prior to conviction,
may also have included individuals who had been arrested or remanded in
custody. We were unable to obtain information regarding perpetrators
mental state at the time of the offence and used contact with services as a
measure of mental disorder. We acknowledge that, by using this method, the
rate of mental illness is likely to be underestimated.

Conclusion
Incidents of homicide followed by suicide involve multiple loss of life, and
create secondary victims of those surviving family members and friends.
These are rare events and the risk factors are common, making risk
prediction difficult. The rates of mental illness are likely to be underestimated
and psychological autopsy would be an invaluable next step to ascertain the
true extent of mental illness and the antecedents of these incidents.
 320 S. Flynn et al.

Acknowledgements
The study was carried out as part of the National Confidential Inquiry into Suicide and
Homicide by People with Mental Illness. We thank the other members of the research
team: Alyson Ashton, Harriet Bickley, James Burns, Kelly Hadfield, Rebecca Lowe,
Phil Stones, and Pauline Turnbull. We acknowledge the help of health authorities and
trust contacts and consultant psychiatrists for completing the questionnaires.

Declaration of interest
LA is the National Director of Mental Health for England.

Role of funding source

The National Confidential Inquiry into Suicide and Homicide by People with Mental
Illness is funded by the National Patient Safety Agency.

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