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Editor—The death of Diana, Princess of Wales has been followed by an unprecedented public and media response. Shevlin et al showed that her death and subsequent funeral have had a profound psychological impact on the public.1 Furthermore, many people have consulted their general practitioners for depression linked to the princess’s death.2
It is therefore perhaps surprising that in contrast to the increased number of consultations for psychological problems the number of admissions for trauma at the North Staffordshire Royal Infirmary has fallen by 10% since Diana’s death. Perhaps more poignantly (figure) the number of admissions of patients with injuries greater than 15 on the injury severity score has fallen. This trend continued for three months; only in December did numbers start to return to previous values. Most of the patients are injured in road traffic accidents, and it would be tempting to imply a causal—albeit probably subliminal—association with driving habits after the tragic events in Paris.
It is too soon to judge whether the tragic manner of Princess Diana’s death will have a lasting impact on admissions for trauma, but we would be interested to know whether other centres have experienced a similar fall in the number of acute and severely injured patients.
Numbers of admissions for trauma (injury severity score ≻15), 1995-7
References
1.Shevlin M, Brundsen V, Walker S, Davies M, Ramkalawan T. Death of Diana, Princess of Wales. BMJ. 1997;315:1467. . (29 November.) [PMC free article] [PubMed] [Google Scholar]
2.Morris B. GPs called into action to help nation recover from shock of Diana’s death. BMA News Review 1997 Sep 24:18.
BMJ. 1998 Jun 6;316(7146):1750.
Number of inappropriate hospital admissions increased
Editor—Further to the letters by Williams et al and Shevlin et al on the effects of the death of Diana, Princess of Wales1-1,1-2 we have made an observation regarding acute hospital admissions. Many general practitioners know that a reduction in demand for admissions at times of significant events, holidays, and so on, is often rapidly followed by an escalation of demand. There is little in the literature about this well recognised phenomenon.
We conducted a study of acute hospital admissions in Belfast. We used the appropriateness evaluation protocol,1-3 which characterises validly and reliably whether acute admissions are appropriate (whether patients show clinical signs that demand admission) or inappropriate. We used a version that has been modified for use in the NHS.1-4 Studies across Europe using the protocol have indicated that inappropriate admissions constitute some 20-25% of total admissions.
Our most recent prospective study was conducted during September 1997 and was in progress at the time of the death of Princess Diana (31 August 1997).
The figure shows the rate of inappropriate admissions during the course of our study. It shows a centred moving average rate of inappropriate admissions on the basis of the last 50 admissions and is updated every time a new admission is made. The average rate of inappropriate admissions was 19%. Immediately before the funeral the number of inappropriate admissions fell to a very low rate. On the weekend of the funeral (6 September 1997), inappropriate admissions fell significantly to almost none (χ2=24.76, df+3; P<0.001).
In the days after the funeral the moving average rate of inappropriate admissions rose rapidly to a rate that was significantly higher than average. Between 10 September and 15 September the rate of inappropriate admissions was 50% above the average for the whole month. No other peaks or troughs in the figure were shown to be statistically significant. This shows that the degree of trauma was so great at this event that people delayed seeking advice, and their own problems took on a secondary importance. This delay only lasted during the extensive media coverage, and after the weekend of the funeral there was an increase in the number of inappropriate admissions.
Centred moving average (50) of proportion of inappropriate admissions during September 1997
The level of appropriate admissions did not fall during this time. This shows, as we already suspected, that hospital is not really necessary for a significant proportion of acute admissions that could be managed by alternative means and for which a delay of perhaps a day or more would not be detrimental to the patient.
References
1-1.Williams ERL, Meadows J, Catalan J. Death of Diana, Princess of Wales. BMJ. 1997;315:1467. . (29 November.) [PMC free article] [PubMed] [Google Scholar]
1-2.Shevlin M, Brunsden V, Walker S, Davies M, Ramkalawan T. Death of Diana, Princess of Wales. BMJ. 1997;315:1467. . (29 November.) [PMC free article] [PubMed] [Google Scholar]
1-3.Gertmann PM, Restuccia J. The appropriateness evaluation protocol: a technique for assessing unnecessary days in hospital care. Med Care. 1981;19:8. [PubMed] [Google Scholar]
1-4.Bristow A, Hudson M, Beech R. Analysing acute inpatient services: the development and application of utilisation review tools. London: Department of Public Health Medicine, United Medical and Dental Schools of Guy’s and St Thomas’s Hospitals; 1997. [Google Scholar]
BMJ. 1998 Jun 6;316(7146):1750.
There was no “Diana effect” on numbers of psychiatric emergencies
Editor—The death of Diana, Princess of Wales on 31 August 1997 and her funeral on 6 September were associated with a 30% reduction in calls to the police and a 28% drop in public order offences during the week of informal public mourning.2-1 The Samaritans reported an increase in the amounts of calls after the death.2-1 There have also been reports of increased depression2-2 and traumatic stress.2-3
The death and funeral might have affected psychiatric emergency presentations including parasuicide. The ensuing public distress might have increased the use of emergency psychiatric services, or the “outpouring of fellowship,” as described in the Guardian,2-1 might have reduced the use of these services, distracting people from their own personal problems.
All people admitted for parasuicide to Edinburgh Royal Infirmary are assessed. People can present as psychiatric emergencies or be referred to the accident and emergency department at the infirmary or at the psychiatric hospital at the Royal Edinburgh Hospital. I studied cases presenting to these services, comparing those presenting in the two weeks in which the death and the funeral occurred (31 August to 13 September) with those presenting in the two weeks before (17 August to 30 August). There were 238 contacts with 126 cases of parasuicide in the two weeks of the death and funeral and a total of 269 contacts including 136 parasuicides in the two weeks before (P<0.1 in two tailed t test). There was no obvious change in the numbers of presentations or cases of parasuicide on the day after the death or the funeral. Thus there seemed to be no “Diana effect” on the numbers of psychiatric emergencies and parasuicides in Edinburgh.
References
2-1.Diana’s death cut crime as nation mourned together. Guardian 1997 Oct 17:4.
2-2.Morris B. GPs called into action to help nation recover from shock of Diana’s death. BMA News Review 1997 Sep 24:18.
2-3.Shevlin M, Brunsden V, Walker S, Davies M, Ramkalawan T. Death of Diana, Princess of Wales. BMJ. 1997;315:1467. . (29 November.) [PMC free article] [PubMed] [Google Scholar]
